Doxycycline: The Secret Weapon of the physician
In an era of impending antibiotic resistance, anti-microbial agents continue to remain valuable, most utilized, and often most abused pharmacological agents. Scientific research and global development institutions have always kept up with the unmet needs against infections. Their powers may eventually wane in the face of dreadfully emerging antibiotic resistance.
However, clinicians contribute to making antimicrobial agents potent and viable for a longer span through a transparent review of durable antibiotics and thereby facilitating their prudent use. Doxycycline potentially remains one such antimicrobial agent in a practitioner's armamentarium.
Doxycycline – belonging to a tetracycline class of antibiotics, first became available in 1967 and has been used clinically now for more than 40 years. Even today, it remains a valuable anti-microbial agent for the management of various infections routinely encountered in daily medical practice.
Unique Pharmacological and Clinical Advantages with Use of Doxycycline
Doxycycline has activity against a very broad range of Gram-positive, Gram-negative, and 'atypical' bacteria as well as some protozoa such as malaria. It is also a useful antibiotic for prophylaxis against and treatment of several important potential biological warfare agents.(1)
The advantages of doxycycline over other members of the tetracycline family include improved oral absorption and a prolonged serum half-life. Excellent absorption and tissue distribution make it particularly useful for severely ill patients compared with other antibiotics.
An additional advantage includes a beneficial effect on the human immune system (2) and anti-inflammatory effects which also gathered the attention of the medical community for its consideration in the management of life-threatening COVID-19 infections
Doxycycline is cost-effective, widely available, and can be conveniently administered via oral or parenteral routes. This gives a practical advantage for its consideration and utilization across various practice settings in India
Doxycycline Listed in World Health Organisation (WHO) Access Group Antibiotics List
Doxycycline is listed on the "ACCESS" category with ATC Code (J01AA02). Its inclusion in this prestigious group implies that it belongs to the group of antibiotics that have activity against a "wide range of commonly encountered susceptible pathogens while also showing lower resistance potential" than antibiotics in the other groups.(3)
These valuable characteristics often form the key criteria for selecting and could eventually help to determine the clinical success of an antibiotic. Doxycycline remains one of the oldest antibiotics to make it to this distinguished basket.
2019 WHO AWaRe (Access, Watch, Reserve) Classification Database was developed based on the recommendations of the WHO Expert Committee on Selection and Use of Essential Medicines.
The objective of this categorization was to improve the use of antibiotics through antibiotic stewardship as one of the key interventions necessary to curb the further emergence and spread of antimicrobial resistance (AMR). Such categorization is also valuable for ensuring appropriate treatment. AWaRe is a useful tool to reduce antimicrobial resistance and ensure access.
The AWaRe database included details of 180 antibiotics classified as Access, Watch, or Reserve. The "ACCESS" group included antibiotics that have activity against a broad spectrum of commonly encountered susceptible microbes while also showing lower resistance potential than antibiotics in the other groups. This group includes 48 antimicrobial agents.
The "WATCH" group included antibiotics that have higher resistance potential and comprise most of the highest priority agents among the critically important antimicrobial agents that are at relatively high risk of selection of bacterial resistance. This category includes 110 antibiotics.
Lastly, the "RESERVE" group consists of antibiotics that should be reserved for treatment of confirmed or suspected infections due to multi-drug-resistant organisms. The agents included in this group need to be used as "last resort" therapeutic options, which should be accessible, but their use should be tailored to very specific patient profiles and clinical scenarios when all other alternatives have failed or are found not suitable. Twenty-two antibiotics have been included in this class.
Doxycycline Listed in WHO Essential Medicines List
Along with seeking a place in the ACCESS category of antibiotics, Doxycycline has even made it to a further smaller group of WHOs Essential Medicines List (EML) for both adults and children (4)
Evidence suggests that in order to promote the responsible use of antibiotics, the "ACCESS" group of antibiotics should make up at least 60% of national consumption. This will not only result in better use of antibiotics but also reduced costs and increased treatment access. Reaching this threshold by 2023 will contribute to countries' achieving health-related targets of the sustainable development goals and this remains the long- term vision of WHO behind the development of the AWaRE database (5) This brings out the need for clinicians to be sensitized to consider antibiotics of the "ACCESS" category, like doxycycline in the larger public health interest.
Doxycycline – Powerful Antimicrobial Agent Choice in Daily Medical Practice
Doxycycline is widely used for sexually transmitted infections, respiratory tract infections, pelvic inflammatory disease, dengue, arthropod-borne rickettsial infections, acne, and even malaria prophylaxis. Given its broad spectrum of activity and the wide array of clinical uses, including against some more obscure and difficult-to-diagnose conditions, doxycycline is sometimes referred to as the "secret weapon" of the physician.
Doxycycline at a dose of 100–200 mg dose per day is typically used in clinical practice for the treatment of various infectious diseases for decades now, and its safety profile is fairly well known.
The unique pharmacological characteristics combined with a very broad spectrum and effective microbiological profile have helped doxycycline stand the test of time and seek a place in the WHO "ACCESS" category group of antibiotics as well its essential medicines list (EML).
It will remain the responsibility of clinicians to continue to make optimal use of "access" category antibiotics like doxycycline in the interest of individual patients as well in the larger interest of public health, thus participating in the vision laid down by WHO against the impending threat of anti-microbial resistance.
The above article has been published by Medical Dialogues under the MD Brand Connect Initiative. For more details on Doxycycline, click HERE
References
Adapted from
1. Natasha E. Holmes, Safety and Efficacy Review of Doxycycline, Clinical Medicine: Therapeutics 2009:1 471–482
2. Majewski M, A current opinion on the safety and efficacy of doxycycline including parenteral administration – A review. Pol Ann Med. (2014), http://dx.doi.org/10.1016/j.poamed.2013.12.001
3. WHO releases the 2019 AWaRe Classification Antibiotics https://www.who.int/medicines/news/2019/WHO_releases2019AWaRe_classification_antibiotics/en/
4. World Health Organization Model List of Essential Medicines, 21st List, 2019. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO
5. Adopt AWARE Portal, WHO Release, URL: https://adoptaware.org/
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