A Comparative Study between only oral Corticosteroid (OCS) versus a combination of Oral corticosteroids and antifungal therapy in acute Allergic Bronchopulmonary aspergillosis (ABPA)

Background: Allergic bronchopulmonary aspergillosis, a well-known entity in today’s era, is an idiopathic inflammatory condition characterized by an allergic inflammatory reaction to Aspergillus fumigates colonization of the airways. Both OCS and antifungal therapy have been found to be effective in the treatment of ABPA, but the efficacy of combining the two groups has recently attracted attention. In this article, we report the findings of comparing the effectiveness of OCS in combination with antifungal medications to OCS monotherapy in ABPA. Material and Methods: All the patients with ABPA attending the Respiratory Medicine OPD were enrolled. Clinical History, Spirometry, absolute eosinophil count, serum IgE (both total and specific against Aspergillus fumigatus, and radiographic evidence were analyzed to arrive at the diagnosis of ABPA. Patients enrolled were randomized to either of the arms – steroid only vs steroid and antifungal combination arm. Patients were followed up for a period of 1 year and response and relapse were recorded. Results: After meeting inclusion and exclusion criteria, 64 patients were randomized either to receive steroid monotherapy or a combination of steroids and antifungals. Both arms experienced a statistically significant decrease in clinical symptoms as well as serum total IgE during the 8-week assessment. None of the arms had any statistically significant adverse drug reaction leading to the termination of therapy. The combination therapy arm resulted in less number of exacerbations, although this data was not statistically significant. Another additional finding seen was that smokers had a higher mean level of total serum IgE than non-smokers. Discussion: It has been mentioned in the literature that azoles reduce the fungal colonization burden of the airway and reduce antigenic stimulation resulting in decreased inflammation, disease severity, and progression. This evidence is supported by this RCT showing addition of itraconazole to the standard oral steroids results in an increased fall in serum total IgE as compared to single oral steroids treatment along with improvement in symptoms and decreasing the risk of future exacerbation in a follow-up period of 1 year. Conclusion: Adding azoles to oral steroids in ABPA improves the outcome of treatment in terms of symptomatology and future risk of exacerbations.

Keywords: Aspergillosis, Steroids, Itraconazole.