Treatment Options for Invasive Aspergillosis

Primary Treatment Options

Voriconazole is recommended as the primary treatment for invasive aspergillosis in most patients with strong evidence supporting its use (A-I level recommendation) 1, 4
The Infectious Diseases Society of America recommends voriconazole as the primary treatment for invasive aspergillosis due to its superior efficacy and survival outcomes compared to other antifungal agents 1, 2
Dosing regimen: 6 mg/kg IV every 12 hours for 1 day (loading dose), followed by 4 mg/kg IV every 12 hours or 200 mg oral twice daily for maintenance 3, 4
Oral therapy can be maximized by using a dose of 4 mg/kg rounded up to convenient pill sizes 4
For seriously ill patients, the parenteral formulation is recommended 4

Liposomal amphotericin B (L-AMB) at 3-5 mg/kg/day IV is an alternative primary therapy for patients who cannot tolerate voriconazole (A-I recommendation) 1, 3
The American College of Clinical Pharmacy recommends liposomal amphotericin B as an alternative primary therapy for patients who cannot tolerate voriconazole 1
Isavuconazole is another alternative first-line agent with comparable efficacy to voriconazole 3, 5

For patients failing primary therapy, options include lipid formulations of amphotericin B (LFAB) (A-II recommendation) 1, 3
Posaconazole (B-II recommendation) 1, 3
Itraconazole (B-II recommendation) 1, 3
Caspofungin (B-II recommendation) 1, 3
Micafungin (B-II recommendation) 1, 3

Voriconazole is the primary recommendation for systemic antifungal therapy of CNS aspergillosis (A-II) 6
The Infectious Diseases Society of America recommends itraconazole, posaconazole, or lipid formulations of amphotericin B for patients intolerant or refractory to voriconazole (B-III) 6

Both surgery and either systemic voriconazole or a lipid formulation of amphotericin B are recommended for invasive Aspergillus fungal sinusitis 2
Surgical removal alone can be used to treat Aspergillus fungal ball of the paranasal sinus 2

Treatment should continue for a minimum of 6-12 weeks 4, 3
In immunosuppressed patients, therapy should be continued throughout the period of immunosuppression and until lesions have resolved 4

Serial clinical evaluation of all symptoms and signs 4
Radiographic imaging, usually with CT, at regular intervals 4
Serial serum galactomannan assays can be used for monitoring, though this remains investigational 4

Antifungal prophylaxis with posaconazole is recommended in HSCT recipients with graft-versus-host disease (GVHD) who are at high risk for invasive aspergillosis 1
The American Society for Transplantation and Cellular Therapy recommends antifungal prophylaxis with posaconazole in neutropenic patients with acute myelogenous leukemia or myelodysplastic syndrome who are at high risk for invasive aspergillosis (A-I) 1