What is the best treatment for an 82-year-old male with ABPA, hypertension, sore throat, breathing difficulties, and oral thrush, on Prednisone (prednisone) 40 mg daily, albuterol (albuterol) and sodium chloride (sodium chloride) via nebulizer, and minocycline (minocycline)?

Treatment for 82-Year-Old Male with ABPA Exacerbation and Oral Thrush

For an 82-year-old male with ABPA exacerbation and oral thrush, the recommended treatment is to continue prednisone at 40 mg daily for symptom control, add oral itraconazole, and prescribe an antifungal medication for the oral thrush.

Management of ABPA Exacerbation

Corticosteroid Therapy

• Continue prednisone at 40 mg daily as it has already shown improvement in the patient's breathing 1, 2
• The European Respiratory Society recommends treating ABPA exacerbations the same way as newly diagnosed ABPA, with oral prednisolone at 0.5 mg/kg/day (approximately 40 mg for this patient) 1
• Plan to taper the dose gradually after clinical improvement, typically over 4 months 2
• Monitor for steroid-related complications, particularly given the patient's age and current thrush 1

Antifungal Therapy

• Add oral itraconazole to the treatment regimen 1, 2
  • Standard dosing is 200 mg twice daily
  • Therapeutic drug monitoring is recommended with target trough levels ≥0.5 mg/L 2
• For patients with recurrent exacerbations, combination therapy with oral prednisolone and itraconazole is particularly beneficial 1
• Caution: Monitor for drug interactions between itraconazole and prednisone, as this combination can increase the risk of exogenous Cushing's syndrome 2

Management of Oral Thrush

• Prescribe an oral antifungal agent for the thrush:
  • Nystatin oral suspension 100,000 units/mL, 4-6 mL four times daily, swish and swallow
  • Or fluconazole 100-200 mg on day 1, followed by 50-100 mg daily for 7-14 days 1
• Consider using a spacer device with the patient's inhaled medications and rinsing mouth after use to prevent recurrence 1

Respiratory Support

Nebulizer Therapy

• Continue current nebulizer therapy with albuterol and sodium chloride as needed 1
• Ensure proper technique with nebulizer use 1
• Consider adding ipratropium bromide (250-500 μg four times daily) to the nebulizer regimen for additional bronchodilation 1

Monitoring and Follow-up

• Evaluate treatment response after 8-12 weeks using:
  • Clinical symptoms (improvement in breathing difficulties and sore throat)
  • Serum total IgE levels (target reduction of at least 20%)
  • Chest imaging 1, 2
• Monitor lung function with spirometry (target improvement in FEV1 of at least 158 mL) 1
• Schedule follow-up with pulmonologist within 4-6 weeks 1

Additional Considerations

Infection Control

• Complete the PCR testing for COVID-19, flu, and RSV as planned
• Monitor for signs of bacterial infection (fever, increased purulence of sputum)
• Continue minocycline for the ulcerating toe as prescribed by podiatrist

Prevention of Complications

• Add calcium (800-1000 mg/day) and vitamin D (400-800 units/day) supplementation to prevent osteoporosis 3
• Monitor blood glucose levels regularly due to risk of steroid-induced hyperglycemia
• Consider proton pump inhibitor for gastrointestinal protection while on high-dose steroids

Treatment Pitfalls to Avoid

• Do not use high-dose inhaled corticosteroids alone as primary therapy for acute ABPA 2
• Do not use biological agents (omalizumab, mepolizumab, etc.) as first-line therapy for ABPA exacerbations 1, 4
• Avoid abrupt discontinuation of prednisone; taper gradually to prevent adrenal crisis 3
• Do not overlook the importance of therapeutic drug monitoring when using itraconazole 2
• Be vigilant about potential drug interactions, particularly between itraconazole and inhaled corticosteroids 2

This treatment approach addresses both the ABPA exacerbation and oral thrush while considering the patient's age and comorbidities. The combination of continued prednisone with the addition of itraconazole provides optimal management for this patient's condition.