What is the recommended treatment for Allergic Bronchopulmonary Aspergillosis (ABPA)?

Treatment of Allergic Bronchopulmonary Aspergillosis (ABPA)

The recommended first-line treatment for acute Allergic Bronchopulmonary Aspergillosis (ABPA) is either oral prednisolone (0.5 mg/kg/day for 2-4 weeks, then tapered over 4 months) or oral itraconazole for 4 months. 1, 2

Treatment Algorithm Based on ABPA Classification

Asymptomatic ABPA

• Systemic therapy is not recommended for asymptomatic ABPA patients 1
• For ABPA-S (serological ABPA without bronchiectasis):
  • Manage like asthma with appropriate asthma medications 1
  • Only use systemic therapy if there is poor asthma control or recurrent exacerbations despite optimal asthma management 1

Acute ABPA Treatment Options

• First-line options (choose one):

  • Oral prednisolone: 0.5 mg/kg/day for 2-4 weeks, then tapered and completed over 4 months 1, 2
  • Oral itraconazole: 400 mg/day in two divided doses for 4 months 2
    • Recommended as initial therapy when systemic glucocorticoids are contraindicated 1
    • Requires therapeutic drug monitoring (target trough level ≥0.5 mg/L) 2

• Important considerations:

  • Combination of itraconazole and glucocorticoids is not recommended as first-line therapy 1
  • However, a short course of glucocorticoids (<2 weeks) may be used initially with oral itraconazole 1
  • High-dose inhaled corticosteroids should not be used as primary therapy for acute ABPA 1
  • Biological agents are not recommended as first-line therapy 1

Second-line Options (for treatment failures or contraindications)

• Voriconazole, posaconazole, or isavuconazole may be used if there are:
  • Contraindications to systemic glucocorticoids AND
  • Intolerance, failure, or resistance to itraconazole therapy 1, 2

Management of ABPA Exacerbations

• ABPA exacerbations should be treated the same way as newly diagnosed ABPA 1
• For recurrent exacerbations (≥2 in the last 1-2 years), especially in patients with extensive bronchiectasis, use a combination of oral prednisolone and itraconazole 1, 2
• Biological agents and nebulized amphotericin B are not recommended for treating acute ABPA exacerbations 1

Monitoring Treatment Response

• Assess response after 8-12 weeks using:
  • Clinical symptoms
  • Serum total IgE levels (should decrease by ≥35% from baseline)
  • Chest radiographs 2
• Continue monitoring with clinical review, serum total IgE levels, and lung function tests every 3-6 months 2, 3

Special Considerations

• Early diagnosis and treatment are essential to prevent irreversible lung damage such as pulmonary fibrosis and bronchiectasis 4
• Patients with blood eosinophil count ≥1000 cells/μL and extensive bronchiectasis (≥10 segments) may benefit from combination therapy 1
• Liver function tests should be performed monthly in patients on itraconazole 2
• Methylprednisolone should not be used with itraconazole due to higher risk of Cushing's syndrome 2

Role of Biological Agents

• Omalizumab may be considered for treatment-dependent ABPA (patients who continue to have symptoms despite conventional therapy) 3
• Mepolizumab has shown promise in case reports for treating ABPA, particularly when not limited by total IgE levels 5
• These agents are not first-line treatments but may be options for steroid-dependent patients 3

Treatment Efficacy

• Proper treatment with oral corticosteroids and/or itraconazole can restore lung function to pre-ABPA levels within 3 months 6
• Itraconazole has been shown to improve symptoms of airway obstruction, pulmonary functions, and decrease exacerbations during follow-up 7
• Adequate therapeutic levels of itraconazole during the first 3 months of treatment are associated with lower risk of ABPA relapses 6