Management of allergic aspergillosis

Abstract

Treatment of allergic bronchopulmonary aspergillosis depends on accurate diagnosis, which is diffi cult because of multiple clinical, radiographic, and immunologic criteria; unstandardized immunoassays; and its similarity to cystic fi brosis. Advances in chest CT interpretation, measuring serum Aspergillus fumigatusspecifi c antibodies and the T-helper type 2 chemokine thymus-activated-and-regulated chemokine, recognizing risk factors, should improve diagnostic accuracy. Oral glucocorticosteroids remain the mainstay of treatment. Dose regimen and duration are not standardized, so expert recommendations are used. Inhaled steroids have not been proven to be effective. Due to relapse and toxicity, itraconazole has been added as second-tier therapy, supported by randomized, placebo-controlled trials in asthma and open-label trials in cystic fi brosis. Itraconazole is steroid sparing with anti-infl ammatory aspects and poor bioavailability. Despite combination steroid-itraconazole therapy, relapses and steroid toxicity have led to open-label use of voriconazole, nebulized amphotericin B, monthly high-dose intravenous methylprednisolone, and omalizumab. Controlled trials are needed to evaluate these and other antifungal or immunomodulatory interventions.

The use of biological agents for the treatment of fungal asthma and allergic bronchopulmonary aspergillosis

“…8 However, because of the toxicity of prolonged systemic glucocorticosteroid therapy and often inadequate control of ABPA with combination steroid-azole therapy, omalizumab is increasingly used in treatment of ABPA. 51 To date 64 omalizumab-treated ABPA patients have been reported in abstracts and peer reviewed publications, with reduced exacerbations and systemic steroid burden being the main benefits of therapy. [52][53][54][55][56][57][58][59][60] However, no placebo-controlled trials have been completed.…”

Fungi in Cystic Fibrosis and Non–Cystic Fibrosis Bronchiectasis

“…Both oral triazoles with anti-Af activity (itraconazole, voriconazole, and posaconazole) and amphotericin B delivered by nebulization have been successfully employed, although the evidence base is not robust. [150][151][152][153][154] Finally, elimination of avoidable environmental exposure may be of benefit when feasible.…”