From the Guidelines
Allergic bronchopulmonary aspergillosis (ABPA) is confirmed through a combination of clinical, radiological, and laboratory findings, and treatment consists primarily of oral corticosteroids, such as prednisolone 0.5 mg/kg/day for 2-4 weeks, tapered and completed over 4 months, or oral itraconazole for 4 months, as recommended by the revised ISHAM-ABPA working group clinical practice guidelines 1.
Diagnosis and Treatment
Diagnosis typically requires the presence of asthma or cystic fibrosis, immediate skin test reactivity to Aspergillus antigens, elevated total IgE (usually >500 IU/mL), elevated specific IgE and IgG antibodies to Aspergillus, and pulmonary infiltrates on imaging.
- The diagnosis of ABPA requires a mandatory demonstration of fungal sensitisation and serum total IgE ≥500 IU·mL−1 and two of the following: fungal-specific IgG, peripheral blood eosinophilia or suggestive imaging 1.
- Treatment options include oral prednisolone or itraconazole monotherapy for treating acute ABPA, with prednisolone and itraconazole combination only for treating recurrent ABPA exacerbations 1.
Management of ABPA
- We do not recommend treating asymptomatic ABPA patients with systemic therapy 1.
- ABPA-S should be treated with systemic therapy only if there is poor asthma control or recurrent exacerbations despite asthma therapy 1.
- Long-term itraconazole, nebulised amphotericin B, or biological agents are recommended options for managing treatment-dependent ABPA 1.
Monitoring and Follow-up
- Monitoring treatment response includes tracking symptoms, pulmonary function tests, and total IgE levels every 6-8 weeks 1.
- Patients should be monitored with clinical review, serum total IgE levels, and lung function test every 3–6 months for the first year and then every 6–12 months 1.
From the Research
ABPA Confirmation
- The diagnosis of allergic bronchopulmonary aspergillosis (ABPA) is based on several criteria, including episodic bronchial obstruction, peripheral blood eosinophilia, immediate cutaneous reactivity to A. fumigatus, precipitating serum antibodies to A. fumigatus, elevated total serum IgE, history of pulmonary infiltrates, elevated serum IgE and serum IgG to A. fumigatus, and proximal bronchiectasis 2.
- The total serum IgE concentration and chest roentgenograms can be used to monitor drug therapy 2.
Treatment Dose
- The most effective treatment for ABPA is oral prednisone 0.5 mg/kg/day for 14 days, on alternate days for three months, and tapering by 5 mg every two weeks for an additional three months 2.
- The optimal steroid dose and duration of therapy have not been standardized, but limited data suggest starting with prednisone approximately 0.5 mg/kg/day 3.
- Itraconazole appears to be useful as a steroid-sparing agent 3, 4.
- High-dose intravenous methylprednisolone is an effective treatment for ABPA in patients with cystic fibrosis, with minor side effects 5.
- A combination of prednisolone and itraconazole may be superior to prednisolone alone in reducing exacerbations in patients with ABPA, but further studies are needed to confirm this 6.
Treatment Options
- Oral corticosteroids, such as prednisone, are the standard therapy for ABPA 2, 3.
- Itraconazole can be used as an adjunct to corticosteroids to reduce the need for glucocorticoid therapy 4.
- High-dose intravenous methylprednisolone can be used as an alternative to oral corticosteroids in patients with cystic fibrosis 5.
- A combination of prednisolone and itraconazole may be considered as a treatment option for ABPA, but further studies are needed to determine its efficacy and safety 6.