What are some treatments for aspergillosis

Cystic fibrosis - Aspergillus fumigatus

When should Aspergillus fumigatus be treated for cystic fibrosis?

In cystic fibrosis, Aspergillus fumigatus is often found in the sputum. Most of those affected do not get sick from it. The detection of the mold is therefore not a reason for treatment. However, if allergic bronchopulmonary aspergillosis (ABPA) has been diagnosed, careful treatment is required.

What drugs are used to treat ABPA?

The therapy has two basic starting points: Curbing the hypersensitivity reaction of the immune system and reducing the amount of mold.

Glucocorticoids are effective means of reducing hypersensitivity and the inflammatory process. In common parlance, they are often simply referred to as “cortisone”.

For use in tablet form, the glucocorticoid prednisone is often used in ABPA. Treatment begins with higher doses and daily intake of prednisone. After a few weeks, patients only take prednisone tablets every other day. Thereafter, the dose is reduced in small steps every 2 weeks and the prednisone is "tapered".

Some experts prefer intravenous therapy with glucocorticoids. In this so-called "pulse therapy", the drug is injected directly into the vein for three days in a row. The treatment is repeated every one to two months.

Inhaling glucocorticoids, as known from asthma, has no proven benefit in ABPA.

The mold can be killed with special drugs, the antimycotics. They are used at ABPA when the cortisone therapy is not working well enough.

The substance itraconazole is used most frequently. It works well against aspergillus and can be taken in tablet form. However, the treatment is not easy to control. In order for the body to absorb enough medication, the environment in the stomach must be acidic enough. In fact, researchers were able to find more itraconazole in the blood if patients had been drinking cola rather than water while taking it. Itraconazole blood levels must therefore be carefully monitored in order to ensure a sufficient dosage. The doctor and pharmacist must also be aware of possible interactions with other CF drugs. Resistance to itraconazole has also been demonstrated more frequently in recent years.

There are other effective anti-mold preparations, e.g. voriconazole or caspofungin. Voriconazole works somewhat better against aspergillus and is absorbed by the body to a greater extent than itraconazole. However, in many patients the skin is then very sensitive to light.

Another anti-mold substance, amphotericin B, is also used as an inhalation by some experts in certain cases.

Some very severely affected patients are treated with omalizumab, a drug against the excessive IgE immune response. There are some case reports with omalizumab therapy on ABPA in cystic fibrosis, but no clinical studies.

Antibiotic therapies are repeatedly required for patients who are simultaneously infected with bacteria such as Pseudomonas aeruginosa. Researchers observed that after intravenous antibiotics, fewer aspergillus were found. This is likely due to an indirect effect, as antibiotics do not kill mold.

In general, good physical therapy and exercise will help get the sputum out. This worsens the growth conditions for aspergillus in the bronchi and the number of germs decreases.

How successful is the treatment?

The majority of patients respond well to treatment. The symptoms recede and the patients feel more productive again. The prognosis is good if the disease is recognized early and treated well.

The doctor uses regular lung function tests and the immunoglobulin E values ​​in the blood to monitor how well the disease has been suppressed (see Fig. 4). This will require more frequent visits to the cystic fibrosis outpatient department.

If the course goes well, the glucocorticoid dose is gradually reduced after a few weeks and set as low as possible so that fewer side effects occur. But there are also patients who keep relapsing as soon as the corticosteroid is stopped.

How long does an ABPA have to be treated?

Treatment of ABPA takes significantly longer than standard antibiotic therapy. Most patients are treated for three to six months.