Standard Steroid Tapering Protocol for Allergic Bronchopulmonary Aspergillosis (ABPA)

Initial Treatment Options

The European Respiratory Society recommends a 4-month course of low-to-moderate dose oral prednisolone starting at 0.5 mg/kg/day for 2-4 weeks, then tapered gradually to complete treatment over 4 months, for patients with ABPA 1, 2
The preferred steroid protocol starts with prednisolone 0.5 mg/kg/day for 2-4 weeks, then tapers gradually over the remaining period to complete a total 4-month course, with monitoring of serum total IgE every 6-8 weeks as a marker of disease activity 1, 2, 3, 4

Low-dose protocols result in fewer adverse events but may have lower clinico-radiological and immunological response at 6 weeks, according to the European Respiratory Society 3
High-dose protocols show better early response but similar frequency of ABPA exacerbations compared to low-dose protocols, as recommended by the European Respiratory Society 1

Regular assessment of clinical symptoms and monitoring of serum total IgE levels every 6-8 weeks are recommended during tapering 2, 4
Chest radiographs to assess for new infiltrates and pulmonary function tests to detect deterioration are also recommended 4

Patients are considered in remission when they remain without pulmonary infiltrates and/or eosinophilia for 6 months after oral steroid withdrawal, as defined by the European Respiratory Society 4
Asymptomatic patients with prolonged mucus plugging may still require treatment to prevent progression to irreversible bronchiectasis, according to the European Respiratory Society 2

Itraconazole (400 mg/day in two divided doses for 4 months) can be used as an alternative to steroids or as a steroid-sparing agent, as recommended by the European Respiratory Society 2
The goal of treatment is to control symptoms, prevent exacerbations, abrogate bronchiectasis progression, and minimize therapy-related adverse events, according to the European Respiratory Society 3

The European Respiratory Society recommends oral prednisolone at 0.5 mg/kg/day (15 mg daily) for 2-4 weeks, followed by a gradual taper over 4 months, along with appropriate antifungal therapy for a 10-year-old boy weighing 30 kg with ABPA 5, 6
Prednisolone 15 mg (0.5 mg/kg/day) orally once daily for 2-4 weeks, then taper to 15 mg on alternate days for 8 weeks, and further taper by 5 mg every 2 weeks until discontinuation, completing a total 4-month course 5, 7

Itraconazole capsules 100 mg twice daily (total 200 mg/day) with meals for 4 months, with a maximum dose not exceeding 600 mg/day, and monitoring for drug interactions with prednisolone and therapeutic drug monitoring (target trough level ≥0.5 mg/L) 5, 7

Liver function tests should be performed monthly if the patient is on itraconazole 7

Combination therapy with prednisolone and itraconazole should be considered for severe or recurrent cases, such as those with extensive bronchiectasis (≥10 segments) 6
Voriconazole 200 mg twice daily (maximum 600 mg/day) can be used as an alternative option for steroid-resistant cases if itraconazole is not tolerated 5, 7

Corticosteroid-related adverse effects, such as hyperglycemia, growth suppression, cushingoid features, and osteoporosis, should be monitored 7
Itraconazole-related adverse effects, such as headache, gastritis, nausea, and liver toxicity, should be monitored 7
Combination therapy increases the risk of exogenous Cushing's syndrome 6

Methylprednisolone should not be used with itraconazole due to the higher risk of Cushing's syndrome 6, 7
High-dose inhaled corticosteroids should be avoided with itraconazole due to potential drug interactions 8