Management

The treatment of allergic bronchopulmonary aspergillosis (ABPA) is directed at the inflammatory component caused by the hypersensitivity reaction to Aspergillus fumigatus, as well as antigen mitigation by reducing the fungal burden in the airways. Timely diagnosis and treatment can prevent progression to end-stage ABPA. (1)

The Infectious Disease Society of America (IDSA) recommends that first-line treatment of acute ABPA should include a combination of a corticosteroid plus antifungal therapy. (2)

The aim of treatment is twofold:

• to suppress the immune reaction to the fungus
• to control asthma

The immune reaction is suppressed using oral steroids. Prednisolone is frequently used at an initial dose of 0.5 mg/kg daily for 2 weeks, followed by 0.5 mg/kg every other day for approximately 8 weeks. Clinicians then gradually taper the dose, typically by 5 mg every 2 weeks, with a total treatment duration of 3 to 5 months, depending on disease severity and response. Some patients require a daily maintenance dose of 5 to 7.5 mg to prevent relapse. (3)

• prednisolone 30 to 45 mg per 24 hours is given to reduce inflammation until the condition has resolved clinically and radiologically
• maintenance therapy consists of prednisolone 20 mg on alternate days

Azole antifungals (e.g., itraconazole, voriconazole, posaconazole) are effective against A fumigatus - itraconazole is used most commonly for the treatment of ABPA due to its better adverse-effect profile, tolerability, and because it is the most well studied. (1)

Asthmatic control is along conventional lines with the use of bronchodilators and inhaled steroids and mucus plugs may be removed by bronchoscopic aspiration.

Patients without central bronchiectasis at diagnosis (serologic ABPA) generally preserve lung function over time, even with intermittent exacerbations. With appropriate treatment and monitoring, long-term disease control is achievable, and prolonged remissions are common. Progression to irreversible bronchiectasis or pulmonary fibrosis may occur in patients with recurrent or treatment-dependent disease. (3)

Reference

1. Agarwal R, Sehgal IS, Dhooria S, et al. Developments in the diagnosis and treatment of allergic bronchopulmonary aspergillosis. Expert Rev Respir Med. 2016 Dec;10(12):1317-34.
2. Patterson TF, Thompson GR 3rd, Denning DW, et al. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016 Aug 15;63(4):e1-e60.
3. Agarwal R et al. Revised ISHAM-ABPA working group clinical practice guidelines for diagnosing, classifying and treating allergic bronchopulmonary aspergillosis/mycoses. Eur Respir J. 2024 Apr;63(4)