First RCT directly comparing itraconazole with prednisolone for acute ABPA
March 05 2018
Allergic bronchopulmonary aspergillosis (ABPA) is an immune reaction against colonisation of the lungs by Aspergillus fumigatus. The global burden is thought to be around 5 million, with 1.4 million cases in India alone. Early diagnosis is essential to prevent progression to bronchiectasis and pulmonary fibrosis.
Guidelines generally recommend treatment with glucocorticoids, but these carry a heavy burden of side effects. Itraconazole monotherapy has been suggested as an alternative treatment option, through reduction of the fungal burden, but supporting evidence is currently lacking.
Dr Ritesh Agarwal and colleagues at PGIMER (Chandigarh, India) conducted an open-label randomised controlled trial comparing oral itraconazole (n=68) against prednisolone (n=63) as a first-line treatment in acute ABPA. All (100%) patients taking prednisolone achieved a treatment response, while 88% of patients on itraconazole did so; there were no obvious characteristics in common between non-responders.
Itraconazole was not associated with many of the Cushingoid side effects that glucocorticoids are notorious for, although elevated ASTs/ALTs were seen in more itraconazole patients (15%) than prednisolone patients (0%).
Overall, these results suggest that itraconazole makes a good alternative for patients who cannot tolerate glucocorticoids (e.g. those with uncontrolled diabetes, obesity or osteoporosis), but treatment must be monitored as around 12% of patients will not respond.
Left: cumulative probability of first exacerbation for patients receiving prednisolone (red, n=63) or itraconazole (blue, n=60). Eight subjects taking itraconazole were excluded as they did not respond to treatment.
Right: bilateral bronciectasis in a patient with longstanding ABPA.