Clarithromycin is a semisynthetic macrolide antibiotic used for a wide variety of mild-to-moderate bacterial infections. Clarithromycin has been linked to rare instances of acute liver injury that can be severe and even fatal.
Clarithromycin (kla rith" roe mye' sin)
is a semisynthetic macrolide antibiotic used widely to treat mild-to-moderate bacterial infections caused by sensitive agents. Clarithromycin, like other macrolide antibiotics such such as eythromycin and azithromycin, is bacteriostatic against many gram positive bacteria including many strains of streptococci, staphylococci, clostridia, corynebacteria, listeria, haemophilus sp., moxicella, and Neisseria meningitidis. Clarithromycin is also active against Chlamydia pneumoniae, Helicobacter pylori, and several atypical mycobacteria. Macrolide antibiotics act by inhibiting protein synthesis of bacteria by binding to the 50S ribosomal element. Resistance occurs by several mechanisms. Clarithromycin was approved for use in the United States in 1993, and currently more than 3 million prescriptions are filled yearly. Typical indications are for upper respiratory infections, bronchitis, sinusitis, community acquired pneumonia, and skin and tissue infections. Clarithromycin is also used for infections caused by Chlamydia pneumoniae, Helicobacter pylori and atypical mycobacteria. Clarithromycin is available in tablets of 250 and 500 mg generically under several commercial names including Biaxin, Claripen and Clacid. Extended release formulations are also available. The typical course is 250 to 500 mg twice daily (or 1000 mg extended release tablets once daily) for 7 to 14 days. Clarithromycin is given chronically in some situations such as prophylaxis against mycobacterium avium complex in patients with HIV infection. Clarithromycin is generally well tolerated, but side effects can include nausea, abdominal pain, diarrhea, dyspepsia, headache, dizziness, angioedema and rash.
Clarithromycin, like other macrolide antibiotics, has been linked to two forms of hepatotoxicity. The first is acute, transient and usually asymptomatic elevations in serum aminotransferase levels which occur in 1% to 2% of patients treated for short periods and a somewhat higher proportion of patients given clarithromycin long term. Asymptomatic elevations in serum enzymes are particularly common among elderly patients given higher doses of clarithromycin.
Clarithromycin can also cause acute, clinically apparent liver injury with jaundice, which is estimated to occur in 3.8 per 100,000 prescriptions. The liver injury usually appears within the first 1 to 3 weeks after initiation of treatment and can arise after clarithromycin is stopped. The pattern of liver enzyme elevations varies, but the resulting hepatitis is often cholestatic and can be prolonged (Case 1). Allergic signs and symptoms have not been consistently reported. While cholestatic hepatitis is most typical of clarithromycin induced liver injury, rare cases with hepatocellular injury and abrupt onset have been described. These hepatocellular cases are more likely to be severe and can result in acute liver failure. However, in most instances, recovery occurs within 4 to 8 weeks of withdrawal of the medication. The typical latency, clinical pattern and course of the cholestatic hepatitis due to clarithromycin resembles that of the other macrolide antibiotics.
Mechanism of Liver Injury
The cause of the idiosyncratic liver injury due to clarithromycin is unknown, but the rapidity of onset and prompt recurrence upon rechallenge suggests hypersensitivity. Clarithromycin is extensively metabolized by the microsomal cytochrome P450 system and is a potent inhibitor of CYP 3A4, for which reason it can cause serious drug-drug interactions with agents that are metabolized by CYP 3A4 such as siapride, terfenadine, ergotamine, colchicine, amlodipine, diltiazem and many statins and benzodiazepines. Thus, in some situations, clarithromycin may lead to liver injury from a concurrent medication because of a decrease in its metabolism and increased blood levels.
Outcome and Management
The minor serum aminotransferase elevations that appear during therapy with clarithromycin are usually benign, asymptomatic and resolve rapidly whether or not clarithromycin is stopped. The acute hepatic injury with jaundice, however, can be prolonged and troublesome and lead to loss of intrahepatic bile ducts and vanishing bile duct syndrome. Rare instances of fatality from clarithromycin induced liver disease have been reported. It is unclear whether there is cross sensivity to hepatic injury about the different macrolide antibiotics, but after severe injury from one macrolide, it is prudent to avoid use of the others.
Case 1. Cholestatic hepatitis after clarithromycin.
[Modified from: Sousa C, Correia J, Santos J, Silvestre F, Bernardo A. [Cholestatic hepatitis probably induced by clarithromycin] Gastroenterol Clin Biol 1997; 21: 632-3. French. PubMed Citation]
A 74 year old man with acute bronchitis was treated with a 10 day course of clarithromycin (500 mg daily) and developed nausea and jaundice by day 7. Because of itching and worsening symptoms, he sought medical advice and was hospitalized. He was jaundiced and had right upper quadrant tenderness over the liver, but was not febrile. He denied a history of alcohol intake and had no risk factors for viral hepatitis. Laboratory tests showed marked elevations in alkaline phosphatase and bilirubin levels with moderate increases in ALT and AST levels. He tested negative for markers of hepatitis A, B and C, had low levels of antinuclear and anti-smooth muscle antibody, and liver ultrasound was normal. A liver biopsy showed intrahepatic cholestasis with centrolobular ballooning degeneration, portal inflammation with a prominence of eosinophils, and ductular proliferation. His other medications that he took chronically were stopped at the same time. He recovered over the next few weeks and all liver tests were normal in follow up 3 months later.
|Medication:||Clarithromycin (500 mg daily for 10 days)|
|Pattern:|| Cholestatic (R=0.6)|
||3+ (jaundice and hospitalization)
|Recovery:||Complete within three months|
|Other medications:||Digoxin, captopril, nitropaste, aminophylline, salbutamol, and budesonide (by inhalation) for several years|
|Time After Starting
||Time After Stopping
|Nausea and jaundice arose on day 7 of a 10 day course of clarithromycin
* Converted from µmol (1.0 mg/dL = 17.1 µmol).
A convincing history for drug induced liver disease and the only new medication taken was clarithromycin. The latency was short (one week) as is typical for macrolide induced hepatotoxicity, and the pattern of liver enzyme elevations was cholestatic which also is typical. Despite the patient’s age and depth of jaundice, recovery was complete, taking somewhat longer than usual for this form of drug induced liver injury probably because of the height of the bilirubin and alkaline phosphatase elevations.
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REPRESENTATIVE TRADE NAMES
Clarithromycin — Generic, Biaxin®
Product labeling at DailyMed, National Library of Medicine, NIH
||CAS REGISTRY NUMBER
References updated: 15 May 2014
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Cadranel JF, Bachmeyer C, Pras V, Bouraya D, Pourvillain S, Biour M, Mougeot-Martin M. [Acute symptomatic cytolytic hepatitis probably related to clarithromycin] Gastroenterol Clin Biol 1996; 20: 1034-5. French. PubMed Citation (41 year old woman developed acute abdominal pain after 3 days of clarithromycin therapy [bilirubin 0.7 mg/dL, ALT 10 times ULN, Alk P normal], resolving with a month of stopping).
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PubMed Citation (40 year old woman developed nausea, abdominal pain and fever at the end of a 7 day course of clarithromycin, with subsequent jaundice and hepatic failure [bilirubin 33.4 mg/dL, ALT 1974 U/L, Alk P 1095 U/L, protime 21 seconds], dying 13 days after presentation).
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Sopena N, Martínez-Vázquez C, Rodríguez-Suárez JR, Segura F, Valencia A, Sabrià M. Comparative study of the efficacy and tolerance of azithromycin versus clarithromycin in the treatment of community-acquired pneumonia in adults. J Chemother 2004; 16: 102-3. PubMed Citation (Comparison of 3 day azithromycin vs 10-14 day clarithromycin course in 70 adult patients with pneumonia showing similar efficacy [>90%] and frequency of side effects [26.5% vs 25%], with no mention of hepatic injury).
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Chalasani N, Fontana RJ, Bonkovsky HL, Watkins PB, Davern T, Serrano J, Yang H, Rochon J; Drug Induced Liver Injury Network (DILIN). Causes, clinical features, and outcomes from a prospective study of drug-induced liver injury in the United States. Gastroenterology 2008; 135: 1924-34. PubMed Citation (Among 300 cases of drug induced liver disease in the US collected from 2004 to 2008, 5 cases were attributed to telithromycin and 3 to azithromycin as single agents, but none to erythromycin or clarithromycin).
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PubMed Citation (23 year old young woman developed toxic epidermal necrolysis with liver, lung and renal injury two weeks after starting a course of clarithromycin, ibuprofen and acetaminophen [bilirubin 10.7 mg/dL, ALT 915 U/L, GGT 252 U/L, INR 1.7], with ultimate complete resolution).
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Fatal fulminant hepatitis following administration of clarithromycin in a patient
chronically treated with antipsycotic drugs. Immunopharmacol Immunotoxicol. 2013; 35: 191-4. PubMed Citation (23 year old man developed nausea, diarrhea and fever within 3 days of starting a 5 day course of clarithromycin, with subsequent jaundice [bilirubin 9.6 mg/dL, ALT 4065 U/L] followed by hepatic failure, coagulopathy, intracerebral hemorrhage and death).
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A, et al. Idiopathic acute liver injury in paediatric outpatients:
incidence and signal detection in two European countries. Drug Saf 2013; 36: 1007-16. PubMed Citation (Analysis of 3 large, electronic healthcare databases identified 785 cases of acute liver injury of unknown cause, 110 of which occurred in relationship to a prescription, the highest relative risk [RR] being associated with clarithromycin [RR=25.9], amoxicillin/ clavulanate [RR=18.6] and amoxicillin [RR=6.0]).
Björnsson ES, Bergmann OM, Björnsson HK, Kvaran RB, Olafsson S. Incidence,
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Hernández N, Bessone F, Sánchez A, di Pace M, Brahm J, Zapata R, A Chirino R, et al. Profile of idiosyncratic drug induced liver injury in Latin America. An analysis of published reports. Ann Hepatol 2014; 13: 231-9. PubMed Citation (Systematic review of literature of drug induced liver injury in Latin American countries published from 1996 to 2012 identified 176 cases, one of which was attributed to clarithromycin [acute liver failure], but none were attributed to other macrolide antibiotics).
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injury in children, 20 of which had a statistically significant association, including clarithromycin [5 cases] and erythromycin [4 cases]).