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Treatment of allergic bronchopulmonary aspergillosis

Praveen Akuthota, MD
Peter F Weller, MD, MACP
Section Editors
Carol A Kauffman, MD
Peter J Barnes, DM, DSc, FRCP, FRS
Deputy Editors
Helen Hollingsworth, MD
Anna R Thorner, MD


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 [5].

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 [10]. 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 [11]. 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 [12].

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Literature review current through: Nov 2017. | This topic last updated: Jun 29, 2017.
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