From the Guidelines
The treatment of allergic bronchopulmonary aspergillosis (ABPA) should prioritize oral corticosteroids and antifungal therapy with itraconazole, with biologics such as omalizumab considered for refractory or steroid-dependent cases, as supported by the most recent guidelines 1. The diagnosis of ABPA typically requires a combination of clinical, radiological, and laboratory findings, including the presence of asthma or cystic fibrosis, immediate skin test reactivity to Aspergillus antigens, elevated total IgE, and peripheral blood eosinophilia.
- Key diagnostic criteria include:
- Elevated total IgE (usually >1000 IU/mL)
- Elevated Aspergillus-specific IgE and IgG antibodies
- Pulmonary infiltrates on imaging
- Peripheral blood eosinophilia Treatment primarily involves oral corticosteroids, typically starting with prednisone 0.5 mg/kg/day for 2 weeks, then 0.5 mg/kg every other day for 6-8 weeks, followed by a gradual taper over 3-6 months based on clinical and immunological response, as recommended by recent guidelines 1.
- Antifungal therapy with itraconazole (200 mg twice daily) is often added as a steroid-sparing agent for 3-6 months, with evidence supporting its efficacy in reducing oral glucocorticoid dose, sputum eosinophil count, and ABPA exacerbations 1. For refractory cases or steroid-dependent patients, biologics such as omalizumab have shown effectiveness in improving symptoms, reducing exacerbations, and decreasing the dose of oral steroids, with a recommended dose of 150-600 mg subcutaneously every 2-4 weeks, dosed by weight and IgE levels 1.
- Other biologics targeting IL-4, IL-5, and IL-13 pathways, such as dupilumab, mepolizumab, and benralizumab, are being investigated for ABPA treatment, with potential benefits in suppressing the inflammatory response to Aspergillus antigens and reducing the hypersensitivity reaction that damages the airways 1.
From the Research
ABPA Confirmation
- The diagnosis of 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 of ABPA
- 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 treatment of ABPA is complicated due to the occurrence of recurrent exacerbations and spontaneous remissions, and the drugs used for treating ABPA include systemic glucocorticoids, antifungal agents, and biologics, each with its own benefits and drawbacks 3.
- A randomized trial compared the efficacy and safety of prednisolone versus prednisolone and itraconazole in acute-stage ABPA complicating asthma, and found a trend towards a decline in ABPA exacerbations at 1 year with the prednisolone-itraconazole combination versus prednisolone monotherapy 4.
- Another randomized trial compared the efficacy and safety of two glucocorticoid protocols in ABPA, and found that medium-dose oral glucocorticoids are as effective and safer than high-dose in treatment of ABPA 5.
- Oral steroids are recommended for 97.1% of patients, and oral steroids plus inhaled corticosteroids plus antifungal agent are used with 41.2% of patients, while omalizumab has been used in limited published experience 6.