Patient handout

Allergic Bronchopulmonary Aspergillosis (ABPA)

PRODUCTION

1. Your condition

This handout is for allergic bronchopulmonary aspergillosis (abpa). Your care team identified this based on: poorly-controlled or steroid-dependent asthma — screen for abpa (isham-abpa; agarwal clin exp allergy 2013 pmid 23889240).

Other reasons your team may use this plan: cystic fibrosis with clinical/spirometric deterioration — cf-abpa screen (isham-abpa; cf-abpa distinct entity, ashkenazi pmid 29950869); expectoration of brownish/black mucus plugs (characteristic of abpa mucoid impaction; agarwal review pmid 38154470); fleeting/transient pulmonary infiltrates or central bronchiectasis on imaging (isham supportive radiology pmid 23889240).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
prednisolone	0.5 mg/kg/day (medium-dose Agarwal protocol)	PO	once daily	TAPER (encoded here, NOT a taper_plan field): medium-dose Agarwal protocol — 0.5 mg/kg/day × 1–2 wk, then 0.5 mg/kg every other day × 8 wk, then taper by 5 mg every 2 wk over ~3–5 months total, guided by symptoms + total IgE. Agarwal Eur Respir J 2015 (PMID 26585431): medium-dose vs high-dose RCT — exacerbation at 1 yr 50% vs 40.9% (p=0.59), glucocorticoid-dependent at 2 yr 14.6% vs 11.4% (p=0.88); cumulative dose + adverse effects significantly LOWER with medium-dose → medium-dose as effective and safer. RxCUI 8638 RxNav-verified IN

Plan: ABPA stage-directed therapy — OCS induction → azole steroid-sparing → biologic (ISHAM-ABPA; Agarwal)

3. When to call your provider

Contact your care team if any of the following happen:

Massive hemoptysis from bronchiectasis → inpatient/IR (registry workup.hemoptysis)
Severe ABPA exacerbation with respiratory compromise → admit
Azole hepatotoxicity (transaminitis/jaundice) → stop azole, admit if severe (Wark Cochrane PMID 15266440)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

On azole: transaminitis (>3–5× ULN) or jaundice = HEPATOTOXICITY → STOP azole, reassess; OR subtherapeutic trough (itraconazole bioassay <1 µg/mL; voriconazole <1 µg/mL) = TREATMENT FAILURE RISK → adherence/absorption review, dose adjust, or switch azole/escalate to biologic (Stevens NEJM 2000 PMID 10717010; Wark Cochrane PMID 15266440)
Massive hemoptysis (>200 mL/24 h or hemodynamic/airway compromise) from ABPA central bronchiectasis (Agarwal PMID 38154470)(life-threatening)
ABPA requiring treatment in a pregnant or potentially-pregnant patient — triazoles (itraconazole/voriconazole) are TERATOGENIC and CONTRAINDICATED (azole embryopathy) (azole label; ISHAM management PMID 23889240)

5. Follow-up

Relapse surveillance (clinical + total-IgE + radiology); complete the corticosteroid taper; long-term bronchiectasis care (airway clearance, exacerbation plan, anti-pseudomonal if colonised); biologic step-down only in sustained remission; vaccination; environmental Aspergillus exposure counselling (Agarwal PMID 38154470; PMID 23889240)

6. Sources

Guideline: ISHAM-ABPA working group diagnostic + staging criteria (Agarwal, Clin Exp Allergy 2013) + 2023 modern review (Agarwal/Muthu/Sehgal, Semin Respir Crit Care Med) — ABPA RCT evidence base (Agarwal PGIMER program) + Cochrane azoles