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Medication Safety Issues
Sound-alike/look-alike issues:
Clarithromycin may be confused with erythromycin
Pronunciation
(kla RITH roe mye sin)
U.S. Brand Names
Generic Available
Yes
Canadian Brand Names
Pharmacologic Category
Pharmacologic Category Synonyms
Use
Children:
Acute otitis media (H. influenzae, M. catarrhalis, or S. pneumoniae)
Community-acquired pneumonia due to susceptible Mycoplasma pneumoniae, S. pneumoniae, or Chlamydia pneumoniae (TWAR)
Pharyngitis/tonsillitis, acute maxillary sinusitis, uncomplicated skin/skin structure infections, and mycobacterial infections
Prevention of disseminated mycobacterial infections due to MAC disease in patients with advanced HIV infection
Adults:
Pharyngitis/tonsillitis due to susceptible S. pyogenes
Acute maxillary sinusitis and acute exacerbation of chronic bronchitis due to susceptible H. influenzae, M. catarrhalis, or S. pneumoniae
Community-acquired pneumonia due to susceptible H. influenzae, H. parainfluenzae, Mycoplasma pneumoniae, S. pneumoniae, or Chlamydia pneumoniae (TWAR)
Uncomplicated skin/skin structure infections due to susceptible S. aureus, S. pyogenes
Disseminated mycobacterial infections due to M. avium or M. intracellulare
Prevention of disseminated mycobacterial infections due to M. avium complex (MAC) disease (eg, patients with advanced HIV infection)
Duodenal ulcer disease due to H. pylori in regimens with other drugs including amoxicillin and lansoprazole or omeprazole, ranitidine bismuth citrate, bismuth subsalicylate, tetracycline, and/or an H2 antagonist
Use: Dental
Alternate oral antibiotic for prevention of infective endocarditis in individuals allergic to penicillins or ampicillin, when amoxicillin cannot be used; alternate antibiotic in the treatment of common orofacial infections caused by aerobic gram-positive cocci and susceptible anaerobes
Use: Unlabeled/Investigational
Pertussis (CDC guidelines); alternate antibiotic for prophylaxis of infective endocarditis in patients who are allergic to penicillin and undergoing surgical or dental procedures (ACC/AHA guidelines)
Pregnancy Risk Factor
C
Pregnancy Implications
Clarithromycin crosses the placenta. Although no teratogenic effects have been reported in humans, adverse fetal effects have been documented in animal studies; therefore, clarithromycin is classified as pregnancy category C. The manufacturer recommends that clarithromycin not be used in a pregnant woman unless there are no alternative therapies. No adequate and well-controlled studies have been completed in pregnant women.
Lactation
Excretion in breast milk unknown/use caution
Breast-Feeding Considerations
It is not known if clarithromycin is excreted in human breast milk, but other macrolides are excreted in human milk and clarithromycin is known to be excreted into animal milk. The manufacturer recommends that caution be exercised when administering clarithromycin to breast-feeding women.
No data is available on infants exposed via human milk. Other macrolides are considered compatible with breast-feeding and clarithromycin is used therapeutically in infants. Nondose-related effects could include modification of bowel flora.
Contraindications
Hypersensitivity to clarithromycin, erythromycin, or any macrolide antibiotic; use with ergot derivatives, pimozide, cisapride
Warnings/Precautions
Concerns related to adverse effects:
• Altered cardiac conduction: Macrolides have been associated with rare QTc prolongation and ventricular arrhythmias, including torsade de pointes; use with caution in patients at risk of prolonged cardiac repolarization.
• Superinfection: Prolonged use may result in fungal or bacterial superinfection, including C. difficile-associated diarrhea (CDAD) and pseudomembranous colitis; CDAD has been observed >2 months postantibiotic treatment.
Disease-related concerns:
• Coronary artery disease (CAD): Use with caution in patients with CAD; postmarketing safety trial suggests increased risk of cardiovascular mortality with short-term clarithromycin use (vs placebo) in patients with stable CAD. However, more smokers were randomized to the clarithromycin arm.
• Renal impairment: Dosage adjustment required with severe renal impairment; decreased dosage or prolonged dosing interval may be appropriate.
Special populations:
• Pediatrics: Safety and efficacy have not been established in children <6 months of age.
Dosage form specific issues:
• Extended release formulation: The extended release formulation consists of drug within a nondeformable matrix; following drug release/absorption, the matrix/shell is expelled in the stool. The use of nondeformable products in patients with known stricture/narrowing of the GI tract has been associated with symptoms of obstruction.
Adverse Reactions
1% to 10%:
Central nervous system: Headache (adults and children 2%)
Dermatologic: Rash (children 3%)
Gastrointestinal: Abnormal taste (adults 3% to 7%), diarrhea (adults 3% to 6%; children 6%), vomiting (children 6%), nausea (adults 3%), abdominal pain (adults 2%; children 3%), dyspepsia 2%
Hepatic: Prothrombin time increased (1%)
Renal: BUN increased (4%)
<1%, postmarketing, and/or case reports (limited to important or life-threatening); Clostridium difficile colitis, alkaline phosphatase increased, anaphylaxis, anorexia, anxiety, behavioral changes, bilirubin increased, confusion, disorientation, GGT increased, glossitis, hallucinations, hearing loss (reversible), hepatic dysfunction, hepatic failure, hepatitis, hypoglycemia, insomnia, interstitial nephritis, jaundice, leukopenia, manic behavior, neutropenia, oral moniliasis, pancreatitis, psychosis, QT prolongation, seizure, serum creatinine increased, Stevens-Johnson syndrome, stomatitis, tinnitus, tongue discoloration, tooth discoloration, torsade de pointes, toxic epidermal necrolysis, transaminases increased, tremor, urticaria, ventricular tachycardia, ventricular arrhythmia, vertigo
Drug Interactions
Substrate of CYP3A4 (major); Inhibits CYP1A2 (weak), 3A4 (strong)
Alfentanil (and possibly other opioid analgesics): Serum levels may be increased by clarithromycin; monitor for increased effect.
Azole antifungal agents: Serum levels/effects may be increased by clarithromycin; monitor.
Benzodiazepines (those metabolized by CYP3A4, including alprazolam, midazolam, triazolam): Serum levels may be increased by clarithromycin; somnolence and confusion have been reported.
Bromocriptine: Serum levels/toxicity (eg, ergotism) may be increased by clarithromycin; monitor for increased effect.
Buspirone: Serum levels may be increased by clarithromycin; monitor.
Calcium channel blockers (felodipine, verapamil, and potentially others metabolized by CYP3A4): Serum levels may be increased by clarithromycin; monitor.
Carbamazepine: Serum levels may be increased by clarithromycin; monitor.
Cilostazol: Serum levels may be increased by clarithromycin; monitor.
Cisapride: Serum levels may be increased by clarithromycin; serious arrhythmias have occurred; concurrent use contraindicated.
Clopidogrel: Therapeutic effect may be decreased by clarithromycin; monitor.
Clozapine: Serum levels may be increased by clarithromycin; monitor.
Colchicine: Serum levels/toxicity may be increased by clarithromycin; monitor. Avoid use, if possible.
CYP3A4 inducers: CYP3A4 inducers may decrease the levels/effects of clarithromycin. Example inducers include aminoglutethimide, carbamazepine, nafcillin, nevirapine, phenobarbital, phenytoin, and rifamycins.
CYP3A4 inhibitors: May increase the levels/effects of clarithromycin. Example inhibitors include azole antifungals, diclofenac, doxycycline, erythromycin, imatinib, isoniazid, nefazodone, nicardipine, propofol, protease inhibitors, quinidine, telithromycin, and verapamil.
CYP3A4 substrates: Clarithromycin may increase the levels/effects of CYP3A4 substrates. Example substrates include benzodiazepines, calcium channel blockers, mirtazapine, nateglinide, nefazodone, tacrolimus, and venlafaxine. Selected benzodiazepines (midazolam and triazolam), cisapride, ergot alkaloids, selected HMG-CoA reductase inhibitors (lovastatin and simvastatin), and pimozide are generally contraindicated with strong CYP3A4 inhibitors.
Delavirdine: Serum levels may be increased by clarithromycin; monitor.
Digoxin: Serum levels may be increased by clarithromycin; digoxin toxicity and potentially fatal arrhythmias have been reported; monitor digoxin levels.
Disopyramide: Serum levels may be increased by clarithromycin; in addition, QTc prolongation and risk of malignant arrhythmia may be increased; avoid combination.
Eletriptan: Serum levels/effects may be increased by clarithromycin; monitor.
Eplerenone: Serum levels/effects may be increased by clarithromycin; monitor.
Ergot alkaloids: Concurrent use may lead to acute ergot toxicity (severe peripheral vasospasm and dysesthesia); concurrent use contraindicated.
HMG-CoA reductase inhibitors (atorvastatin, lovastatin, and simvastatin); Clarithromycin may increase serum levels of “statins” metabolized by CYP3A4, increasing the risk of myopathy/rhabdomyolysis (does not include fluvastatin, pravastatin, or rosuvastatin). Switch to pravastatin, fluvastatin, or rosuvastatin or suspend treatment during course of clarithromycin therapy.
Immunosuppressants (eg, cyclosporine, sirolimus, tacrolimus): Serum levels/effects may be increased by clarithromycin; monitor serum concentrations and for increased immune suppression.
Methylprednisolone: Serum levels may be increased by clarithromycin; monitor.
Phenytoin: Serum levels may be increased by clarithromycin; other evidence suggested phenytoin levels may be decreased in some patients; monitor.
Phosphodiesterase 5 inhibitors (eg, sildenafil, tadalafil, vardenafil): Serum levels may be increased by clarithromycin. Do not exceed single sildenafil doses of 25 mg in 48 hours, a single tadalafil dose of 10 mg in 72 hours, or a single vardenafil dose of 5 mg in 24 hours.
Pimozide: Serum levels may be increased, leading to malignant arrhythmias; concomitant use is contraindicated.
Protease inhibitors (amprenavir, nelfinavir, and ritonavir): May increase serum levels of clarithromycin.
QTc-prolonging agents: Concomitant use may increase the risk of malignant arrhythmias.
Quinidine: Serum levels may be increased by clarithromycin; in addition, the risk of QTc prolongation and malignant arrhythmias may be increased during concurrent use.
Quinolone antibiotics (moxifloxacin): Concurrent use may increase the risk of malignant arrhythmias.
Rifamycin derivatives (eg, rifabutin): Serum levels may be increased by clarithromycin; monitor.
Selective serotonin reuptake inhibitors (SSRIs): Serum levels/effects may be increased by clarithromycin; monitor.
Theophylline: Serum levels may be increased by clarithromycin; monitor.
Thioridazine: Risk of QTc prolongation and malignant arrhythmias may be increased.
Valproic acid (and derivatives): Serum levels may be increased by clarithromycin; monitor.
Warfarin: Effects may be potentiated; monitor INR closely and adjust warfarin dose as needed or choose another antibiotic
Zopiclone: Serum levels may be increased by clarithromycin; monitor.
Ethanol/Nutrition/Herb Interactions
Food: Immediate release: Food delays rate, but not extent of absorption; Extended release: Food increases clarithromycin AUC by ~30% relative to fasting conditions.
Herb/Nutraceutical: St John's wort may decrease clarithromycin levels.
Storage
Store tablets and granules for oral suspension at controlled room temperature. Reconstituted oral suspension should not be refrigerated because it might gel. Microencapsulated particles of clarithromycin in suspension is stable for 14 days when stored at room temperature.
Mechanism of Action
Exerts its antibacterial action by binding to 50S ribosomal subunit resulting in inhibition of protein synthesis. The 14-OH metabolite of clarithromycin is twice as active as the parent compound against certain organisms.
Pharmacodynamics/Kinetics
Absorption: Immediate release: Rapid; food delays rate, but not extent of absorption
Distribution: Widely into most body tissues except CNS
Protein binding: 42% to 50%
Metabolism: Partially hepatic via CYP3A4; converted to 14-OH clarithromycin (active metabolite)
Bioavailability: 50%
Half-life elimination: Immediate release: Clarithromycin: 3-7 hours; 14-OH-clarithromycin: 5-9 hours
Time to peak: Immediate release: 2-3 hours
Excretion: Primarily urine (20% to 40% as unchanged drug; additional 10% to 15% as metabolite)
Clearance: Approximates normal GFR
Dosage
Usual dosage range:
Children ?6 months: Oral: 7.5 mg/kg every 12 hours (maximum: 500 mg/dose)
Adults: Oral: 250-500 mg every 12 hours or 1000 mg (two 500 mg extended release tablets) once daily for 7-14 days
Indication-specific dosing:
Children: Oral:
Community-acquired pneumonia, sinusitis, bronchitis, skin infections: 15 mg/kg/day divided every 12 hours for 10 days
Mycobacterial infection (prevention and treatment): 7.5 mg/kg (up to 500 mg) twice daily. Note: Safety of clarithromycin for MAC not studied in children <20 months.
Pertussis (unlabeled use; CDC guidelines):
Children 1-5 months: 15 mg/kg/day divided every 12 hours for 7 days
Children ?6 months: 15 mg/kg/day divided every 12 hours for 7 days (maximum: 1 g/day)
Prophylaxis against infective endocarditis (unlabeled use): 15 mg/kg 30-60 minutes before procedure. Note: American Heart Association (AHA) guidelines now recommend prophylaxis only in patients undergoing invasive procedures and in whom underlying cardiac conditions may predispose to a higher risk of adverse outcomes should infection occur. As of April 2007, routine prophylaxis for GI/GU procedures is no longer recommended by the AHA.
Adults: Oral:
Acute exacerbation of chronic bronchitis:
M. catarrhalis and S. pneumoniae: 250 mg every 12 hours for 7-14 days or 1000 mg (two 500 mg extended release tablets) once daily for 7 days
H. influenzae: 500 mg every 12 hours for 7-14 days or 1000 mg (two 500 mg extended release tablets) once daily for 7 days
H. parainfluenzae: 500 mg every 12 hours for 7 days or 1000 mg (two 500 mg extended release tablets) once daily for 7 days
Acute maxillary sinusitis: 500 mg every 12 hours or 1000 mg (two 500 mg extended release tablets) once daily for 14 days
Mycobacterial infection (prevention and treatment): 500 mg twice daily (use with other antimycobacterial drugs, eg, ethambutol or rifampin)
Peptic ulcer disease: Eradication of Helicobacter pylori: Dual or triple combination regimens with bismuth subsalicylate, amoxicillin, an H2-receptor antagonist, or proton-pump inhibitor: 500 mg every 8-12 hours for 10-14 days
Pertussis (unlabeled use; CDC guidelines): 500 mg twice daily for 7 days
Pharyngitis, tonsillitis: 250 mg every 12 hours for 10 days
Pneumonia:
C. pneumoniae, M. pneumoniae, and S. pneumoniae: 250 mg every 12 hours for 7-14 days or 1000 mg (two 500 mg extended release tablets) once daily for 7 days
H. influenzae: 250 mg every 12 hours for 7 days or 1000 mg (two 500 mg extended release tablets) once daily for 7 days
Prophylaxis against infective endocarditis (unlabeled use): 500 mg 30-60 minutes prior to procedure. Note: American Heart Association (AHA) guidelines now recommend prophylaxis only in patients undergoing invasive procedures and in whom underlying cardiac conditions may predispose to a higher risk of adverse outcomes should infection occur. As of April 2007, routine prophylaxis for GI/GU procedures is no longer recommended by the AHA.
Skin and skin structure infection, uncomplicated: 250 mg every 12 hours for 7-14 days
Elderly: Pharmacokinetics are similar to those in younger adults; may have age-related reductions in renal function; monitor and adjust dose if necessary
Dosing adjustment in renal impairment:
Clcr <30 mL/minute: Half the normal dose or double the dosing interval
In combination with ritonavir:
Clcr 30-60 mL/minute: Decrease clarithromycin dose by 50%
Clcr <30 mL/minute: Decrease clarithromycin dose by 75%
Dosing adjustment in hepatic impairment: No dosing adjustment is needed as long as renal function is normal
Dental Usual Dosing
Prophylaxis against infective endocarditis (unlabeled use): Oral:
Children: 15 mg/kg 30-60 minutes before procedure
Adults: 500 mg 30-60 minutes prior to procedure
Note: American Heart Association (AHA) guidelines now recommend prophylaxis only in patients undergoing invasive procedures and in whom underlying cardiac conditions may predispose to a higher risk of adverse outcomes should infection occur. As of April 2007, routine prophylaxis for GI/GU procedures is no longer recommended by the AHA.
Administration: Oral
Clarithromycin immediate release tablets and oral solution may be given with or without meals. Give every 12 hours rather than twice daily to avoid peak and trough variation.
Biaxin® XL: Should be given with food. Do not crush or chew extended release tablet.
Dietary Considerations
Clarithromycin immediate release tablets and oral solution may be given with or without meals. May be taken with milk. Biaxin® XL should be taken with food.
Patient Education
Do not take any new medication during therapy unless approved by prescriber. Take full course of therapy even if feeling better; do not discontinue this medication without consulting prescriber. Tablets or suspension may be taken with or without food or milk. Extended release tablets should be taken with food. Do not crush or chew extended release tablets. Do not refrigerate oral suspension (more palatable at room temperature). Maintain adequate hydration (2-3 L/day of fluids) unless instructed to restrict fluid intake. May cause nausea, heartburn, or abnormal taste (small frequent meals, frequent mouth care, chewing gum or sucking lozenges may help); diarrhea (buttermilk, boiled milk, or yogurt may help); or headache or abdominal cramps (consult prescriber for analgesic). Report rapid heartbeat or palpitations, persistent fever or chills, easy bruising or bleeding, joint pain, severe persistent diarrhea, skin rash, sores in mouth, foul-smelling urine, or respiratory difficulty. Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to become pregnant. Consult prescriber if breast-feeding.
Geriatric Considerations
Considered one of the drugs of choice in the outpatient treatment of community-acquired pneumonia in elderly. After doses of 500 mg every 12 hours for 5 days, 12 healthy elderly subjects had significantly increased Cmax and Cmin, elimination half-lives of clarithromycin and 14-OH clarithromycin compared to 12 healthy young subjects. These changes were attributed to a significant decrease in renal clearance; at a dose of 1000 mg twice daily, 100% of 13 elderly subjects experienced an adverse event compared to only 10% taking 500 mg twice daily.
Cardiovascular Considerations
Because of potential drug interactions, serious arrhythmias may occur when clarithromycin and other macrolides are used in combination with cisapride. Clarithromycin may also increase theophylline, some HMG-CoA reductase inhibitors, digoxin, warfarin, and cyclosporine levels (among others). Clarithromycin may be used in penicillin-allergic patients for prevention of bacterial endocarditis.
The FDA issued an alert for clarithromycin (Biaxin®, Abbott Laboratories) on December 8, 2005. These actions were based upon results of a Danish trial (CLARICOR) that was recently published online in the British Medical Journal (Jesperson, 2005). This was a multicenter, double-blind, randomized, placebo-controlled trial evaluating the effects of clarithromycin (500 mg daily for 14 days) on mortality in patients with stable coronary artery disease. Over 13,000 patients having a discharge diagnosis (from 1993-99) of myocardial infarction or angina pectoris were recruited for the trial. The primary outcome was a composite of all cause mortality, MI, or unstable angina during the three-year follow up. The secondary outcome measure consisted of cardiovascular mortality, MI, or unstable angina. Two thousand one hundred and seventy two patients were randomized to clarithromycin and 2200 to placebo. The groups were well matched except there were more smokers in the clarithromycin group. Compliance was over 90% in both groups. There was no difference between the two groups with regard to the composite outcomes (primary or secondary). All cause mortality was significantly higher in the clarithromycin group (HR 1.27; CI 1.03-1.54; p = 0.03) as a result of a higher cardiovascular mortality (HR 1.45; CI 1.09-1.92; p = 0.01). When a multivariant analysis was done, all cause mortality was insignificantly increased (HR 1.21; CI 0.99-1.48; p = 0.07), but cardiovascular mortality continued to be significantly increased in the clarithromycin group (HR 1.38; CI 1.03-1.85; p = 0.03). One hundred and eighty four patients died in the clarithromycin group (89 from cardiovascular events) and 159 patients died in the placebo group (70 from cardiovascular events). The authors conclude that short-term clarithromycin therapy in patients with stable coronary artery disease may cause significantly higher cardiovascular mortality. This result came as a surprise to the authors who were not evaluating the safety of clarithromycin in patients with CAD. Further study is needed to evaluate the clinical validity of this unexpected finding.
Dental Health: Effects on Dental Treatment
Key adverse event(s) related to dental treatment: Abnormal taste.
Dental Health: Vasoconstrictor/Local Anesthetic Precautions
Clarithromycin is one of the drugs confirmed to prolong the QT interval and is accepted as having a risk of causing torsade de pointes. In terms of epinephrine, it is not known what effect vasoconstrictors in the local anesthetic regimen will have in patients with a known history of congenital prolonged QT interval or in patients taking any medication that prolongs the QT interval. Until more information is obtained, it is suggested that the clinician consult with the physician prior to the use of a vasoconstrictor in suspected patients, and that the vasoconstrictor (epinephrine, levonordefrin [Neo-Cobefrin®]) be used with caution. See Dental Comment.
Dental Comment
The FDA issued a special alert in December 2005 stating that short-term therapy with clarithromycin in patients with stable coronary artery disease may cause significantly higher cardiovascular mortality. The use of 500 mg clarithromycin daily for 14 days in patients with the above condition resulted in significantly higher all-cause mortality compared to patients taking placebo. This information is provided to the dental practitioner on the possible association between short-term use of clarithromycin for infections and increases in mortality in patients with a history of stable coronary artery disease.
Clarithromycin is known to prolong the QT interval. The QT interval is measured as the time and distance between the Q point of the QRS complex and the end of the T wave in the ECG tracing. After adjustment for heart rate, the QT interval is defined as prolonged if it is more than 450 msec in men and 460 msec in women. A long QT syndrome was first described in the 1950s and 60s as a congenital syndrome involving QT interval prolongation and syncope and sudden death. Some of the congenital long QT syndromes were characterized by a peculiar electrocardiographic appearance of the QRS complex involving a premature atria beat followed by a pause, then a subsequent sinus beat showing marked QT prolongation and deformity. This type of cardiac arrhythmia was originally termed “torsade de pointes” (translated from the French as “twisting of the points”).
Prolongation of the QT interval is thought to result from delayed ventricular repolarization. The repolarization process within the myocardial cell is due to the efflux of intracellular potassium. The channels associated with this current can be blocked by many drugs and predispose the electrical propagation cycle to torsade de pointes.
Clarithromycin is considered as having a risk of causing torsade de pointes. The risk of drug-induced torsade de pointes is extremely low when a single QT interval prolonging drug is prescribed. It is not known what effect vasoconstrictors in the local anesthetic regimen will have in patients with a known history of congenital prolonged QT interval or in patients taking any medication that prolongs the QT interval. Until more information is obtained, it is suggested that the clinician consult with the physician prior to the use of a vasoconstrictor in suspected patients, and that the vasoconstrictor (epinephrine, levonordefrin [Neo-Cobefrin®]) be used with caution.
Mental Health: Effects on Mental Status
Macrolides have been reported to cause nightmares, confusion, anxiety, and mood lability
Mental Health: Effects on Psychiatric Treatment
Contraindicated with pimozide; increases carbamazepine and triazolam levels; monitor for signs of toxicity
Nursing: Physical Assessment/Monitoring
Assess results of culture/sensitivity tests and patient's allergy history prior to therapy. Assess potential for interactions with other pharmacological agents or herbal products patient may be taking (eg, drugs that affect or are affected by CYP3A4 enzyme activity; see Drug Interactions). Assess therapeutic effectiveness (according to purpose for use) and adverse reactions. Teach patient proper use, possible side effects/appropriate interventions, and adverse symptoms to report.
Dosage Forms
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Granules for oral suspension: 125 mg/5 mL (50 mL, 100 mL); 250 mg/5 mL (50 mL, 100 mL)
Biaxin®: 125 mg/5 mL (50 mL, 100 mL); 250 mg/5 mL (50 mL, 100 mL) [fruit punch flavor]
Tablet: 250 mg, 500 mg
Biaxin®: 250 mg, 500 mg
Tablet, extended release: 500 mg
Biaxin® XL: 500 mg
Pricing: U.S. (www.drugstore.com)
Suspension (reconstituted) (Clarithromycin)
125 mg/5 mL (50): $22.53
125 mg/5 mL (100): $41.91
250 mg/5 mL (50): $42.71
250 mg/5 mL (100): $76.72
Tablet, 24-hour (Biaxin XL)
500 mg (20): $115.38
Tablet, 24-hour (Biaxin XL Pac)
500 mg (14): $88.19
Tablets (Biaxin)
250 mg (60): $335.68
500 mg (20): $109.99
Tablets (Clarithromycin)
250 mg (30): $109.99
500 mg (30): $109.99
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International Brand Names
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