Disposition of oral azithromycin in humans

Background: The oral bioavailability of azithromycin is approximately 37% in healthy subjects; little is known about the disposition of the remaining 63% of the dose. This study attempted to describe the fate of azithromycin before absorption. Methods: Twelve subjects with ileostomies in place for >1 month were studied in this open-label, randomized, three-center, two-period, two-treatment crossover study. Subjects randomly received a single 500 mg intravenous infusion (over 1 hour) or two 250 mg oral capsules after a fast for >12 hours. Blood and ileostomy samples were collected serially after each administration and analyzed for azithromycin and two metabolites (descladinose and 9a-N-desmethyl metabolites) by HPLC with electrochemical detection. Results: Mean +/- SD peak concentration values after oral and intravenous administration were 0.21 +/- 0.08 and 3.40 +/- 1.12 mu g/ml. Mean values for area under the serum concentration versus time curve were 1.27 +/- 0.65 and 7.14 +/- 1.34 mu g . hr/ml, respectively, The absolute bioavailability of 16.2% was approximately one-half the value observed previously in healthy subjects. Recovery in ileostomy fluid (percent of dose in 24 hours) of azithromycin, descladinose, and 9a-N-desmethyl metabolites were 13%, 0.5%, and 1% (total, 15%) after intravenous dosing and 47%, 13%, and 2% (total, 62%) after oral dosing. Total and heal clearances were 776 +/- 126 and 158 +/- 63 ml/min after intravenous dosing. Conclusion: Because more descladinose metabolite was detected after oral dosing, acid degradation of azithromycin before absorption contributed to some loss in oral bioavailability, Further, ileal clearance (biliary plus intestinal excretion clearance) in this population represented 21% of total clearance. Taken together, these data suggest that the cause of low oral bioavailability of azithromycin is the result of incomplete absorption rather than acid degradation or extensive first-pass metabolism.