ABPA Complicating Asthma: Treatment Responses to Prednisolone vs Itraconazole

In individuals with acute allergic bronchopulmonary aspergillosis (ABPA) complicating asthma, prednisolone may be a more effective treatment but may lead to more adverse effects compared with itraconazole, according to a study published by Chest.

Researchers identified 131 treatment-naive individuals with ABPA and randomly assigned them 1:1 to receive 4 months of treatment with either oral itraconazole (n=68) or prednisolone (n=63). The purpose of the study was to assess the response to treatment 6 weeks after initiation, decline of immunoglobulin E (IgE) levels, and the number of individuals who experienced asthma exacerbations during the course of treatment. The secondary outcomes were the time to first ABPA asthma exacerbation, number of exacerbations, and adverse effects related to treatment. Of note, 8 individuals treated with itraconazole did not respond to treatment and subsequently received prednisolone, with a demonstrated composite response after 6 weeks.

Of the 131 individuals observed, the overall composite response was significantly higher in the prednisolone group compared with those receiving itraconazole (100% vs 88%; P =.007) and remained significantly higher despite adjusting for baseline IgE or forced expiratory volume in 1 second. Side effects were reportedly higher in those receiving glucocorticoid treatment (P <.001). The overall percentage decrease in IgE observed in both groups was similar at both 6 weeks and 3 months (55% vs 52%; P =.87 and 67% vs 66%; P =.80, respectively). Combined, the number of individuals who experienced asthma exacerbations after 1 and 2 years were 13 (10.6%) and 31 (25.2%), respectively, with no differences in number of exacerbations after 2 years.

The time to first exacerbation, change in lung function at 6 weeks, and total number of asthma exacerbations were similar between the 2 groups. However, there was a higher occurrence of adverse events in the glucocorticoid group (cushingoid habitus, weight gain, acne, and hypertrichosis), whereas abnormal liver function test results occurred more often (15%) in those treated with itraconazole.

This study was not blinded, was single centered, and had potential for selection bias, all of which may limit the findings.

Researchers concluded that treatment was more effective for acute-stage ABPA complicating asthma in individuals treated with oral glucocorticoids, but those individuals experienced a higher rate of adverse effects. The majority of individuals treated with itraconazole experienced a response to treatment; however, it was not as high as the response in those treated with prednisolone, and individuals were observed to have a higher incidence of abnormal liver function tests. Therefore, clinicians can consider both treatment options, as itraconazole was still effective with fewer adverse effects, and may be a valid treatment option for patients with uncontrolled diabetes, severe osteoporosis, obesity, and other diagnoses where treatment with a glucocorticoid-sparing agent is desired. Both treatment options should be closely monitored for adverse effects and efficacy.

Reference

Agarwal R, Dhooria S, Sehgal IS, et al. A randomized trial of itraconazole versus prednisolone in acute-stage allergic bronchopulmonary aspergillosis complicating asthma [published online January 10, 2018]. Chest. doi:10.1016.j.chest.2018.01.005