Erytromycine

Clinical question 2h:

What is the effect of erythromycin in the treatment of nausea and/or vomiting in patients in the palliative phase of cancer, heart failure, COPD, MS, ALS or renal failure?

Recommendation

Erythromycin is not recommended for the treatment of nausea or vomiting for patients in the palliative phase, unless there is gastroparesis due to diabetes mellitus or after vagotomy.

Introduction

Erythromycin is a motilin agonist and therefore has a prokinetic action. It induces antral contractions with acceleration in gastric emptying [Annesse 1992 ]. This has been demonstrated in healthy volunteers but also in patients with gastroparesis as a result of diabetes mellitus [Tack 1992; Kendall 1997] or after a vagotomy [Kendall 1997].

As prokinetic agent, erythromycin is usually administered intravenously. It can also be administered orally. If used for more than a few weeks, tachyphylaxia develops due to downregulation of the motilin receptor. The clinical response decreases after 4 weeks use of oral erythromycin [Richards 1993].

Erythromycin is affected by interactions with drugs metabolised by CYP3A4. Administration of erythromycin is also associated with the development of corrected QT interval prolongation.

Literature discussion

There were 375 publications found during literature research, of which 200 were after 1998. The great majority concerns the use of erythromycin in patients with gastroparesis, especially as a result of diabetes mellitus. In the studies involving gastroparesis, none looked specifically at malignancy-associated gastroparesis.
There is one study involving patients with postoperative gastroparesis [Ramirez 1994]. There are also 2 retrospective case series that report the use of erythromycin after radiotherapy or bone marrow transplantation without quantifying the effect [Brand 1998; Eagle 2001].

No studies have been found that involve treatment of nausea and/or vomiting that is not related to demonstrated gastroparesis.

While erythromycin has a stronger effect on gastric emptying than domperidone and metoclopramide, this does not always correlate with an improvement in symptoms [Sturm 1999].

Erythromycin is effective for diabetic gastroparesis and after vagotomy. If one of these two disorders is the cause of the nausea or vomiting, erythromycin may be considered. After approximately 4 weeks, there is a risk of tachyphylaxis with the resulting possible reduction in efficacy.

No statement can be made about the effect of erythromycin in patients in the palliative phase with nausea and vomiting.