The role of antifungals in the management of patients with severe asthma
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(2020) 10:46 Rapeport et al. Clin Transl Allergy https://doi.org/10.1186/s13601-020-00353-8
Open Access
REVIEW
The role of antifungals in the management of patients with severe asthma W. Garth Rapeport1* , Kazuhiro Ito1,2 and David W. Denning3
Abstract In patients with asthma, the inhalation of elevated amounts of fungal spores and hyphae may precipitate the onset of asthma or worsen control to the extent of being life-threatening. Sensitisation to fungi, especially Aspergillus fumigatus, is found in 15% to 48% of asthmatics in secondary care and is linked to worse asthma control, hospitalisation, bronchiectasis and fixed airflow obstruction, irrespective of whether allergic bronchopulmonary aspergillosis (ABPA) is diagnosed. ABPA represents a florid response to the presence of Aspergillus spp. but up to 70% of patients with severe asthma exhibit sensitisation to different fungi without meeting the diagnostic criteria for ABPA. The presence of persistent endobronchial colonisation with fungi, especially A. fumigatus, is linked to significantly higher rates of radiological abnormalities, lower post-bronchodilator FEV1 and significantly less reversibility to short acting bronchodilators. The therapeutic benefit for antifungal intervention in severe asthma is based on the assumption that reductions in airway fungal burden may result in improvements in asthma control, lung function and symptoms (especially cough). This contention is supported by several prospective studies which demonstrate the effectiveness of antifungals for the treatment of ABPA. Significantly, these studies confirm lower toxicity of treatment with azoles versus high dose oral corticosteroid dosing regimens for ABPA. Here we review recent evidence for the role of fungi in the progression of severe asthma and provide recommendations for the use of antifungal agents in patients with severe asthma, airways fungal infection (mycosis) and fungal colonisation. Documenting fungal airways colonisation and sensitisation in those with severe asthma opens up alternative therapy options of antifungal therapy, which may be particularly valuable in low resource settings. Keywords: Severe asthma, ABPA, Antifungals, Biologics, Itraconazole, Voriconazole, Aspergillus Background Severe asthma is a complex heterogenous disease which has been described as “the requirement for high dose inhaled corticosteroids plus a second controller and/ or systemic corticosteroids to prevent it from becoming ‘‘uncontrolled’’ or which remains ‘‘uncontrolled’’ despite this therapy” [1]. The natural history of severe asthma is characterised by a long-term decline in lung function, irreversible airways remodelling and increased risk for life-threatening *Correspondence: [email protected] 1 Airways Disease, National Heart and Lung Institute, Imperial College, London SW3 6LY, UK Full list of author information is available at the end of the article
exacerbations. In recent years, significant effort has been directed towards the identification of specific phenotypes which ar
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