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17th January 2024

Management

Management will depend on what stage of disease an affected patient is at during diagnosis. Five distinct stages of disease have been proposed; table 4 below summarises each stage and the associated recommended management for it.

As part of overall management for ABPA, appropriate monitoring for medications such as steroids and azole antifungals must occur, as both can cause adrenal suppression, and azole antifungals can be hepatotoxic. Yearly spirometry is advised, and total IgE should be checked every 2 months after acute treatment for at least one year. Chest physiotherapy and oxygen therapy may need to be considered as part of optimising symptoms especially in the later stage of disease.

Stage Primary treatment Other treatment considerations
Acute – patients with active features of disease e.g., cough, fever.
  • Initially, 1-2 weeks of prednisolone (0.5mg/kg/day in asthma, 1-2mg/kg/day in CF).
  • Then alternating days for up to 2 months with dose tapering by 5-10mg every 2 weeks.
  • The serum IgE level should drop significantly, and infiltrates on imaging should clear.
  • Avoid exposure to source of Aspergillus fumigatus.
  • Optimise management of the underlying respiratory condition.
  • Itraconazole or ketoconazole orally can be considered in some cases if ongoing steroid therapy is needed – specialist input is recommended.
Remission – any asymptomatic patient, off steroids for more than 6 months and no infiltrates on imaging is considered to be in remission.
  • Ongoing optimisation of the underlying respiratory condition as per published guidelines for that condition is recommended.
  • Patients should be counselled to continue avoiding the source of the fungal antigens.
Relapse – patients who have increased serum IgE (more than 100% of their baseline) or worsening clinical symptoms are considered to be having an exacerbation.
  • The prednisolone therapy described in the acute phase is re-implemented. Imaging should be repeated after 2 months to ensure resolution of any changes.
  • Patients should be counselled to continue avoiding the source of the fungal antigens.
  • Continue to optimise management of the underlying respiratory condition if needed.
  • Itraconazole or ketoconazole orally can be considered in some cases if ongoing steroid therapy is needed – specialist input is recommended.
Steroid dependent – only occurs in patients with asthma who cannot be weaned off steroids. Can occur alongside chronic lung changes and ongoing raised IgE despite treatment. Bronchiectasis will likely be present.
  • Indefinite oral steroids as a maintenance dose may be required. A dose of approximately 10-40mg per day/every other day is needed, and the lowest dose able to control symptoms should be used.
  • As above.
Fibrosis – patients in this stage are dependent on steroids to control symptoms and have chronic lung obstruction and restriction. Cavitating lesions and bullae may be seen on imaging, indicative of irreversible change and poor prognosis.
  • Steroids will be dosed as in stage 4 and likely continued indefinitely.
  • As above, alongside potential palliative care involvement to help further control symptoms.

Table 4: Summary of management algorithm for ABPA. Adapted from: Radojicic, C. (2020) Allergic bronchopulmonary aspergillosis, Allergic bronchopulmonary aspergillosis – Symptoms, diagnosis and treatment | BMJ Best Practice. BMJ Best Practice. Available at: https://bestpractice.bmj.com/topics/en-gb/836/pdf/836/Allergic%20bronchopulmonary%20aspergillosis.pdf (Accessed: January 15, 2023) and Akuthota, P. and Weller, P. (2022) Treatment of allergic bronchopulmonary aspergillosis, UpToDate. Edited by C. Kauffman et al. UpToDate. Available at: https://www.uptodate.com/contents/treatment-of-allergic-bronchopulmonary-aspergillosis?search=abpa&source=search_result&selectedTitle=2~57&usage_type=default&display_rank=2 (Accessed: January 15, 2023). 

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