New insights into the treatment of asthma complicated by allergic bronchopulmonary aspergillosis.

Abstract

Introduction: Allergic bronchopulmonary aspergillosis (ABPA) is a lung disorder that arises in individuals with asthma or cystic fibrosis due to an exaggerated immune response to Aspergillus fumigatus. It leads to mucus plugging, recurrent exacerbations, and progressive bronchiectasis. Despite established diagnostic criteria, ABPA remains underdiagnosed, primarily due to its overlap with severe asthma and limited clinical awareness. Evolving insights into immunopathogenesis and the emergence of targeted therapies have begun to transform the management of ABPA.

Areas covered: We discuss the current evidence on immunopathogenesis, treatment, and monitoring of ABPA in asthma. The review covers established and emerging therapies, including systemic glucocorticoids, oral triazoles (such as itraconazole), inhaled antifungals, and biological agents. We provide practical guidance for initiating treatment based on disease phenotype and discuss treatment monitoring using clinical symptoms, serum biomarkers, chest imaging, and lung function tests.

Expert opinion: The management of ABPA is poised for a paradigm shift toward precision medicine. Future strategies will likely be driven by international registries, biomarker discovery using omics-based platforms, and the identification of endotype- and phenotype-specific treatments. Randomized trials comparing biologic therapies, combination approaches using antifungals and biologics, and the development of inhaled antifungal delivery systems are likely to reshape the management of ABPA.