Clarithromycin - the antibiotic of choice for osteonecrosis of the jaw in MM

Medication-related osteonecrosis of the jaw (MRONJ) is a common complaint in patients with multiple myeloma (MM). It is usually the consequence of long-term treatment with bone-modifying agents, such as bisphosphonates and denosumab, and treatment requires an extended course of antibiotics. Few guidelines specify which antibiotic should be used with only vague guidance recommending the use of ‘broad spectrum antibiotics’. However, the consensus seems to have arrived at the use of antibiotics from the penicillin group, with alternatives depending on the results of microbial culture.

In a short communication published in Oral Oncology in July 2018, Yehuda Zadik, from the Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel, recommends the use of the oral antibiotic clarithromycin for the treatment of MRONJ in patients with MM. Clarithromycin is more stable and better tolerated than other options, such as erythromycin, and can be administered in shorter dosing schedules due to a longer half-life. For the treatment of patients with MM, clarithromycin has the added advantage of immunomodulatory capacity, as it down-regulates several proinflammatory cytokines including IL-1, IL-6 and TNF-α, which will provide added benefits.

Dr Zadik, therefore, recommends administering clarithromycin in twice daily doses of 250–500 mg in repeated 28-day cycles. Several papers attest to its use in combination with backbone regimens of lenalidomide and dexamethasone, or thalidomide and dexamethasone, with a median of 6–26 cycles per patient. The following can be considered as alternatives: quinolones, metronidazole, clindamycin, doxycycline.