[Question #3273] Azithromycin and Myasthenia Gravis

36 months ago
I recently had an STI health screen done at a local clinic. I tested positively for gonorrhea and was prescribed 2g Azithromycin. I will be collecting my medication tomorrow morning. 

However I have just read online that Azithromycin is not recommended for people with Myasthenia Gravis, which I have been diagnosed with. I neglected to mention the Myasthenia to the healthcare provider that wrote the prescription. However I am also unable to take the Ceftriaxone injection. Please could you provide your opinion and recommendation on this. 

I am confused as I can't take the injection yet Azithromycin is discouraged.

- Would it be safe for me to take the Azithromycin or is it a big no - no?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
36 months ago
Welcome to the forum. Thanks for your question.

I have to wonder why you cannot have the ceftriaxone injection. To my knowledge, there is nothing about myasthenia gravis that prevents intramuscular injections, especially with the very small volume and small needles needed for 250 mg ceftriaxone. (As you probably know, some MG treatments are given by injection.) Also, azithromycin is falling out of favor as a gonorrhea treatment; the frequency of resistant strains is rising and although 2g azithro usually still works well, it's a bit chancy.

As for the safety of single dose azithromycin in MG, I know nothing at all. Similar antibiotics, especially erythromycin, have been associated with MG crisis, and on a quick search of the medical literature, I found a single case report of crisis triggered by azithromycin; it's in an obscure journal and I don't know what dose was given. With only a single such report, my guess is that such reactions are rare, but I simply don't know enough about this to advise you about the safety of a 2g single dose. If in fact there is good reason to avoid both ceftriaxone and azithromycin, I would recommend treatment with cefixime 400 mg by mouth plus either azithromycin 1g or doxycycline for 7 days. Although cefixime is no longer recommended as first line treatment, it remains highly effective, with only a slightly higher chance of treatment failure at some anatomic sites, especially the throat.

So my advice is to have another dialog with the STI provider you saw, and ideallly your MG provider as well, with an eye to standard gonorrhea treatment with ceftriaxone, or perhaps cefixime. Either of these should be accompanied by a second antibiotic, either azithromycin (but only 1g) or 7 days of doxycycline.

Finally, if you are treated with anything other than ceftriaxone plus either azithro or doxy, you should have follow-up gonorrhea testing in 2-3 weeks; and avoid all sexual contact in the meantime.

I hope this information is helpful. Let me know if anything isn't clear. I'll be interested to hear how your doctors decide to go forward; please return with a comment to let me know after it's all sorted out.