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PubMed This is a summary of 22 peer-reviewed journal articles Updated
Pulmonology

Managing Your Treatment and Reducing Steroid Risks

At a Glance

ABPA treatment balances control of lung inflammation with medication safety: acute episodes may use prednisolone or itraconazole, while recurrent or steroid-dependent disease may require blood-test monitoring, careful steroid tapering, or specialist-directed biologic injections.

Treating Allergic Bronchopulmonary Aspergillosis (ABPA) is a balancing act. The goal is to calm your immune system’s overreaction while minimizing the side effects of the medications used to do so. In 2024, the International Society for Human and Animal Mycology (ISHAM) updated its guidelines to provide a clearer path for managing both new cases and recurring flare-ups [1].

The 2024 Treatment Roadmap

Your treatment plan depends on whether this is an acute episode, an exacerbation, or a treatment-dependent problem [1]. Please note that “monotherapy” refers to the ABPA-specific medication; you must continue optimizing your standard asthma or CF therapies alongside it.

Acute Disease (New Diagnosis or Exacerbation)

For a first-time episode or a standard exacerbation, the 2024 guidelines recommend using just one primary ABPA-directed medication [1][2]. Your doctor may choose:

  • Oral Prednisolone: A corticosteroid that quickly reduces lung inflammation [1].
  • OR Itraconazole: An antifungal medication that reduces the amount of Aspergillus in your airways, which in turn lowers the “trigger” for your immune system [1][3].

Recurrent Exacerbations

If the ABPA frequently returns, your doctor may consider specialist-directed combination therapy [1]. This involves taking both prednisolone and itraconazole together, but this is reserved for specific cases because it adds steroid toxicity and drug interactions without established routine benefit [1][2].

Refractory or “Steroid-Dependent” ABPA

If your symptoms return every time you try to lower your steroid dose, or if the standard drugs aren’t working, your doctor may consider biologic therapies, which are often prescribed off-label for ABPA based on your asthma phenotype [1][3]. These are targeted injections that block specific parts of the immune system:

  • Omalizumab: Blocks IgE, the main “allergy” antibody [4].
  • Mepolizumab or Benralizumab: Targets eosinophils, the white blood cells that cause airway swelling and mucus [5][6].
  • Dupilumab: Blocks the chemical signals (IL-4 and IL-13) that drive the entire allergic response [7].

Why We Avoid Long-Term Steroids

While oral steroids like prednisolone are highly effective, they are “heavy hitters” with significant long-term risks. Doctors use “steroid-sparing” strategies—like adding an antifungal or a biologic—specifically to avoid these side effects [8][9]:

  • Metabolic Changes: Weight gain, “cushingoid” changes (like a rounded face), and the development of Type 2 diabetes [8][10].
  • Bone and Muscle Health: Increased risk of osteoporosis (weak bones), fractures, and muscle weakness [8][11].
  • Infection Risk: Taking systemic corticosteroids for too long suppresses your immune system, making you more susceptible to standard infections. ⚠️ Never Stop Steroids Abruptly: You must taper oral steroids exactly as instructed. Stopping abruptly can cause a life-threatening adrenal crisis with symptoms like severe weakness, vomiting, fainting, and confusion. Seek emergency medical care immediately if you experience these while tapering [12][13].

The Importance of Itraconazole Monitoring

If you are prescribed itraconazole, your doctor should perform Therapeutic Drug Monitoring (TDM) [14][15]. This is a blood test to ensure there is enough medicine in your system to work, but not so much that it becomes toxic [16].

  1. Variable Absorption: Itraconazole is notoriously hard for the body to absorb consistently, especially for people with cystic fibrosis [17][18].
  2. The “Trough” Level: Blood is usually drawn right before your next dose (the “trough”) once the drug has reached a steady state in your body (often after 7 to 14 days) [19][20].
  3. Safety Checks: Because itraconazole can affect your liver, your doctor will also monitor your liver enzymes through regular blood tests [19][11].
  4. Drug Interactions: Itraconazole interacts with many other drugs, including some inhalers and statins. Always provide your doctor with a full list of your current medications [21][22].

By monitoring these levels closely, your care team can adjust your dose to find the “sweet spot” where the fungus is controlled and your lungs can begin to heal [18].

Common questions in this guide

What medicines are commonly used for a new or worsening ABPA episode?
For an acute ABPA episode or standard flare, current guidance generally recommends one primary ABPA-directed medicine: oral prednisolone or itraconazole. Your usual asthma or cystic fibrosis treatments should also continue to be optimized with your clinician.
Why are long-term steroids a concern in ABPA?
Long-term oral prednisolone can cause weight gain and diabetes, weaken bones and muscles, and increase infection risk. Doctors may use itraconazole or a biologic as a steroid-sparing strategy when appropriate, but these choices require individualized supervision.
What blood tests are needed when taking itraconazole for ABPA?
Therapeutic drug monitoring measures how much itraconazole is in your blood, often with a sample taken just before a dose after the medicine has reached a steady level, usually about 7 to 14 days. Clinicians also check liver enzymes and review your medication list because itraconazole has variable absorption and many drug interactions.
When might biologic injections be considered for ABPA?
A biologic may be considered when ABPA is refractory or repeatedly returns during steroid reduction, especially when standard treatment is not working. Options mentioned include omalizumab, mepolizumab, benralizumab, and dupilumab; use for ABPA may be off-label and depends on your asthma or allergic profile.
Is it safe to stop prednisolone as soon as ABPA symptoms improve?
No. Oral steroids should be reduced only according to the prescribed taper because abrupt stopping can cause a dangerous adrenal crisis, with severe weakness, vomiting, fainting, or confusion; seek emergency care for these symptoms.
Why might itraconazole and prednisolone be prescribed together?
Specialists may use the combination for recurrent ABPA exacerbations, but it is not routine for everyone. The combination can increase steroid toxicity and drug-interaction concerns, so the expected benefit must be weighed against the risks.

Questions For You

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Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Is this being treated as a first-time acute episode or a recurrent exacerbation?
  2. 2.If I am starting on one medication (monotherapy), which one are you choosing and why?
  3. 3.When should I have my first blood test to check my itraconazole levels (Therapeutic Drug Monitoring)?
  4. 4.What is our long-term plan to reduce my steroid dose and avoid side effects like bone loss or high blood sugar?
  5. 5.If my symptoms don't improve with standard treatment, at what point would we consider adding a biologic like omalizumab or mepolizumab?

References

References (22)
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    Revised ISHAM-ABPA working group clinical practice guidelines for diagnosing, classifying and treating allergic bronchopulmonary aspergillosis/mycoses.

    Agarwal R, Sehgal IS, Muthu V, et al.

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    A randomised trial of prednisolone versus prednisolone and itraconazole in acute-stage allergic bronchopulmonary aspergillosis complicating asthma.

    Agarwal R, Muthu V, Sehgal IS, et al.

    The European respiratory journal 2022; (59(4)) doi:10.1183/13993003.01787-2021.

    PMID: 34503983
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    [Allergic bronchopullmonary aspergillosis (ABPA) - an Update].

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    Real-world efficacy of anti-IL-5 treatment in patients with allergic bronchopulmonary aspergillosis.

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    Mepolizumab as Possible Treatment for Allergic Bronchopulmonary Aspergillosis: A Review of Eight Cases.

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This page is for informational purposes only and does not constitute medical advice. Do not change or stop ABPA medicines without your clinician’s instructions, and seek urgent care for severe symptoms during a steroid taper.