What is the recommended treatment for the presentation of allergic bronchopulmonary aspergillosis (ABPA)?

Treatment of Allergic Bronchopulmonary Aspergillosis (ABPA)

For acute ABPA, the recommended first-line treatment is either oral prednisolone (0.5 mg/kg/day for 2-4 weeks, tapered and completed over 4 months) or oral itraconazole for 4 months. 1, 2

Treatment Algorithm Based on ABPA Classification

ABPA-S (Serological ABPA)

• Treat as asthma with standard asthma medications
• Systemic therapy only if:
  • Poor asthma control despite optimal management
  • Recurrent exacerbations despite asthma therapy
• Monitor serum total IgE levels regularly

Symptomatic ABPA with Bronchiectasis (ABPA-B)

• First-line options (choose one):

  1. Oral prednisolone: 0.5 mg/kg/day for 2-4 weeks, then taper over 4 months
  2. Oral itraconazole: 400 mg/day in two divided doses for 4 months
     • Monitor liver function tests
     • Check therapeutic drug levels (target >0.5 μg/mL)
     • Use as first-line when systemic glucocorticoids are contraindicated

• Do not use as first-line therapy:

  • Combination of itraconazole and glucocorticoids
  • Newer azoles (voriconazole, posaconazole, isavuconazole)
  • High-dose inhaled corticosteroids alone
  • Biological agents
  • Nebulized amphotericin B

Management of ABPA Exacerbations

ABPA exacerbations are characterized by:

• Sustained worsening (≥2 weeks) of clinical symptoms
• New infiltrates on chest imaging
• Increase in serum total IgE by ≥50% above baseline

Treatment approach:

• Treat like newly diagnosed ABPA with either prednisolone or itraconazole
• For recurrent exacerbations (≥2 in 1-2 years): Use combination of oral prednisolone and itraconazole, especially in patients with extensive bronchiectasis 1

Monitoring Treatment Response

Evaluate after 8-12 weeks using:

• Clinical improvement (≥50% symptom reduction)
• Chest radiograph improvement
• ≥20% reduction in serum total IgE 2

Long-term monitoring:

• Clinical review every 3-6 months for first year, then every 6-12 months
• Regular serum total IgE measurements
• Lung function tests

Special Considerations

• Drug interactions: Be aware of potential interactions between itraconazole and inhaled corticosteroids (risk of Cushing's syndrome) 2
• Therapeutic drug monitoring: Maintain itraconazole levels >0.5 μg/mL 2
• Supportive care: Consider airway clearance techniques and nebulized hypertonic saline to reduce sputum viscosity 2

Evidence Strength

The recommendations are based on expert consensus rather than large randomized controlled trials. A notable RCT by Stevens et al. (2000) demonstrated that itraconazole led to improvement in 46% of patients with corticosteroid-dependent ABPA compared to 19% with placebo (p=0.04) 3. This supports the use of itraconazole as an effective adjunctive therapy.

Common Pitfalls to Avoid

• Failing to differentiate between ABPA exacerbation, asthma exacerbation, and infective bronchiectasis exacerbation
• Using high-dose inhaled corticosteroids alone as primary therapy for acute ABPA
• Using biological agents as first-line therapy
• Not monitoring serum total IgE levels to assess treatment response
• Overlooking potential drug interactions with azole antifungals

Early diagnosis and appropriate treatment are essential to prevent progression to fibrotic lung disease, which can lead to respiratory failure and increased mortality 4.