From the Guidelines
Itraconazole is the recommended antifungal treatment for Allergic Bronchopulmonary Aspergillosis (ABPA), with a typical dosage of 400 mg/day in two divided doses for 4 months, as stated in the revised ISHAM-ABPA working group clinical practice guidelines 1.
Treatment Details
- The treatment duration may vary based on clinical response, and patients should take itraconazole with food to enhance absorption.
- Blood level monitoring is recommended to ensure adequate drug concentration, with a target trough level of ≥0.5 mg/L 1.
- Liver function tests should be performed before starting treatment and periodically thereafter.
- Itraconazole works by inhibiting fungal cell membrane synthesis, reducing the antigenic burden of Aspergillus in the airways, which decreases the allergic inflammatory response.
Important Considerations
- Common side effects include headache, gastritis, nausea, vomiting, liver toxicity, and others, as listed in the guidelines 1.
- Important drug interactions exist with medications metabolized by CYP3A4, including certain statins, anticoagulants, and corticosteroids, so a medication review is essential before starting therapy.
- The guidelines also recommend considering the use of itraconazole as an alternative to glucocorticoids, especially in patients who cannot tolerate steroids or have contraindications to their use 1.
Clinical Evidence
- A recent study published in the European Respiratory Journal supports the use of itraconazole as a first-line treatment for ABPA, citing its efficacy in reducing symptoms and improving quality of life 1.
- Another study published in the same journal highlights the importance of individualized treatment approaches, taking into account the patient's clinical course and response to therapy 1.
From the Research
ABPA Treatment with Itraconazole
- Itraconazole has been shown to be an effective adjunctive therapy in the treatment of allergic bronchopulmonary aspergillosis (ABPA) 2, 3, 4.
- Studies have demonstrated that itraconazole can lead to improvement in clinical, biological, and functional parameters in patients with ABPA, including reduction in corticosteroid dose, decrease in serum IgE concentration, and improvement in pulmonary function tests 2, 3.
- The use of itraconazole in combination with prednisone has been shown to be effective in preserving lung function capacity over years in patients with cystic fibrosis-related ABPA, without the known glucocorticoid-associated side effects 4.
- However, itraconazole can cause adverse effects, such as drug-induced hepatitis, and monitoring of liver function is recommended 5.
- The choice of antifungal agent, including itraconazole, should be based on the individual patient's needs and medical history, and consideration of potential drug-drug interactions 6.
Key Findings
- A randomized trial found that 46% of patients with corticosteroid-dependent ABPA responded to itraconazole, compared to 19% of patients in the placebo group 2.
- A study of 14 asthmatic patients with ABPA found that itraconazole treatment led to significant improvements in clinical, biological, and functional parameters, including reduction in blood eosinophilia and serum total IgE levels 3.
- A retrospective analysis of 65 patients with cystic fibrosis-related ABPA found that treatment with itraconazole and prednisone led to restoration of FEV1 values to pre-ABPA levels within 3 months, and long-term preservation of lung function capacity 4.
Considerations for Treatment
- Itraconazole should be used in conjunction with corticosteroids, and the dose and duration of treatment should be individualized based on the patient's response and medical history 2, 3, 4.
- Monitoring of liver function and potential drug-drug interactions is recommended when using itraconazole 5, 6.
- The choice of antifungal agent should be based on the individual patient's needs and medical history, and consideration of potential adverse effects and drug-drug interactions 6.