Treatment of allergic bronchopulmonary aspergillosis
- Praveen Akuthota, MD
Praveen Akuthota, MD
- Associate Clinical Professor
- University of California, San Diego
- Peter F Weller, MD, FACP
Peter F Weller, MD, FACP
- Editor-in-Chief — Infectious Diseases
- Section Editor — Tropical Medicine
- William Bosworth Castle Professor of Medicine
- Harvard Medical School
- Professor of Immunology and Infectious Diseases
- Harvard T. H. Chan School of Public Health
- Section Editors
- Carol A Kauffman, MD
Carol A Kauffman, MD
- Section Editor — Fungal Infections
- Professor of Internal Medicine
- University of Michigan Medical School
- Veterans Affairs Ann Arbor Healthcare System
- Peter J Barnes, DM, DSc, FRCP, FRS
Peter J Barnes, DM, DSc, FRCP, FRS
- Editor-in-Chief — Pulmonary and Critical Care Medicine
- Section Editor — Asthma
- Professor of Medicine
- National Heart and Lung Institute, Imperial College, London
- Deputy Editors
- Helen Hollingsworth, MD
Helen Hollingsworth, MD
- Deputy Editor — Pulmonary, Critical Care, and Sleep Medicine
- Associate Professor of Medicine
- Boston University School of Medicine
- Anna R Thorner, MD
Anna R Thorner, MD
- Deputy Editor — Infectious Diseases
- Assistant Professor of Medicine, Part-time
- Harvard Medical School
Allergic bronchopulmonary aspergillosis (ABPA) is a complex hypersensitivity reaction that occurs in response to colonization of the airways with Aspergillus fumigatus and almost exclusively in patients with asthma or cystic fibrosis (CF) [1-4]. In some cases, repeated episodes of bronchial obstruction, inflammation, and mucoid impaction can lead to bronchiectasis, fibrosis, and respiratory compromise .
The treatment and prognosis of ABPA will be reviewed here. The clinical manifestations and diagnosis of ABPA and general issues related to the management of asthma and bronchiectasis are discussed separately. (See "Clinical manifestations and diagnosis of allergic bronchopulmonary aspergillosis" and "An overview of asthma management" and "Treatment of bronchiectasis in adults" and "Management of bronchiectasis in children without cystic fibrosis".)
Treatment of allergic bronchopulmonary aspergillosis (ABPA) aims to control episodes of acute inflammation and to limit progressive lung injury. The roles of systemic glucocorticoids and antifungal agents vary with the disease activity. Antifungal therapy may help to decrease exacerbations. Inhaled glucocorticoids may help control symptoms of asthma but do not have documented efficacy in preventing acute episodes of ABPA.
Acute ABPA — For acute ABPA manifest by radiographic opacities (usually upper or middle lobes) and an elevated total serum IgE (generally >1000 IU/mL), systemic glucocorticoids are the mainstay of treatment [6-9]. In addition, the 2016 Infectious Diseases Society of America (IDSA) guidelines on the treatment of aspergillosis recommend that therapy of acute or recurrent ABPA should consist of a combination of glucocorticoids and itraconazole . Voriconazole is a reasonable alternative to itraconazole because it is better tolerated in some patients and is well absorbed.
Systemic glucocorticoids — Systemic glucocorticoids are considered the mainstay of treatment of acute ABPA based on the results of case series; no clinical trials have been performed. As an example, a case series of 84 patients found no patients who failed to respond to a course of prednisone with clearing of radiographic opacities, a decline of >50 percent in total IgE, and a return of blood eosinophil counts to normal . In a separate series, 126 patients with a new diagnosis of ABPA all responded to a course of oral glucocorticoids with development of remission (decline in IgE levels >35 percent and clearance of chest radiographic lesions) by six weeks .
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