Which steroid regimen (low dose or high dose) should be used for the treatment of allergic bronchopulmonary aspergillosis in children with asthma? A systematic review of literature and evidence-based guideline recommendation

Abstract

Background: Allergic bronchopulmonary aspergillosis (ABPA) is a complex pulmonary disorder caused by immunological response to Aspergillus fumigatus antigen. Untreated patients develop recurrent exacerbations of respiratory symptoms, bronchiectasis, and even respiratory failure. Oral glucocorticoids are currently the mainstay of treatment in acute ABPA and prednisolone is the most commonly used medication. Different regimes have been used for treating ABPA. Objective: This systematic review was undertaken to identify the most appropriate steroid treatment regimen for acute ABPA in children with asthma, by comparing the efficacy and safety of lower dose vs. higher dose; in order to develop an evidence-based recommendation. Methods: We undertook a comprehensive literature search for high quality guidelines addressing the issue. Finding none, we conducted a systematic review of randomized controlled trials (RCTs) to compare low dose versus high dose steroid regimens for the treatment of ABPA in children with asthma. Results: We identified one randomized controlled trial addressing the review question. However, it was conducted in adult patients. It showed no statistically significant difference in efficacy between low dose vs high dose regimens; however, adverse effects were more frequent with higher doses and duration. The available evidence was graded as ‘very low certainty’ due to methodological limitations. Conclusions: We recommend using low dose steroid therapy regimen (0.5 mg/kg/day for the first 2 weeks, followed by a progressive tapering) for treatment of ABPA in children with asthma (conditional recommendation, very low certainty of evidence). Larger studies are urgently needed to identify the optimal regimen for treating children with asthma having ABPA.