Clarithromycin Budesonide

Macrolide-type antibiotics Clarithromycin, erythromycin, telithromycin, troleandomycin Opioids Alfentanyl, cocaine, fentanyl, sufentanil Steroids Budesonide, cortisol, 17- 3-estradiol, progesterone... 

Acetaminophen, aldrin, alfentanil, amiodarone, aminopyrine, amitriptyline, amprenavir, androstenedione,antipyrine, astemizole, benzphetamine, budesonide, carbamazepine, celecoxib, chlorpromazine, chlorzoxazone, cisapride, clarithromycin, clozapine, cocaine, codeine, cortisol, cyclophosphamide,cyclosporin, dapsone, delavirdine, dextromethorphan, digitoxin, diltiazem, diazepam, erythromycin, 17j3-estradiol, ethinylestradiol, etoposide, felbamate, fentanyl, flutamide, hydroxyarginine, ifosphamide, imipramine, indinavir, ketoconazole, lansoprazole, loratidine, losartan, lovastatin, (iS)"mephen3d in, methadone, mianserin, miconazole, mifepristone, nelfinavir, nevirapine, nicardipine, nifedipine, odansetron, omeprazole, orphenadrine, proguanil, propafenone, quinidine, quinine, rapamycin, retinoic acid, ritonavir, saquinavir, selegiline, serindole, sufentanil, sulfinpyrazone, tacrolimus, tamoxifen, tamsulosin, taxol, teniposide, terfenadine, tetrahydrocannabinol, theophylline, toremifene, triazolam, trimethadone, trimethoprim, troleandomycin, verapamil, warfarin, zatosetron, Zolpidem, zonisamide... 

Two other reports describe the development of Cushing s syndrome in patients with cystic fibrosis given inhaled budesonide, and then itraconazole for bronchopulmonary aspergillosis. One patient was also taking clarithromycin, which may have contributed to the increased budesonide effects (see also Corticosteroids+Macrolides , p. 1056). The other patient was a 4-year-old boy who developed Cushing s syndrome 2 weeks after starting treatment with itraconazole 200 mg daily and inhaled budesonide 400 micrograms daily. ... 

Troleandomycin and, to a lesser extent, clarithromycin and erythromycin can reduce the clearance of methylprednisolone, thereby increasing both its therapeutic and adverse effects. A patient receiving long-term clarithromycin developed Cushing s syndrome after starting treatment with inhaled budesonide. There appears to be no pharmacokinetic interaction between erythromycin and inhaled ciclesonide. Similarly, prednisolone appears not to be affected by macrolides, except possibly in those also taking enzyme-inducers such as phenobarbital. Isolated case reports describe the development of acute mania and psychosis in two patients, apparently due to an interaction between prednisone and clarithromycin. 

A 40-year-old woman with cystic fibrosis given clarithromycin 500 mg twice daily for 4 years for a Mycobacterium abscessus infection developed Cushing s syndrome with adrenal suppression 6 weeks after starting to use inhaled budesonide 400 micrograms daily. A slow rise in morning free cortisol levels was found 4 weeks after stopping budesonide, but she died 8 weeks later of severe respiratory failure. ... 

What is known suggests that clarithromycin, erythromycin and troleandomycin can inhibit the metabolism of methylprednisolone. The volume of distribution is also decreased. Clarithromycin may inhibit the metabolism of budesonide. ... 

One case report indicates that clarithromycin may enhance the effects of inhaled budesonide and although the authors suggest that prolonged use of clarithromycin and the terminal condition of the patient may have been factors, they advise close monitoring if the combination is used. Note that rectal budesonide produces higher plasma levels than the oral or inhaled use. The manufacturers of one UK rectal preparation advise that potent inhibitors of CYP3A4 (they name clarithromycin) should be avoided. However, given the evidence available, this seems a very cautious approach. 

---