The UK’s National Aspergillosis Centre Approach to the Management of Chronic Pulmonary Aspergillosis
February 26 2018
Chronic pulmonary aspergillosis (CPA) is a serious long-term fungal disease of the lung associated with significant morbidity and mortality. Long-term (often 6 months or more) oral antifungal therapy is the cornerstone of management of patients with this condition. However, treatment of CPA is not straightforward given the often-multiple associated co-morbidities, complex clinical picture, drug interactions, toxicities and intolerances.
The available evidence for current treatments in CPA is limited and based mostly on retrospective cohort studies. Fewer than 5 randomised clinical trials have so far been conducted: 1 for oral itraconazole, and 3 or 4 for intravenous therapy with or without oral antifungals.
In 2009, the UK Department of Health commissioned the National Aspergillosis Centre (NAC) to provide long-term highly specialised care for patients with CPA. Since its establishment, the NAC has been a world leader in developing expertise in the clinical management of CPA with sophisticated diagnostic testing and monitoring for patients with these conditions. We currently have a cohort of over 450 patients on active follow-up. Additionally, the NAC is actively involved in developing research, knowledge, and expertise in CPA as well as supporting the advancements in high quality clinical care required to contribute to the care of patients with all forms of aspergillosis.
Dr Firas Maghrabi and Prof David W Denning, both physicians involved in the care of patients with CPA, recently published an article in Current Fungal Infection Reports in which they discussed the management of CPA from their own experience at the NAC. Current practice at the NAC suggests that oral itraconazole or voriconazole are used interchangeably as first-line treatment. In the event of intolerance or toxicity, patients may be swapped from itraconazole to voriconazole or vice versa. In the event of resistance or further intolerance, third-line treatment with posaconazole may be initiated. In those with pan-azole resistance, short-term courses of intravenous liposomal amphotericin B or micafungin are used as fourth-line therapy, while keeping in mind the nephrotoxic effects of amphotericin B.
Aspergillus-specific IgG, inflammatory markers (mainly CRP, ESR & plasma viscosity) and St George’s Quality of Life Questionnaire are assessed at baseline, and used to monitor disease progression and response to therapy. Imaging is conducted (ideallya chest CT scan) at baseline and repeated after 6 months of treatment, then 1–2 yearly thereafter with low-dose scanning. Immunological investigations include antibody responses to Streptococcus pneumoniae and Haemophilus influenzae vaccines, as well as biomarkers of natural killer cells, B-cells and T-cells.
The authors concluded that there is a pressing need to raise awareness of this devastating disease to encourage early treatment as well as to enable prospective drug trials and studies to identify potential patient factors that correlate with progression, severity and overall outcomes in order to target future therapies.
- Read the full article: Maghrabi and Denning (2017) The Management of Chronic Pulmonary Aspergillosis: The UK National Aspergillosis Centre Approach. Curr Fungal Infect Rep. 11(4):242-251
In January 2017, the NAC was the first centre to be designated as an Excellence Centre by the European Confederation of Medical Mycology (ECMM), achieving Diamond Status.