Optimum duration of oral steroid therapy for ABPA in asthmatic children: A systematic review of literature and evidence-based guideline recommendation

Background: Allergic bronchopulmonary aspergillosis (ABPA) is a complication of asthma. Oral glucocorticoids are the mainstay of ABPA treatment and prednisolone is most commonly used for this purpose. However, there is lack of clarity on the most appropriate steroid treatment regimen. Objective: We undertook this systematic review to identify the optimum duration of steroid therapy for ABPA in children with asthma, to formulate an evidence-based recommendation. Our research question was framed as: In children with asthma having ABPA, what is the efficacy and safety of longer (>16 weeks), compared to shorter (<16 weeks) oral steroid therapy, on multiple clinical outcomes? Materials and Methods: We systematically searched existing guidelines for recommendations on steroid duration in ABPA, followed by systematic reviews answering the research question. As no relevant guideline or systematic review was identified, we conducted a de novo systematic review, searching for randomized controlled trials (RCT) comparing oral steroid regimens longer than 16 weeks versus those upto 16 weeks. We selected multiple patient-centric outcomes at 12 and >12 months to compare the two regimens. Results: We identified only one RCT addressing the review question. However, it was conducted in adult patients. There was no statistically significant long term difference in efficacy between longer (>16 weeks) and shorter (≤16 weeks) 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. Conclusion: We recommend against oral steroid regimens longer than 16 weeks, in children with asthma and ABPA. (conditional recommendation, very low certainty of evidence). There is a need for larger RCTs, evaluating the optimum steroid regimen (both dose and duration) in children.