by Juan Ding, OD, PhD

I talked earlier about an off label treatment of dry eye and Meibomian gland dysfunction (MGD), doxycycline; and today I will talk about another off label use of azithromycin (AZM) to treat MGD.

AZM is a macrolide type of antibiotic that has a unique characteristic, to promote lipid accumulation in cells. This works well in MGD, because the Meibomian gland cells work by producing and storing lipid and then releasing it to the tear film. With this additional help, my coworkers and I found that the Meibomian gland cells produce more fat ¹. And these effects are unique as doxycycline and other tetracyclines do not have this benefit ². Other scientists found that AZM significant improves dry eye symptoms and work slightly better than doxycycline ³. Further, the dosage and usage is easier with AZM, which is used for 500 mg on the first day and then 250 mg/day for a further 4 days, whereas doxycycline was used for 100 mg twice a day for 7 days and then 100 mg/day for a further 21 days ³.

AZM also exists in an eye drop format, for example, azasite (1% AZM ophthalmic solution). This also works well for MGD and dry eye, though it’s quite expensive and sometimes not covered by insurance.

Side effects of AZM include diarrhea or loose stools, nausea, abdominal pain, stomach upset, vomiting, constipation, dizziness, etc. it is safe to use during pregnancy and breastfeeding.

I prefer the AZM eye drop, which works more targeted to the ocular surface without systemic side effect. Due to its cost, I typically use it only in patients with MGD and blepharitis (inflammation of the eyelid margin) that have failed other treatments. I have had some very grateful patients who report they can finally open their eyes or that their eyes are no longer constantly red. The usage of this of course requires a prescription and supervision under a qualified physician.

I wish they make this cheaper and make an ointment form of this.

References:

1. Liu Y, Kam WR, Ding J, Sullivan DA. Effect of azithromycin on lipid accumulation in immortalized human meibomian gland epithelial cells. JAMA Ophthalmol. Feb 2014;132(2):226-228.
2. Liu Y, Kam WR, Ding J, Sullivan DA. Can tetracycline antibiotics duplicate the ability of azithromycin to stimulate human meibomian gland epithelial cell differentiation? Cornea. Mar 2015;34(3):342-346.
3. De Benedetti G, Vaiano AS. Oral azithromycin and oral doxycycline for the treatment of Meibomian gland dysfunction: A 9-month comparative case series. Indian J. Ophthalmol. Apr 2019;67(4):464-471.