ABPA management when the prednisolone and itraconazole combination did not achieve the required response

Recurrent allergic bronchopulmonary aspergillosis (ABPA) may not respond adequately to an initial combination regimen. When defined response benchmarks are not reached, the patient is considered to have treatment-dependent ABPA, and a structured next-line protocol applies.

Prior treatment & reason for escalation

The preceding regimen — a combination of oral prednisolone and oral itraconazole, each given for 4 months, for recurrent ABPA exacerbations — did not achieve the required response after 8–12 weeks:

Major improvement in symptoms (Likert score or VAS ≥50%) and chest radiographs
At least a 20% reduction in serum total IgE

Failure to meet these targets defines treatment-dependent ABPA and triggers escalation to this protocol.

Next-line approach (partial overview)

This protocol addresses treatment-dependent ABPA with a range of options spanning long-term antifungal therapy and targeted biological agents, with specific criteria governing when each is appropriate and what alternatives apply in cases of intolerance or insufficient response. Complete options, selection criteria, and sequencing are detailed in the full protocol →

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1183/13993003.00061-2024

Long-term itraconazole (100%), nebulised amphotericin B (LoC: 100%) or biological agents (LoC: 71%) are recommended options for managing treatment-dependent ABPA.
Oral voriconazole, posaconazole and isavuconazole should not be used as first-line agents for treating acute ABPA (LoC: 78.1–96.9%). They may be used if there are contraindications to systemic glucocorticoids and intolerance, failure or resistance to itraconazole therapy (LoC: 12.8–64.1%).
Finally, continuous low-dose glucocorticoids should be the last option in managing treatment-dependent ABPA.

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