Role of Biologics in Allergic Bronchopulmonary Aspergillosis (ABPA)

Introduction to Biologics in ABPA

The European Respiratory Society recommends biologics as effective treatment options for treatment-dependent ABPA, with omalizumab being the most extensively studied agent, though emerging evidence suggests anti-IL-4Rα therapy (dupilumab) may be superior to other biologic classes 1, 2

Biologics should be considered in patients with treatment-dependent ABPA (10-25% of patients) who require ongoing therapy to maintain disease control despite conventional treatment with oral glucocorticoids and/or itraconazole 1, 2, 3
The American Thoracic Society suggests biologics for patients with frequent exacerbations (≥2 in the last 1-2 years) despite optimal conventional therapy, although the specific guideline is not mentioned in the provided text, the European Respiratory Journal is referenced 4
Biologics serve as an alternative to continuous low-dose glucocorticoids in steroid-dependent patients, which should be the last resort 1, 2, 3
The European Respiratory Society recommends biologics for maintenance therapy during remission to prolong the remission period, particularly in those with prior treatment-dependent disease 1, 2, 4

Omalizumab is the most extensively studied biologic in ABPA with the strongest evidence base 1, 2, 3
Omalizumab is a rational choice given ABPA's hallmark elevated IgE levels 1, 2, 3
Real-world data demonstrates improvement in symptoms, reduction in exacerbations and asthma hospitalizations, improved lung function, and reduced oral steroid doses with omalizumab 1, 3

For treatment-dependent ABPA, consider long-term itraconazole, nebulized amphotericin B, or biological agents (Level of Consensus: 71% for biologics) 1, 2
The preferred biologic choice based on current evidence is dupilumab (anti-IL-4Rα), although the specific guideline society is not mentioned in the provided text, the European Respiratory Journal is referenced
Omalizumab (most studied, proven safe even with very high IgE) is an alternative if dupilumab is unavailable or contraindicated 3

Initial assessment (8-12 weeks) should include clinical symptoms improvement, serum total IgE reduction ≥35% from baseline, and chest radiograph improvement 1, 3, 4
Ongoing monitoring should include clinical review, serum total IgE levels, and lung function tests every 3-6 months for the first year, then every 6-12 months 1, 2, 3