HealingWell
Search Close Search
☰

Clarithromycin - safety with mild to moderate heart palpitations

Support Forums
>
Lyme Disease
✚ New Topic ✚ Reply
❬ ❬ Previous Thread |Next Thread ❭ ❭
Posted 7/26/2021 10:54 AM (GMT -5)
just thought i would get some input here as i know many of you will have had some kind of heart arrhythmia and also been on numerous antibiotics

i am considering a few weeks (probably 2weeks on 2 off in cycles ) of Clarithromycin on top of my current mainly herbal regime for Bart and Lyme.

there are a few reasons for this
-my treatment is ongoing and i am making improvements - but its very slow going - will still be a long road back at this rate - and my financial reserves are dwindling so i could really do with making more progress.
-its active for both bart and lyme - and should combine well with my current regime
-my partner - who became ill at the same time as me with the same illness - had a very positive response to clarithromycin at high dose - and said she felt "Amazing" while on it for 2 weeks - maintained gains after stopping
-i have taken the very similar azithromycin for long periods before without any serious side effects - liver enzymes eventually went high after several months on doxy, azithro, rifampicin combined

the slight concern i have is that for the last 6-12 months and especially while increasing doses while treating with herbs - i have been getting significant heart palpitations ( although symptoms improving overall) so it seems like some kind of herx related reaction - my PCP did a quick EKG and diagnosed "ectopic beats" which they felt completely comfortable about - apparently no cause for concern

but since clarithromycin has some risk of causing arrhythmias and can cause a prolonged QT interval ( which is serious ) - i have some concerns about using it - or at least think its worth doing some more digging

drugs.com says:
Cardiovascular
Common (1% to 10%): Vasodilation, phlebitis
Uncommon (0.1% to 1%): ECG QT prolonged, cardiac arrest, atrial fibrillation, extrasystoles, palpitations
Rare (0.01% to 0.1%): Arrhythmia
Frequency not reported: QT interval prolongation
Postmarketing reports: Ventricular arrhythmia, ventricular tachycardia, torsades de pointes, hemorrhage

rxlist.com says:
Associated with heart rhythm disorder (QT interval prolongation) and infrequent cases of arrhythmias, including torsade de pointes; avoid using with ongoing proarrhythmic conditions (uncorrected low blood levels of potassium or low blood levels of magnesium), clinically significant slow heart rate; do not coadminister with class IA (quinidine, procainamide) or class III (dofetilide, amiodarone, sotalol) antiarrhythmics

NICE says:
Cautions
For all MACROLIDES
With intravenous use or oral use

electrolyte disturbances (predisposition to QT interval prolongation); may aggravate myasthenia gravis; predisposition to QT interval prolongation

so it seems like the QT interval prolongation issue is related to electrolyte disturbance

QUESTIONS

1, does anyone know any more specifics on that - ie which electrolyte - and shifted up or down?

2, does any one else have any experience of taking macrolides with pre-existing arrhythmias
if so how did it go ?

3, did you do any additional monitoring for safety ?
Posted 7/26/2021 11:17 AM (GMT -5)
I would be concerned about the long qt and taking clarithromycin.

Are “atopic beats” another term for long qt?
Posted 7/26/2021 11:26 AM (GMT -5)
nope - they are different

one is supposedly harmless that loads of people have - with no known cause

the other is usually genetic and rare - but can be caused by reaction to medications ( perhaps predisposed by genetics and or other factors) - its actually a slowing down of the heart - where it takes too long for the system to recharge after every pulse - whereas ectopic beats are kind a the other end of things where you get occasional premature beats

https://my.clevelandclinic.org/health/diseases/17183-long-q-t-syndrome-lqts
Posted 7/26/2021 1:52 PM (GMT -5)

Garzie said...
just thought i would get some input here as i know many of you will have had some kind of heart arrhythmia and also been on numerous antibiotics

i am considering a few weeks (probably 2weeks on 2 off in cycles ) of Clarithromycin on top of my current mainly herbal regime for Bart and Lyme.

there are a few reasons for this
-my treatment is ongoing and i am making improvements - but its very slow going - will still be a long road back at this rate - and my financial reserves are dwindling so i could really do with making more progress.
-its active for both bart and lyme - and should combine well with my current regime
-my partner - who became ill at the same time as me with the same illness - had a very positive response to clarithromycin at high dose - and said she felt "Amazing" while on it for 2 weeks - maintained gains after stopping
-i have taken the very similar azithromycin for long periods before without any serious side effects - liver enzymes eventually went high after several months on doxy, azithro, rifampicin combined

the slight concern i have is that for the last 6-12 months and especially while increasing doses while treating with herbs - i have been getting significant heart palpitations ( although symptoms improving overall) so it seems like some kind of herx related reaction - my PCP did a quick EKG and diagnosed "ectopic beats" which they felt completely comfortable about - apparently no cause for concern

but since clarithromycin has some risk of causing arrhythmias and can cause a prolonged QT interval ( which is serious ) - i have some concerns about using it - or at least think its worth doing some more digging

drugs.com says:
Cardiovascular
Common (1% to 10%): Vasodilation, phlebitis
Uncommon (0.1% to 1%): ECG QT prolonged, cardiac arrest, atrial fibrillation, extrasystoles, palpitations
Rare (0.01% to 0.1%): Arrhythmia
Frequency not reported: QT interval prolongation
Postmarketing reports: Ventricular arrhythmia, ventricular tachycardia, torsades de pointes, hemorrhage

rxlist.com says:
Associated with heart rhythm disorder (QT interval prolongation) and infrequent cases of arrhythmias, including torsade de pointes; avoid using with ongoing proarrhythmic conditions (uncorrected low blood levels of potassium or low blood levels of magnesium), clinically significant slow heart rate; do not coadminister with class IA (quinidine, procainamide) or class III (dofetilide, amiodarone, sotalol) antiarrhythmics

NICE says:
Cautions
For all MACROLIDES
With intravenous use or oral use

electrolyte disturbances (predisposition to QT interval prolongation); may aggravate myasthenia gravis; predisposition to QT interval prolongation

so it seems like the QT interval prolongation issue is related to electrolyte disturbance

QUESTIONS

1, does anyone know any more specifics on that - ie which electrolyte - and shifted up or down?

2, does any one else have any experience of taking macrolides with pre-existing arrhythmias
if so how did it go ?

3, did you do any additional monitoring for safety ?

This happened to me while on clinda and I had to stop taking it as I landed in the er and it showed I left enlarged ventricular in my heart, something I didnt have previously. So your partner had great results and felt amazing after 2 weeks of clarithro?? about how long was your partner infected with symptoms?. Sounds like a speedy recovery which is great.
Posted 7/26/2021 3:13 PM (GMT -5)
that was around 4 years from illness onset - but she had recovered quite a bit already - not sure what really did it for her - she was taking buhner herbs for those 4 years - knotweed and cats claw mainly - andrographis in the beginning

and also adaptogens - eleuthero, rhodiola, ashwaghanda, gingko

she took theanine for anxiety - and we both took supplements we thought might help
she also did a fully strict ketogenic paleo diet for those last 2 years where she recovered to 80-90%
and she had a few courses of antibiotics for a recurrent ear infection she kept getting since she was a child - thats why she was taking the clarithromycin - 2x 500mg a day

and she just got better - i think perhaps not quite 100% - as i think she has some mental health issues with mood etc - but back working 12hrs days
Posted 7/27/2021 10:27 AM (GMT -5)
we got a bit off topic - so bumping for anyone to input on having palpitations or arrhythmias and treating with macrolides
Posted 7/27/2021 10:58 AM (GMT -5)
Hi Garzie,

Have you looked into enzyme CYP3A4?

Azithromycin is not a substrate nor an inhibitors of CYP3A4.

Clarithromycin however, is both a substrate AND an inhibitor of CYP3A4.

I drew some pretty arrows on this screenshot for you to consider:

https://i.ibb.co/482w9r3/2021-07-27-09-07.png

I guess what I'm trying to say is, CYP3A4 in the liver can often activate other drugs and herbs and make them a lot more potent and vice versa. And it can also make important medication and herbs less active.

So there might be something in your protocol that's being amplified and/or the antibiotics themselves. Or rendered inactive.

In regards to Long-QT. I take and have taken some medication (not for lyme) that has this warning, but I read that the medication induced version of Long-QT is usually reversible when the medication is stopped.

That doesn't take away of course of the danger while on the medication, so I guess I don't have a real solution for that right now.

But I hope you will look into CYP3A4.

Rifampin caused me some suffering through a CYP3A4 interaction.
Posted 7/27/2021 11:05 AM (GMT -5)

RainyCloud said...
Hi Garzie,

Have you looked into enzyme CYP3A4?

Azithromycin is not a substrate nor an inhibitors of CYP3A4.

Clarithromycin however, is both a substrate AND an inhibitor of CYP3A4.

I drew some pretty arrows on this screenshot for you to consider:

https://i.ibb.co/482w9r3/2021-07-27-09-07.png

I guess what I'm trying to say is, CYP3A4 in the liver can often activate other drugs and herbs and make them a lot more potent and vice versa. And it can also make important medication and herbs less active.

So there might be something in your protocol that's being amplified and/or the antibiotics themselves. Or rendered inactive.

In regards to Long-QT. I take and have taken some medication (not for lyme) that has this warning, but I read that the medication induced version of Long-QT is usually reversible when the medication is stopped.

That doesn't take away of course of the danger while on the medication, so I guess I don't have a real solution for that right now.

But I hope you will look into CYP3A4.

Rifampin caused me some suffering through a CYP3A4 interaction.

Is milk thistle related to cyp3a4? I might have the wrong number.... but it looked familiar. Ah yes the internet says it inhibits it.

https://www.sciencedirect.com/topics/biochemistry-genetics-and-molecular-biology/silybum-marianum

Post Edited (Bailey) : 7/27/2021 10:12:41 AM (GMT-6)

Posted 7/27/2021 12:22 PM (GMT -5)
thanks Rainy

i had to look up the definition of substrate - but t make sense - its both the substance metabolised by CYP3A4 and an inhibitor of that same pathway - since the same pathway that is needed to detoxify the substance is inhibited by the same substance - often more pronounced concentrations result.

this could be a good and bad thing - good for antimicrobial activity - not so good for liver function

it will also tend to raise the blood concentrations of other substances like herbs and other drugs metabolized by this pathway ( most of them ) its the same mechanism that Chinese skullcap acts as a potentiator - but I'm not sure if in itself this is the mechanism that drives the long QT interval

as other articles - like the NICE one above say that's to do with electrolyte imbalances - which are normally not driven by the effects in the liver - but instead changes in absorption or excretion through the kidneys etc

thanks for your input - will do some more digging - maybe there is a way to offset some of the risk factors eg manage electrolytes ..
Posted 7/27/2021 3:35 PM (GMT -5)
this paper sheds some more light on the issue - specifically related to drug induced long QT

looks like its not fully understood in terms of risk factors - but most serious outcomes are associated with pre-existing risk factors that the abx on top kind of exacerbate

https://academic.oup.com/cid/article/43/12/1603/278706

it also seems like the electrolyte most involved is low potassium - so perhaps that's one precaution - try to maintain healthy levels of that while on a macrolide

Post Edited (Garzie) : 8/8/2021 10:30:41 AM (GMT-6)

Posted 7/27/2021 4:05 PM (GMT -5)
I've got heart palpitations and some premature heart beats. Macrolides seem to be exacerbating those issues. Those became more frequent/apparent after a course of Azithromycin (even though I've discontinued taking it).

Keep in mind Clarithromycin causes different type of (re)polarization issues than Azithromycin. As per: https://pubmed.ncbi.nlm.nih.gov/12235254/

"Erythromycin and clarithromycin led to early afterdepolarizations (EADs) and torsade de pointes (TdP) after lowering of potassium concentration. In the presence of azithromycin, no EAD or TdP occurred. Erythromycin and clarithromycin changed the MAP configuration to a triangular pattern, whereas azithromycin caused a rectangular pattern of MAP prolongation. In 13 additional hearts, 150 microM azithromycin was administered after previous treatment with 300 microM erythromycin and suppressed TdP provoked by erythromycin. In conclusion, macrolide antibiotics lead to similar prolongation of repolarization but show a different proarrhythmic potential (erythromycin > clarithromycin > azithromycin). In the presence of azithromycin, neither EAD nor TdP occur. This effect may be related to a rectangular pattern of action potential prolongation, whereas erythromycin and clarithromycin cause triangular action potential prolongation and induce TdP. "

Azithromycin seems safer than Clarithromycin due to rectangular (vs triangular) pattern of MAP prolongation. Taking magnesium and potassium supplements seem to lower the risk of Torsade de Pointes (type of abnormal heart rhythm that can lead to sudden cardiac death. It is a polymorphic ventricular tachycardia that exhibits distinct characteristics on the electrocardiogram (ECG). It was described by French physician François Dessertenne in 1966. Prolongation of the QT interval can increase a person's risk of developing this abnormal heart rhythm, occurring in between 1% and 10% of patients who receive QT-prolonging antiarrhythmic drugs. ).

Most people seem to be fine but having experienced effects of Azithromycin, I will personally not take the risk of taking Clarithromycin - unless I'm on constant ECG on hospital bed. Out of millions of those that took Macrolides, I wouldn't want to be in that unlucky 1%. Lyme already put me in that group ;-)

Post Edited (wladek83) : 7/27/2021 3:12:34 PM (GMT-6)

Posted 7/28/2021 9:57 AM (GMT -5)
thanks for that post wladek83 - some interesting information there - i will read that paper in full
Posted 7/28/2021 4:58 PM (GMT -5)
Hello wladek83 - I noticed this was your first post and wanted to welcome you to the forum.

You can introduce yourself by starting a new thread - if you want to.
Posted 7/30/2021 3:15 PM (GMT -5)
just following up on this topic after doing some more reading.

it seems the electrolyte that is most associated with these drug induced arrhythmia type effects is potassium. low potassium can cause or exacerbate hear arrhythmias

something occurred to me wile thinking around this

the expanded protocol in buhners healing lyme second edition book includes additional herbs to help balance the immune system

one of these is Licorice - only in small amounts - as it is intended to be taken long term. around 0.5ml of tincture 3x a day

Licorice is an unusual herb in that its one of the few with significant toxicity - but only if taken long term.

the active ingredient and its effects on the body build up slowly over time - so it can creep up on you
and one of the main long term adverse effects of Licorice is its disturbance of the potassium balance in the body - resulting in low potassium levels.

so - since this hear arrhythmia thing has done exactly that - crept up on me while nothing much else has been changing in my overall protocol - at least nothing that seems to match - i am now thinking that it could be the Licorice effects are driving this.

i will try adding some potassium salt to my diet in the short term and will stop the Licorice in the buhner herbs as soon as my current already mixed batch is used up - 3-4days left only. but i do expect it to take a long time to stabilise, if this is the cause, as that is quite well known to take a while to normalise after stopping dosing the Licorice.
Posted 8/8/2021 1:02 PM (GMT -5)
further reading on this topic gives some balance to the otherwise somewhat alarming sounding risks to clarithromycin.

so a few things:
1, the long QT interval in itself is not a problem - its noted because its thought to be associated with and therefore a surrogate marker and warning sign of something called TdP - which is a kind a spiky random arrhythmia which is much more dangerous and associated with sudden death

2, the thing is long QT is not a great marker for TdP - just about everyone who takes erythromycin or clarithromycin will get some increased QT interval to some extent - but v v few will get any serious TdP and even less will die from it.

3, the risk factors for increased TdP and increased risk of death are:
-female sex
-increased age
-inappropriately high dose
-low potassium levels
-pre-existing heart disease
-drug-drug interactions
-hereditary long QT interval

and in those people who have died from TdP - 2 or more of these were present in the vast majority

4, and around 80-90% of cases of macrolide induced TDP are associated with intravenously administered macrolides. And this is critical because blood concentrations with IV macrolides are typically 10x those of oral macrolides and this is key because drug dose is a key risk factor.

so in conclusion -
overall the risks of oral clarithromycin casing TdP and sudden death are perhaps somewhat overstated - and although the risk is real - with oral administration and without 2 or more of the above risk factors above present - its very unlikely that a person would have a lethal event.

that is not to say it can't happen - just about getting the risks in perspective

it does still make sense to monitor if taking these drugs - especially erythromycin and clarithromycin - and i am looking into ways of doing that - perhaps measuring long Qt interval before and during treatment - and having the ability to check for long Qt/TdP during treatment or if any increased arrhythmias occur
✚ New Topic ✚ Reply