From the Guidelines
The treatment for recurrent allergic bronchopulmonary aspergillosis (ABPA) should involve a combination of oral prednisolone and itraconazole, as recommended by the most recent guidelines 1. This approach is based on the revised ISHAM-ABPA working group clinical practice guidelines for diagnosing, classifying, and treating allergic bronchopulmonary aspergillosis/mycoses, which suggest that combination therapy with prednisolone and itraconazole is effective for treating recurrent ABPA exacerbations.
Key Treatment Components
- Oral prednisolone: The mainstay of treatment for acute and recurrent ABPA, 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 serological response.
- Itraconazole: An antifungal agent that can be added to reduce fungal burden and decrease steroid requirements, particularly in patients with recurrent ABPA exacerbations.
- Monitoring: Regular monitoring of pulmonary function, serum IgE levels, and chest imaging is essential to assess treatment response and detect early relapse.
Additional Considerations
- Inhaled corticosteroids and bronchodilators may be used concurrently to manage underlying asthma symptoms.
- Pulmonary rehabilitation and airway clearance techniques are important adjunctive measures.
- The treatment approach should be individualized based on the patient's clinical response, serum IgE levels, and presence of bronchiectasis.
The most recent guidelines 1 and studies 1 support the use of combination therapy with prednisolone and itraconazole for recurrent ABPA, while earlier guidelines 1 recommended oral corticosteroids and itraconazole as separate treatment options. However, the most recent and highest-quality study 1 should be prioritized when making treatment decisions.
From the Research
Treatment Options for Recurrent ABPA
- The treatment of recurrent allergic bronchopulmonary aspergillosis (ABPA) typically involves a combination of oral corticosteroids and antifungal agents, such as itraconazole 2.
- Biologics, including omalizumab, mepolizumab, and benralizumab, have been shown to be effective in reducing symptoms and preventing recurrences in patients with refractory ABPA 3.
- Azole antifungal agents may be used as an alternative to corticosteroids for the treatment of exacerbations and to reduce the risk of future exacerbations 4.
- Asthma biologics may also be of interest in the treatment of ABPA, although their place in therapy remains to be determined 4.
Management of ABPA Exacerbations
- Exacerbations of ABPA are typically treated with a moderate dose of oral corticosteroids, such as prednisone 0.5 mg/kg/day for 14 days, followed by tapering 5.
- Antifungal agents, such as itraconazole, may be used in conjunction with corticosteroids to treat exacerbations and prevent recurrences 2.
- The goal of treatment is to reduce symptoms, prevent long-term complications, and minimize the side effects of systemic corticosteroids 4.
Monitoring and Prevention of Recurrences
- Regular monitoring of total serum IgE concentration and chest roentgenograms can be used to monitor drug therapy and prevent recurrences 5.
- Itraconazole therapeutic drug monitoring may be useful in preventing disease flares, particularly in patients who are susceptible to recurrences 2.
- Avoiding exposure to mold and maintaining good asthma control may also help to prevent recurrences of ABPA 4.