Allergic bronchopulmonary aspergillosis therapy reference (2026)

ABPA therapy in 2026 organises around several layers.

Acute exacerbation: oral corticosteroids (prednisone) are the backbone for treating acute ABPA exacerbations, typically with a tapering schedule over weeks to months. Antifungal therapy with itraconazole (or alternative azoles) is added in many cases for steroid-sparing effect.

Maintenance: low-dose corticosteroid plus itraconazole is a traditional maintenance approach for recurrent ABPA. The challenge is balancing long-term corticosteroid side effects against ABPA control.

Biologic therapy: omalizumab (anti-IgE) is increasingly used in ABPA, particularly in cystic fibrosis-associated ABPA and in recurrent ABPA. Mepolizumab and benralizumab (anti-IL-5 pathway) are used for the eosinophilic-driven aspect, often as part of severe-asthma management in patients who also have ABPA. Dupilumab and tezepelumab use is widening based on the cross-condition atopic-and-eosinophilic biologic class maturity (covered in earlier rounds).

Antifungal therapy: itraconazole remains the most-used azole in ABPA. Voriconazole and isavuconazole are alternatives for itraconazole intolerance or interaction concerns. Inhaled antifungal programs are in earlier-stage development.

The diagnostic-pathway and monitoring question matters. Diagnostic criteria combine clinical features, IgE level, eosinophil count, Aspergillus-specific IgE and IgG, imaging (high-resolution CT showing characteristic central bronchiectasis and mucus impaction). Serial IgE monitoring guides therapy adjustment. Multidisciplinary care (pulmonology, allergy-immunology, sometimes infectious diseases for fungal-specific input) is standard.