What is the standard steroid tapering protocol for Allergic Bronchopulmonary Aspergillosis (ABPA) management?

Standard Steroid Tapering Protocol for Allergic Bronchopulmonary Aspergillosis (ABPA)

The recommended steroid tapering protocol for ABPA is a 4-month course of low-to-moderate dose oral prednisolone starting at 0.5 mg/kg/day for 2-4 weeks, then tapered gradually to complete treatment over 4 months. 1

Initial Treatment Options

Preferred Steroid Protocol

• Start with prednisolone 0.5 mg/kg/day for 2-4 weeks 1
• Taper gradually over the remaining period to complete a total 4-month course 1
• Monitor serum total IgE every 6-8 weeks as a marker of disease activity 1

Alternative Steroid Protocols

• Low-dose protocol: prednisolone 0.5 mg/kg/day for 2 weeks, then alternate days for 8 weeks, then taper by 5 mg every 2 weeks until discontinuation after 3-5 months 1
• Intermediate-dose protocol: prednisolone 0.5,0.25, and 0.125 mg/kg/day for 4 weeks each, then taper by 5 mg every 2 weeks until discontinuation 1
• High-dose protocol: prednisolone 0.75 mg/kg/day for 6 weeks, then 0.5 mg/kg/day for 6 weeks, then taper by 5 mg every 6 weeks until discontinuation after 8-10 months (associated with more adverse events) 1

Considerations for Protocol Selection

• Low-dose protocols result in fewer adverse events but may have lower clinico-radiological and immunological response at 6 weeks 1
• High-dose protocols show better early response but similar frequency of ABPA exacerbations compared to low-dose protocols 1
• The European Respiratory Society DECG (Diagnosis and Evidence Consensus Group) recommends the 4-month course of low-to-moderate dose protocol 1

Monitoring During Tapering

• Regular assessment of clinical symptoms 1
• Monitor serum total IgE levels every 6-8 weeks 1
• Chest radiographs to assess for new infiltrates 1
• Pulmonary function tests to detect deterioration 1

Important Considerations and Pitfalls

• Avoid methylprednisolone when using itraconazole concurrently due to higher risk of exogenous Cushing's syndrome and adrenal insufficiency 1
• Be aware that inhaled corticosteroids (budesonide or fluticasone) combined with itraconazole can also cause exogenous Cushing's syndrome 1
• Consider antifungal therapy (itraconazole) as an adjunct or alternative to steroids, particularly for steroid-dependent ABPA 2
• Patients are considered in remission when they remain without pulmonary infiltrates and/or eosinophilia for 6 months after oral steroid withdrawal 1
• Asymptomatic patients with prolonged mucus plugging may still require treatment to prevent progression to irreversible bronchiectasis 1

Alternative Approaches

• Itraconazole (400 mg/day in two divided doses for 4 months) can be used as an alternative to steroids or as a steroid-sparing agent 1, 2
• Biological agents such as omalizumab may be considered for steroid-dependent ABPA to reduce asthma exacerbations and have steroid-sparing effects 3, 4
• Some clinicians use a 2-week course of glucocorticoids in patients started on oral azoles, then transition to high-dose inhaled corticosteroids as symptoms improve 1

Remember that the goal of treatment is to control symptoms, prevent exacerbations, abrogate bronchiectasis progression, and minimize therapy-related adverse events 1.