How do you treat Allergic Bronchopulmonary Aspergillosis (ABPA)?

From the Guidelines

Treatment of Allergic Bronchopulmonary Aspergillosis (ABPA) should primarily involve oral corticosteroids, such as prednisolone, and antifungal medications, with the standard initial therapy being prednisolone at 0.5 mg/kg/day for 2 weeks, then tapered over 4 months, or oral itraconazole for 4 months as an alternative. The choice between these two options depends on the clinical presentation and the presence of contraindications to systemic glucocorticoids 1. For patients with acute ABPA, oral prednisolone or itraconazole monotherapy is recommended, with combination therapy reserved for recurrent ABPA exacerbations 1. In cases where systemic glucocorticoids are contraindicated, oral itraconazole is recommended as the initial therapy 1. It's also important to note that asymptomatic ABPA patients do not routinely require systemic therapy, but treatment decisions should be individualized based on factors such as asthma control and the presence of bronchiectasis or mucus plugging 1. The goal of therapy is to reduce inflammation, control fungal burden, prevent progression to fibrosis, and minimize steroid-related side effects, with treatment response monitored through clinical improvement, pulmonary function tests, and decreasing IgE levels 1. Key considerations in the management of ABPA include:

• The use of oral antifungal triazoles, such as itraconazole, as an alternative to glucocorticoids or as a steroid-sparing agent 1
• The potential for adverse events with both glucocorticoids and antifungal agents, such as hyperglycemia, hirsutism, and liver toxicity 1
• The importance of therapeutic drug monitoring (TDM) for antifungal agents, such as itraconazole, to ensure adequate trough levels 1
• The need for individualized treatment decisions based on patient-specific factors, such as asthma control, bronchiectasis, and mucus plugging 1.

From the Research

Treatment Options for Allergic Bronchopulmonary Aspergillosis (ABPA)

• The mainstay of treatment for ABPA remains oral corticosteroids, though this does not completely prevent exacerbations and may not prevent the decline in lung function 2.
• Azole antifungal agents, such as itraconazole, have been shown to be effective in the treatment of ABPA, with improvements in immunological markers of disease activity and symptom scores 2, 3, 4.
• Itraconazole has been shown to modify the immunologic activation associated with ABPA and improve clinical outcome, at least over the period of 16 weeks 2, 3.
• Omalizumab, an anti-IgE antibody, has been used in the treatment of ABPA in patients with cystic fibrosis, with a steroid-sparing effect, decreasing IgE levels, and improvement in respiratory symptoms 5.

Specific Treatment Regimens

• Ketoconazole 400 mg daily for 12 months has been shown to reduce immunological markers of disease activity and symptom scores 2.
• Itraconazole 200 mg twice daily for 16 weeks has been shown to improve clinical outcome and reduce the number of exacerbations requiring oral corticosteroids 2, 3.
• Omalizumab treatment has been shown to decrease IgE levels and improve respiratory symptoms in patients with ABPA and cystic fibrosis, with a mean duration of treatment of 12.5 months 5.

Considerations and Precautions

• Adrenal suppression with inhaled corticosteroids and itraconazole is a potential concern 2.
• The use of antifungal agents, such as itraconazole, should be limited to cases where oral corticosteroids are contraindicated or refused by the patient, or in patients requiring large doses of oral steroids 6.
• More data are necessary to confirm the efficacy of itraconazole in ABPA, and randomized controlled trials are warranted to better define its usefulness in this disorder 2, 6.