Azithromycin interactions to avoid

Azithromycin, also known under the brand name Zithromax or Z-Pak, is an antibiotic prescribed to treat various bacterial infections. It belongs to the macrolide class of antibiotics that work by blocking the growth of bacteria. Azithromycin is often used to treat tonsillitis, community-acquired pneumonia, and exacerbations of chronic obstructive pulmonary disease (COPD). It’s not effective against viral infections. 

Although azithromycin is an effective antibiotic, it may be linked to several drug interactions. Other medications, including prescription medications, over-the-counter (OTC) drugs, and vitamins, may affect azithromycin’s effectiveness or increase the risk of harmful side effects. Read on to learn more about potential azithromycin drug interactions and how to reduce the risk of serious problems. 

Key takeaways

• Azithromycin is an antibiotic that belongs to the drug class known as macrolides. This drug class also includes antibiotics like Biaxin (clarithromycin) and Erythrocin (erythromycin). 
• In general, azithromycin may have a lower risk of drug interactions than other macrolides because it’s less involved with the liver enzymes responsible for many interactions. However, azithromycin can still interact with various medications, such as antacids, statins, and heart rhythm medications. 
• Depending on the other medication being taken, interactions may lead to increased side effects of azithromycin, increased bleeding risks, liver problems, and an irregular heartbeat. 
• Before starting treatment with azithromycin, it’s recommended to consult a doctor or healthcare provider about other medications you take. A qualified professional can help determine the best course of action to prevent or manage azithromycin drug interactions. 

Azithromycin drug interactions

Azithromycin interacts with several types of drugs. The type and severity of the interaction will depend on the medication and dosage being taken. Let’s explore some of the most common azithromycin interactions.   

Blood thinners

Azithromycin may interact with blood thinners, also known as anticoagulants, increasing the risk of bleeding. If you’re taking a blood thinner with azithromycin, your healthcare provider might need to closely monitor the blood thinning effect and adjust the blood thinner dosage. Examples of common blood thinners include:

• Coumadin (warfarin)
• Xarelto (rivaroxaban)
• Eliquis (apixaban)
• Pradaxa (dabigatran)
• Arixtra (fondaparinux)

Certain antacids

Taking certain antacids containing aluminum or magnesium within 2 hours before or after taking azithromycin can reduce its absorption and effectiveness. Examples of these antacids may include:

• Maalox (aluminum hydroxide, magnesium hydroxide)
• Mylanta (aluminum hydroxide, magnesium hydroxide)
• Rolaids (calcium carbonate, magnesium hydroxide)

To avoid this interaction, it’s recommended to space out the administration of azithromycin and antacids by at least 2 hours.

Statins

Taking azithromycin with statin medications—drugs used to treat high cholesterol—may increase the risk of a serious muscle condition called rhabdomyolysis. Symptoms of rhabdomyolysis may include muscle pain and dark urine. Examples of statins that may interact with azithromycin include:

• Lipitor (atorvastatin)
• Zocor (simvastatin)
• Crestor (rosuvastatin)

Your healthcare provider may suggest temporarily stopping the use of statins or adjusting their dosage while taking azithromycin, especially for those at a higher risk of muscle and liver problems.

Antiarrhythmics

Azithromycin can interact with antiarrhythmic drugs, such as amiodarone and sotalol, which are used to treat irregular heartbeats. This interaction can increase the risk of QT prolongation and potentially life-threatening heart rhythm problems. If you’re taking an antiarrhythmic medication, your healthcare provider may consider prescribing an alternative antibiotic.

• Cordarone (amiodarone)
• Betapace (sotalol)
• Tambocor (flecainide)
• Rythmol (propafenone)

Ergomar (ergotamine) or Migranal (dihydroergotamine)

It’s recommended to avoid taking macrolide antibiotics with ergotamine or dihydroergotamine, which are medications used to treat migraines. The combination of macrolides like azithromycin with these drugs may increase the levels of ergotamine or dihydroergotamine in the blood. As a result, there may be an increased risk of ergotism, which can include symptoms like vomiting, dizziness, drowsiness, and seizures. If azithromycin is prescribed, a healthcare provider may suggest alternative medications for migraines.

Colcrys (colchicine)

Azithromycin may interact with colchicine, a medication used to treat gout and prevent gout attacks. This interaction can increase the risk of colchicine toxicity, potentially causing severe side effects like muscle weakness, nausea, and vomiting. Your healthcare provider may need to adjust the colchicine dosage or prescribe an alternative antibiotic, especially if you have liver or kidney disease.

Digitek (digoxin)

Azithromycin can increase the blood levels of digoxin, a medication used to treat heart failure and irregular heartbeats (arrhythmias). This interaction may enhance the risk of digoxin toxicity, leading to side effects like nausea, dizziness, and an irregular heartbeat. Your healthcare provider might need to monitor digoxin levels closely and adjust the digoxin dosage if needed.

Viracept (nelfinavir)

Azithromycin may interact with the antiretroviral drug nelfinavir, which is used to treat HIV infections. This interaction can lead to increased levels of azithromycin in the blood, leading to increased side effects of azithromycin. For example, this interaction may increase a person’s risk of developing QT prolongation, a heart rhythm disorder that can become life-threatening. If you’re taking nelfinavir, your healthcare provider may choose another antibiotic with fewer interactions.

Sandimmune (cyclosporine)

Although the risk of this interaction is considered low, cyclosporine, an immunosuppressant drug, may interact with azithromycin and potentially lead to increased levels of cyclosporine in the blood. This interaction may increase the risk of adverse effects, such as high blood pressure and kidney problems. 

Orap (pimozide)

Azithromycin is not recommended for individuals taking pimozide, a medication used to treat schizophrenia and other psychiatric disorders. The combination can increase the risk of QT prolongation and possibly lead to severe heart rhythm disturbances. You may need to consult your healthcare provider for an alternative antibiotic option if you’re also taking pimozide.

Azithromycin food interactions

With the exception of Zmax or extended-release azithromycin, which should be taken on an empty stomach, azithromycin can be taken with or without food. However, it may be best to take all forms of azithromycin one hour before or two hours after a meal for optimal absorption. If you experience an upset stomach while taking azithromycin, you should take it with food.

Azithromycin and caffeine

There is limited information on the interaction between azithromycin and caffeine. In most cases, you can safely consume moderate amounts of caffeine, like a cup of coffee or tea, while taking azithromycin. Some studies show that caffeine may increase the antibacterial effects of antibiotics like azithromycin. 

Azithromycin and alcohol

Alcohol consumption should be limited or avoided while taking azithromycin. Mixing alcohol and azithromycin may increase the risk of side effects and reduce the effectiveness of the medication. In addition, alcohol weakens the immune system, which may decrease the body’s ability to fight bacterial infections.

Other azithromycin interactions

Azithromycin may also interact with dietary supplements and vitamins in addition to prescription or OTC medications. Dietary substances that azithromycin can interact with may include:

• Magnesium: Magnesium is an essential mineral that plays a vital role in many body functions. However, you may want to be cautious with magnesium supplements, as they could reduce the absorption of azithromycin. To avoid this potential interaction, it’s recommended to separate the intake of azithromycin and magnesium supplements by at least 1 to 2 hours.
• Vitamin H (biotin): Biotin can be found in various foods and supplements, and it can help maintain healthy skin, hair, and nails. The natural bacteria found in the intestines also contribute to the production of biotin. Azithromycin can alter the intestinal flora, which may decrease the levels or effects of biotin.  
• Vitamin K: It’s known that azithromycin may increase the blood thinning effects of warfarin and other anticoagulants. Antibiotics like azithromycin may decrease the blood levels of vitamin K, a fat-soluble vitamin involved in blood clotting. 

It’s always a good idea to discuss the use of azithromycin and any potential interactions with your healthcare provider, including any nutritional supplements, vitamins, or herbal products.

Other considerations

People with certain medical problems may be at a higher risk of adverse effects with azithromycin. Those with the following medications may need to use azithromycin with caution: 

• Allergic reactions: If you’re allergic to other macrolide antibiotics, such as erythromycin, you might also have an allergic reaction to azithromycin. Symptoms may include skin rash, itching, swelling, trouble breathing, or severe dizziness.
• QT prolongation: Azithromycin may cause the prolongation of the QT interval, leading to a heart rhythm disturbance called torsade de pointes. This is a rare but potentially serious type of arrhythmia that can cause irregular heartbeat, dizziness, or fainting. Risk factors include existing heart problems, electrolyte imbalances, and the use of other medications that prolong the QT interval.
• Muscle weakness: Azithromycin might worsen muscle weakness if you have myasthenia gravis, a chronic autoimmune disorder affecting muscle strength. If you have myasthenia gravis, discuss the risks and benefits of azithromycin treatment with your healthcare provider.
• Liver disease: Individuals with liver disease may be more susceptible to the side effects of azithromycin, as the drug is metabolized in the liver. Abnormal liver function, hepatitis, cholestatic jaundice, and hepatic failure have been reported, some of which have resulted in death. Therefore, if you have existing liver conditions, use azithromycin with caution and under close supervision from your healthcare provider.

In addition to the conditions listed above, tell your healthcare provider if you have other medical conditions like pneumonia, cystic fibrosis, or kidney problems. You should also discuss whether you are pregnant or breastfeeding, as it’s not entirely known how this medication affects an unborn or breastfeeding child. 

How to minimize azithromycin interactions

Although azithromycin is associated with various interactions, there are ways to prevent potential interactions. Here are some practical steps to minimize the risk of drug interactions with azithromycin:

Consult a healthcare provider

Before starting azithromycin treatment, it’s important to consult a healthcare provider. They can assess the potential risks and benefits of the medicine, especially if you’re taking other medications.

Keep a list of medications

Maintain a detailed list of all the medications you take, including:

• Prescription medications
• Over-the-counter drugs
• Herbal supplements
• Vitamins and minerals

By providing this list to your healthcare provider, they can adjust dosages, discontinue medications, or recommend alternatives if they determine there’s a risk for drug interactions with azithromycin.

Understand warning signs 

Be aware of the potential warning signs of drug interactions. Some common warning signs may include:

• Unexpected side effects
• Changes in the effectiveness of a drug
• New symptoms or worsening of existing symptoms

By recognizing these signs, you can promptly inform your healthcare provider of any concerns. That way, they can make the appropriate adjustments to your medication regimen.

Follow dosage instructions

Azithromycin can be prescribed as a single-dose or multi-day regimen as a film-coated tablet or oral suspension. Make sure to follow the prescribed dosage instructions to help minimize potential interactions.

When to talk to a healthcare provider about azithromycin interactions

You should discuss potential azithromycin interactions with your healthcare provider at the time they prescribe the medication. In addition, you can consult your local pharmacist if you have concerns about possible drug interactions.

There are several situations when you should consult healthcare professionals about azithromycin interactions. For example, talk to your healthcare provider if you:

• Take any prescription or over-the-counter medications
• Use any dietary supplements or herbal products
• Have any medical conditions or a history of certain illnesses, such as liver problems or kidney disease
• Experience any unexpected side effects or changes in health, such as dark urine, stomach pain, or trouble breathing

Keep in mind that this article does not provide a complete list of azithromycin interactions. It’s recommended to tell your healthcare provider about your overall medical history before starting treatment with azithromycin.