From the Guidelines
The treatment for recurrent allergic bronchopulmonary aspergillosis (ABPA) should involve a combination of oral prednisolone and itraconazole. This approach is based on the most recent guidelines from the International Society for Human and Animal Mycology (ISHAM) working group, which recommends this combination for treating recurrent ABPA exacerbations 1. The guidelines suggest that this combination therapy is particularly beneficial for patients with frequent relapses, as it helps to reduce the fungal burden and decrease steroid requirements.
Key Components of Treatment
- Oral prednisolone: typically started at a dose of 0.5 mg/kg/day for 1-2 weeks, then gradually tapered over 2-3 months based on clinical and radiological improvement
- Itraconazole: added as an antifungal agent at a dose of 200 mg twice daily for at least 3-6 months
- Maintenance therapy with low-dose steroids (5-10 mg prednisone every other day) may be necessary for patients with frequent relapses
- Bronchodilators and aggressive airway clearance techniques are important adjunctive measures
- Underlying asthma should be optimally controlled with standard asthma medications
Rationale for Treatment
The ISHAM working group guidelines are based on a comprehensive review of the literature and expert consensus 1. The guidelines recommend against the use of biological agents, nebulised amphotericin B, and high doses of inhaled corticosteroids (ICS) alone as first-line therapy for ABPA 1. Instead, the combination of oral prednisolone and itraconazole is recommended for recurrent ABPA exacerbations, as it has been shown to be effective in reducing the fungal burden and decreasing steroid requirements.
Monitoring Treatment Success
Treatment success should be monitored through symptom improvement, lung function tests, decreased total IgE levels, and resolution of radiographic abnormalities. This combination approach targets both the inflammatory response to Aspergillus antigens and reduces the fungal burden, helping to prevent progressive lung damage and bronchiectasis that can occur with recurrent ABPA episodes.
From the Research
Treatment of Recurrent Allergic Bronchopulmonary Aspergillosis (ABPA)
The treatment of recurrent ABPA involves a combination of pharmacological therapy and avoidance of mold exposure.
- The primary treatment for exacerbations of ABPA is oral corticosteroids, with a moderate dose being used as first-line treatment 2, 3.
- Azole antifungal agents, such as itraconazole, are used as an alternative for the treatment of exacerbations and as a preferential strategy to reduce the future risk of exacerbations and for corticosteroid sparing 2, 4.
- Asthma biologics may be of interest in the treatment of ABPA, although their place remains to be determined 2.
- The treatment of ABPA also involves optimized asthma therapy and environmental control measures to prevent exposure to Aspergillus fumigatus 5.
- In patients with cystic fibrosis-related ABPA, a combination of short-term prednisone and itraconazole therapy has been shown to be effective in preserving lung function capacity over years without the known glucocorticoid-associated side effects 4.
Management of ABPA
The management of ABPA is complicated due to the occurrence of recurrent exacerbations and spontaneous remissions.
- Early diagnosis is essential for the management of ABPA, and diagnostic criteria are regularly revised 2, 3, 5.
- The treatment of ABPA should be individualized, taking into account the severity of the disease, the presence of complications, and the patient's response to treatment 6.
- Long-term management of ABPA remains poorly studied, and there is a need for new oral antifungal agents and immunomodulatory therapy 5.
- Avoiding complications of ABPA while limiting the side effects of systemic drugs remains a major challenge of ABPA management 2.