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Biaxin, Biaxin XL
The following serious adverse reactions are described below and elsewhere in the labeling:
- Acute Hypersensitivity Reactions [see WARNINGS AND PRECAUTIONS]
- QT Prolongation [see WARNINGS AND PRECAUTIONS]
- Hepatotoxicity [see WARNINGS AND PRECAUTIONS]
- Serious Adverse Reactions Due to Concomitant Use with Other Drugs [see WARNINGS AND PRECAUTIONS]
- Clostridium difficile Associated Diarrhea [see WARNINGS AND PRECAUTIONS]
- Exacerbation of Myasthenia Gravis [see WARNINGS AND PRECAUTIONS]
Clinical Trials Experience
Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice.
Based on pooled data across all indications, the most frequent adverse reactions for both adult and pediatric populations observed in clinical trials are abdominal pain, diarrhea, nausea, vomiting and dysgeusia. Also reported were dyspepsia, liver function test abnormal, anaphylactic reaction, candidiasis, headache, insomnia, and rash.
The subsequent subsections list the most common adverse reactions for prophylaxis and treatment of mycobacterial infections and duodenal ulcer associated with H. pylori infection. In general, these profiles are consistent with the pooled data described above.
Prophylaxis Of Mycobacterial Infections
In AIDS patients treated with BIAXIN over long periods of time for prophylaxis against M. avium, it was often difficult to distinguish adverse reactions possibly associated with BIAXIN administration from underlying HIV disease or intercurrent illness. Median duration of treatment was 10.6 months for the BIAXIN group and 8.2 months for the placebo group.
Table 4: Incidence Rates (%) of Selected Adverse
Reactionsa in Immunocompromised Adult Patients
Receiving Prophylaxis Against M. avium Complex
|Body as a Whole|
|Skin & Appendages|
|a Includes those events possibly or probably
related to study drug and excludes concurrent conditions
b 2% or greater Adverse Reaction Incidence Rates for either treatment group
c Significant higher incidence compared to the placebo-treated group
Discontinuation due to adverse reactions occurred in 18% of patients receiving BIAXIN compared to 17% of patients receiving placebo in this trial. Primary reasons for discontinuation in BIAXIN treated patients include headache, nausea, vomiting, depression, and taste perversion.
Changes In Laboratory Values
Selected laboratory adverse experiences that were reported during therapy in greater than 2 % of adult patients treated with BIAXIN in a randomized double-blind clinical trial involving 682 patients are presented in Table 5.
In immunocompromised patients receiving prophylaxis against M. avium, evaluations of laboratory values were made by analyzing those values outside the seriously abnormal value (i.e., the extreme high or low limit) for the specified test.
Table 5: Percentage of Patientsa
Exceeding Extreme Laboratory Values in Patients Receiving Prophylaxis
Against M. avium Complex
|BIAXIN 500 mg twice a day||Placebo|
|WBC Count||< 1 x 109/L||2/103 (4%)||0/95|
|SGOT||> 5 x ULNb||7/196 (4%)||5/208 (2%)|
|SGPT||> 5 x ULNb||6/217 (3%)||4/232 (2%)|
|a Includes only patients with baseline values
within the normal range or borderline high (hematology variables) and within
normal range or borderline low (chemistry variables)
b ULN= Upper Limit of Normal
Treatment Of Mycobacterial Infections
The adverse reaction profiles for both the 500 mg and 1000 mg twice a day dose regimens were similar.
In AIDS patients and other immunocompromised patients treated with the higher doses of BIAXIN over long periods of time for mycobacterial infections, it was often difficult to distinguish adverse reactions possibly associated with BIAXIN administration from underlying signs of HIV disease or intercurrent illness.
The following analysis summarizes experience during the first 12 weeks of therapy with BIAXIN. Data are reported separately for trial 1 (randomized, double-blind) and trial 2 (openlabeled, compassionate use) and also combined. Adverse reactions were reported less frequently in trial 2, which may be due in part to differences in monitoring between the two studies.
In adult patients receiving BIAXIN 500 mg twice a day, the most frequently reported adverse reactions, considered possibly or possibly related to study drug, with an incidence of 5% or greater, are listed below (Table 6). Approximately 8% of the patients who received 500 mg twice a day and 12% of the patients who received 1000 mg twice a day discontinued therapy due to drug related adverse reactions during the first 12 weeks of therapy; adverse reactions leading to discontinuation in at least 2 patients included nausea, vomiting, abdominal pain, diarrhea, rash, and asthenia.
Table 6: Selected Treatment-Relateda
Adverse Reaction Incidence Rates (%) in Immunocompromised Adult Patients
During the First 12 Weeks of Therapy with 500 mg Twice a Day BIAXIN Dose
|Adverse Reaction||Trial 1
|a Includes those events possibly or probably related to study drug and excludes concurrent conditions|
A limited number of pediatric AIDS patients have been treated with BIAXIN suspension for mycobacterial infections. The most frequently reported adverse reactions excluding those due to the patient's concurrent conditions were consistent with those observed in adult patients.
Changes In Laboratory Values
In the first 12 weeks of starting on BIAXIN 500 mg twice a day, 3% of patients has SGOT increases and 2% of patients has SGPT increases > 5 times the upper limit of normal in trial 2 (469 enrolled adult patients) while trial 1 (154 enrolled patients) had no elevation of transaminases. This includes only patients with baseline values within the normal range or borderline low.
Duodenal Ulcer Associated With H. pylori Infection
In clinical trials using combination therapy with BIAXIN plus omeprazole and amoxicillin, no adverse reactions specific to the combination of these drugs have been observed. Adverse reactions that have occurred have been limited to those that have been previously reported with BIAXIN, omeprazole or amoxicillin.
The adverse reaction profiles are shown below (Table 7) for four randomized double-blind clinical trials in which patients received the combination of BIAXIN 500 mg three times a day, and omeprazole 40 mg daily for 14 days, followed by omeprazole 20 mg once a day, (three studies) or 40 mg once a day (one study) for an additional 14 days. Of the 346 patients who received the combination, 3.5% of patients discontinued drug due to adverse reactions.
Table 7: Adverse Reactions
with an Incidence of 3% or Greater
|Adverse Reaction||BIAXIN + Omeprazole
(n=346) % of Patients
(n=355) % of Patients
(n=166) % of Patientsa
|a Only two of four studies|
Changes in Laboratory Values
Changes in laboratory values with possible clinical significance in patients taking BIAXIN and omeprazole in four randomized double-blind trials in 945 patients are as follows: Hepatic: elevated direct bilirubin < 1%; GGT < 1%; SGOT (AST) < 1%; SGPT (ALT) < 1%, Renal: elevated serum creatinine < 1%.
Less Frequent Adverse Reactions Observed During Clinical Trials Of Clarithromycin
Based on pooled data across all indications, the following adverse reactions were observed in clinical trials with clarithromycin at a rate less than 1%:
General Disorders and Administration Site Conditions: Malaise, pyrexia, asthenia, chest pain, chills, fatigue
Hepatobiliary Disorders: Cholestasis, hepatitis
Immune System Disorders: Hypersensitivity
Metabolism and Nutrition Disorders: Anorexia, decreased appetite
Psychiatric Disorders: Anxiety, nervousness
Renal and Urinary Disorders: Blood creatinine increased, blood urea increased
Gastrointestinal Adverse Reactions
In the acute exacerbation of chronic bronchitis and acute maxillary sinusitis studies overall gastrointestinal adverse reactions were reported by a similar proportion of patients taking either BIAXIN Filmtab or BIAXIN XL Filmtab; however, patients taking BIAXIN XL Filmtab reported significantly less severe gastrointestinal symptoms compared to patients taking BIAXIN Filmtab. In addition, patients taking BIAXIN XL Filmtab had significantly fewer premature discontinuations for drug-related gastrointestinal or abnormal taste adverse reactions compared to BIAXIN Filmtab.
The following adverse reactions have been identified during post-approval use of BIAXIN. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
Ear and Labyrinth: Deafness was reported chiefly in elderly women and was usually reversible.
Gastrointestinal: Pancreatitis acute, tongue discoloration, tooth discoloration was reported and was usually reversible with professional cleaning upon discontinuation of the drug.
There have been reports of BIAXIN XL Filmtab in the stool, many of which have occurred in patients with anatomic (including ileostomy or colostomy) or functional gastrointestinal disorders with shortened GI transit times. In several reports, tablet residues have occurred in the context of diarrhea. It is recommended that patients who experience tablet residue in the stool and no improvement in their condition should be switched to a different clarithromycin formulation (e.g. suspension) or another antibacterial drug.
Immune System: Anaphylactic reactions, angioedema
Musculoskeletal and Connective Tissue: Myopathy rhabdomyolysis was reported and in some of the reports, clarithromycin was administered concomitantly with statins, fibrates, colchicine or allopurinol [see CONTRAINDICATIONS and WARNINGS AND PRECAUTIONS].
Psychiatric: Abnormal behavior, confusional state, depersonalization, disorientation, hallucination, depression, manic behavior, abnormal dream, psychotic disorder. These disorders usually resolve upon discontinuation of the drug.
Read the Biaxin, Biaxin XL (clarithromycin) Side Effects Center for a complete guide to possible side effects
Co-administration of BIAXIN is known to inhibit CYP3A, and a drug primarily metabolized by CYP3A may be associated with elevations in drug concentrations that could increase or prolong both therapeutic and adverse effects of the concomitant drug.
BIAXIN should be used with caution in patients receiving treatment with other drugs known to be CYP3A enzyme substrates, especially if the CYP3A substrate has a narrow safety margin (e.g., carbamazepine) and/or the substrate is extensively metabolized by this enzyme. Adjust dosage when appropriate and monitor serum concentrations of drugs primarily metabolized by CYP3A closely in patients concurrently receiving clarithromycin.
Table 8: Clinically Significant Drug Interactions with
|Drugs That Are Affected By BIAXIN|
|Drug(s) with Pharmacokinetics Affected by BIAXIN||Recommendation||Comments|
|Not Recommended||Disopyramide, Quinidine: There have been postmarketing reports of torsades de pointes occurring with concurrent use of clarithromycin and quinidine or disopyramide. Electrocardiograms should be monitored for QTc prolongation during coadministration of clarithromycin with these drugs [see WARNINGS AND PRECAUTIONS].
Serum concentrations of these medications should also be monitored. There have been spontaneous or published reports of CYP3A based interactions of clarithromycin with disopyramide and quinidine.
There have been postmarketing reports of hypoglycemia with the concomitant administration of clarithromycin and disopyramide. Therefore, blood glucose levels should be monitored during concomitant administration of clarithromycin and disopyramide.
|Digoxin||Use With Caution||Digoxin: Digoxin is a substrate for P-glycoprotein (Pgp) and clarithromycin is known to inhibit Pgp. When clarithromycin and digoxin are coadministered, inhibition of Pgp by clarithromycin may lead to increased exposure of digoxin. Elevated digoxin serum concentrations in patients receiving clarithromycin and digoxin concomitantly have been reported in postmarketing surveillance. Some patients have shown clinical signs consistent with digoxin toxicity, including potentially fatal arrhythmias. Monitoring of serum digoxin concentrations should be considered, especially for patients with digoxin concentrations in the upper therapeutic range.|
|Warfarin||Use With Caution||Oral anticoagulants: Spontaneous reports in the postmarketing period suggest that concomitant administration of clarithromycin and oral anticoagulants may potentiate the effects of the oral anticoagulants. Prothrombin times should be carefully monitored while patients are receiving clarithromycin and oral anticoagulants simultaneously [see WARNINGS AND PRECAUTIONS].|
|Antiepileptics: Carbamazepine||Use With Caution||Carbamazepine: Concomitant administration of single doses of clarithromycin and carbamazepine has been shown to result in increased plasma concentrations of carbamazepine. Blood level monitoring of carbamazepine may be considered. Increased serum concentrations of carbamazepine were observed in clinical trials with clarithromycin. There have been spontaneous or published reports of CYP3A based interactions of clarithromycin with carbamazepine.|
|Itraconazole||Use With Caution||Itraconazole: Both clarithromycin and itraconazole are substrates and inhibitors of CYP3A, potentially leading to a bi-directional drug interaction when administered concomitantly (see also Itraconazole under “Drugs That Affect BIAXIN” in the table below). Clarithromycin may increase the plasma concentrations of itraconazole. Patients taking itraconazole and clarithromycin concomitantly should be monitored closely for signs or symptoms of increased or prolonged adverse reactions.|
|Fluconazole||No Dose Adjustment||Fluconazole: [see Pharmacokinetics]|
|Colchicine (in patients with renal or hepatic impairment)||Contraindicated||Colchicine: Colchicine is a substrate for both CYP3A and the efflux transporter, P-glycoprotein (Pgp). Clarithromycin and other macrolides are known to inhibit CYP3A and Pgp. The dose of colchicine should be reduced when co-administered with clarithromycin in patients with normal renal and hepatic function [see CONTRAINDICATIONS and WARNINGS AND PRECAUTIONS].|
|Colchicine (in patients with normal renal and hepatic function)||Use With Caution|
|Contraindicated||Pimozide: [See CONTRAINDICATIONS]
Quetiapine: Quetiapine is a substrate for CYP3A4, which is inhibited by clarithromycin. Coadministration with clarithromycin could result in increased quetiapine exposure and possible quetiapine related toxicities. There have been postmarketing reports of somnolence, orthostatic hypotension, altered state of consciousness, neuroleptic malignant syndrome, and QT prolongation during concomitant administration. Refer to quetiapine prescribing information for recommendations on dose reduction if coadministered with CYP3A4 inhibitors such as clarithromycin.
|Tolterodine (patients deficient in CYP2D6 activity)||Use With Caution||Tolterodine: The primary route of metabolism for tolterodine is via CYP2D6. However, in a subset of the population devoid of CYP2D6, the identified pathway of metabolism is via CYP3A. In this population subset, inhibition of CYP3A results in significantly higher serum concentrations of tolterodine. Tolterodine 1 mg twice daily is recommended in patients deficient in CYP2D6 activity (poor metabolizers) when co-administered with clarithromycin.|
Saquinavir (in patients with decreased renal function)
Boceprevir (in patients with normal renal function)
|Use With Caution No Dose Adjustment||Atazanavir: Both clarithromycin and atazanavir are substrates and inhibitors of CYP3A, and there is evidence of a bi-directional drug interaction (see Atazanavir under “Drugs That Affect BIAXIN” in the table below) [see Pharmacokinetics].
Saquinavir: Both clarithromycin and saquinavir are substrates and inhibitors of CYP3A and there is evidence of a bi-directional drug interaction (see Saquinavir under “Drugs That Affect BIAXIN” in the table below) [see Pharmacokinetics].
Ritonavir, Etravirine: (see Ritonavir and Etravirine under “Drugs That Affect BIAXIN” in the table below) [see Pharmacokinetics]. Maraviroc: Clarithromycin may result in increases in maraviroc exposures by inhibition of CYP3A metabolism. See Selzentry® prescribing information for dose recommendation when given with strong CYP3A inhibitors such as clarithromycin. Boceprevir: Both clarithromycin and boceprevir are substrates and inhibitors of CYP3A, potentially leading to a bi-directional drug interaction when coadministered. No dose adjustments are necessary for patients with normal renal function (see Victrelis® prescribing information).
Zidovudine: Simultaneous oral administration of clarithromycin immediate-release tablets and zidovudine to HIV-infected adult patients may result in decreased steady-state zidovudine concentrations. Administration of clarithromycin and zidovudine should be separated by at least two hours [see Pharmacokinetics].
The impact of co-administration of clarithromycin extended-release tablets or granules and zidovudine has not been evaluated.
|Calcium Channel Blockers:|
|Use With Caution||Verapamil: Hypotension, bradyarrhythmias, and lactic acidosis have been observed in patients receiving concurrent verapamil, [see WARNINGS AND PRECAUTIONS].
Amlodipine, Diltiazem: [See WARNINGS AND PRECAUTIONS]
Nifedipine: Nifedipine is a substrate for CYP3A. Clarithromycin and other macrolides are known to inhibit CYP3A. There is potential of CYP3A-mediated interaction between nifedipine and clarithromycin. Hypotension and peripheral edema were observed when clarithromycin was taken concomitantly with nifedipine [see WARNINGS AND PRECAUTIONS].
|Ergot Alkaloids: Ergotamine Dihydroergotamine||Contraindicated||Ergotamine, Dihydroergotamine: Postmarketing reports indicate that coadministration of clarithromycin with ergotamine or dihydroergotamine has been associated with acute ergot toxicity characterized by vasospasm and ischemia of the extremities and other tissues including the central nervous system [see CONTRAINDICATIONS].|
|Cisapride||Contraindicated||Cisapride: [See CONTRAINDICATIONS]|
|HMG-CoA Reductase Inhibitors:|
Use With Caution
No Dose Adjustment
|Lovastatin, Simvastatin, Atorvastatin, Pravastatin, Fluvastatin: [See CONTRAINDICATIONS) and WARNINGS AND PRECAUTIONS]|
|Use With Caution||Nateglinide, Pioglitazone, Repaglinide, Rosiglitazone: [See WARNINGS AND PRECAUTIONS and ADVERSE REACTION]
Insulin: [See WARNINGS AND PRECAUTIONS and ADVERSE REACTION]
|Use With Caution||Cyclosporine: There have been spontaneous or published reports of CYP3A based interactions of clarithromycin with cyclosporine.
Tacrolimus: There have been spontaneous or published reports of CYP3A based interactions of clarithromycin with tacrolimus.
|Use With Caution||Sildenafil, Tadalafil, Vardenafil: Each of these phosphodiesterase inhibitors is primarily metabolized by CYP3A, and CYP3A will be inhibited by concomitant administration of clarithromycin. Co-administration of clarithromycin with sildenafil, tadalafil, or vardenafil will result in increased exposure of these phosphodiesterase inhibitors. Co-administration of these phosphodiesterase inhibitors with clarithromycin is not recommended. Increased systemic exposure of these drugs may occur with clarithromycin; reduction of dosage for phosphodiesterase inhibitors should be considered (see their respective prescribing information).|
|Proton Pump Inhibitors:|
|Omeprazole||No Dose Adjustment||Omeprazole: The mean 24-hour gastric pH value was 5.2 when omeprazole was administered alone and 5.7 when coadministered with clarithromycin as a result of increased omeprazole exposures [see Pharmacokinetics] (see also Omeprazole under “Drugs That Affect BIAXIN” in the table below).|
|Theophylline||Use With Caution||Theophylline: Clarithromycin use in patients who are receiving theophylline may be associated with an increase of serum theophylline concentrations [see Pharmacokinetics]. Monitoring of serum theophylline concentrations should be considered for patients receiving high doses of theophylline or with baseline concentrations in the upper therapeutic range.|
|Triazolobenzodiazepines and Other Related Benzodiazepines:|
|Use With Caution||Midazolam: When oral midazolam is coadministered with clarithromycin, dose adjustments may be necessary and possible prolongation and intensity of effect should be anticipated [see WARNINGS AND PRECAUTIONS and Pharmacokinetics].
Triazolam, Alprazolam: Caution and appropriate dose adjustments should be considered when triazolam or alprazolam is co-administered with clarithromycin. There have been postmarketing reports of drug interactions and central nervous system (CNS) effects (e.g., somnolence and confusion) with the concomitant use of clarithromycin and triazolam. Monitoring the patient for increased CNS pharmacological effects is suggested.
|No Dose Adjustment|| In postmarketing experience, erythromycin has been reported to decrease the clearance of triazolam and midazolam, and thus, may increase the pharmacologic effect of these benzodiazepines.
Temazepam, Nitrazepam, Lorazepam: For benzodiazepines which are not metabolized by CYP3A (e.g., temazepam, nitrazepam, lorazepam), a clinically important interaction with clarithromycin is unlikely.
|Cytochrome P450 Inducers:|
|Rifabutin||Use With Caution||Rifabutin: Concomitant administration of rifabutin and clarithromycin resulted in an increase in rifabutin, and decrease in clarithromycin serum levels together with an increased risk of uveitis (see Rifabutin under “Drugs That Affect BIAXIN” in the table below).|
|Other Drugs Metabolized by CYP3A:|
St. John’s Wort
|Use With Caution||There have been spontaneous or published reports of CYP3A based interactions of clarithromycin with alfentanil, methylprednisolone, cilostazol, bromocriptine, vinblastine, phenobarbital, and St. John’s Wort.|
|Other Drugs Metabolized by CYP450 Isoforms Other than CYP3A:|
|Use With Caution||There have been postmarketing reports of interactions of clarithromycin with drugs not thought to be metabolized by CYP3A, including hexobarbital, phenytoin, and valproate.|
|Drugs that Affect BIAXIN|
|Drug(s) that Affect the Pharmacokinetics of BIAXIN||Recommendation||Comments|
|Itraconazole||Use With Caution||Itraconazole: Itraconazole may increase the plasma concentrations of clarithromycin. Patients taking itraconazole and clarithromycin concomitantly should be monitored closely for signs or symptoms of increased or prolonged adverse reactions (see also Itraconazole under “Drugs That Are Affected By BIAXIN” in the table above).|
|Atazanavir||Use With Caution||Atazanavir: When clarithromycin is co-administered with atazanavir, the dose of clarithromycin should be decreased by 50% [see CLINICAL PHARMACOLOGY].
Since concentrations of 14-OH clarithromycin are significantly reduced when clarithromycin is coadministered with atazanavir, alternative antibacterial therapy should be considered for indications other than infections due to Mycobacterium avium complex. Doses of clarithromycin greater than 1000 mg per day should not be co-administered with protease inhibitors.
|Ritonavir (in patients with decreased renal function)||Ritonavir: Since concentrations of 14-OH clarithromycin are significantly reduced when clarithromycin is co-administered with ritonavir, alternative antibacterial therapy should be considered for indications other than infections due to Mycobacterium avium [see Pharmacokinetics]. Doses of clarithromycin greater than 1000 mg per day should not be co-administered with protease inhibitors.|
|Saquinavir (in patients with decreased renal function)
Saquinavir (in patients with normal renal function) Ritonavir (in patients with normal renal function)
|No Dose Adjustment||Saquinavir: When saquinavir is co-administered with ritonavir, consideration should be given to the potential effects of ritonavir on clarithromycin (refer to ritonavir above) [see Pharmacokinetics].
Etravirine: Clarithromycin exposure was decreased by etravirine; however, concentrations of the active metabolite, 14-OH-clarithromycin, were increased. Because 14-OH-clarithromycin has reduced activity against Mycobacterium avium complex (MAC), overall activity against this pathogen may be altered; therefore alternatives to clarithromycin should be considered for the treatment of MAC.
|Proton Pump Inhibitors:|
|Omeprazole||Use With Caution||Omeprazole: Clarithromycin concentrations in the gastric tissue and mucus were also increased by concomitant administration of omeprazole [see Pharmacokinetics].|
|Miscellaneous Cytochrome P450 Inducers:|
|Use With Caution||Inducers of CYP3A enzymes, such as efavirenz, nevirapine, rifampicin, rifabutin, and rifapentine will increase the metabolism of clarithromycin, thus decreasing plasma concentrations of clarithromycin, while increasing those of 14-OH-clarithromycin. Since the microbiological activities of clarithromycin and 14-OH-clarithromycin are different for different bacteria, the intended therapeutic effect could be impaired during concomitant administration of clarithromycin and enzyme inducers. Alternative antibacterial treatment should be considered when treating patients receiving inducers of CYP3A. There have been spontaneous or published reports of CYP3A based interactions of clarithromycin with rifabutin (see Rifabutin under “Drugs That Are Affected By BIAXIN” in the table above).|
Read the Biaxin, Biaxin XL Drug Interactions Center for a complete guide to possible interactions
Last reviewed on RxList: 6/28/2016
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