Meta-Analysis Assesses Steroid, Antifungal, and Combination Therapies for Acute ABPA
A new meta-analysis of randomized controlled trials (RCTs) evaluating treatments for acute allergic bronchopulmonary aspergillosis (ABPA), presented at the American College of Allergy, Asthma & Immunology 2025 Annual Scientific Meeting, found that corticosteroids remain the most effective short-term option, while antifungals may serve as viable steroid-sparing alternatives.
Combination therapy may reduce relapse, though statistical significance was not achieved.
The systematic review, conducted per PRISMA guidelines, analyzed 6 RCTs involving 450 patients. Therapies compared included corticosteroid monotherapy, antifungal monotherapy (itraconazole or voriconazole), and combination corticosteroid-antifungal regimens.
At 6 to 8 weeks, corticosteroids demonstrated the highest clinical response rate (~100%), which was significantly greater than that of itraconazole (88%; p = 0.007) and similar to voriconazole (96%). All treatment arms achieved comparable reductions in total IgE levels, ranging from 45% to 50%.
One-year exacerbation rates were also similar across monotherapy groups (20%–30%). However, combination therapy was associated with a lower relapse rate at one year (20.6%) compared with monotherapy (33.0%), a difference that approached but did not reach statistical significance (p ≈ 0.05). The pooled odds ratio for relapse with combination therapy was 0.61 (95% CI, 0.20–1.90; p = 0.39).
Adverse events varied by treatment type. Corticosteroids were associated with metabolic side effects, including weight gain, cushingoid features, and hyperglycemia, while antifungal agents caused transient hepatic enzyme elevations. Importantly, no patients in any treatment arm discontinued therapy due to adverse events.
“No RCTs have evaluated biologics in acute ABPA,” the authors noted. Existing evidence on biologics such as omalizumab, mepolizumab, and dupilumab is limited to steroid-refractory or chronic ABPA cohorts.
The study concludes that while corticosteroids remain first-line for acute ABPA, antifungals show comparable long-term efficacy. Combination therapy may offer relapse prevention benefits. “Future RCTs should evaluate biologics in acute ABPA and compare their efficacy with first-line therapies,” the authors wrote.
Reference
Comparative meta-analysis of corticosteroids, antifungal therapy, and combination treatment in allergic bronchopulmonary aspergillosis. Presented at: American College of Allergy, Asthma & Immunology 2025 Annual Scientific Meeting; November 6-10, 2025; Orlando, FL.
