Page 45 - Škrgat, Sabina, ed. 2023. Severe Asthma Forum - Monitoring and Treatable Traits in Severe Asthma. Koper: University of Primorska Press. Severe Asthma Forum, 2
P. 45
agement of AFAD ommendation from the group of Wardlav1 45
recommends that three months is necessary
To a large extent management of AFAD is and usually sufficient. Repeated courses are aspergillus sensitisation and severe asthma clinical outcomes
similar to the management of the underlying sometimes necessary.
airway disease with personalised approach.
An approach toward treatment of T2 treat- Conclusions
able trait (eosinophilic pattern of disease) in-
cludes inhaled corticosteroids. They are a cor- The term AFAD has a liberal definition, based
nerstone of therapy. There exist a theoretical on the presence of IgE sensitisation to thermo-
risk of augmentation od fungal colonisation, tolerant fungi and evidence of fungal-relat-
but with the approach toward using the low- ed lung damage23. As such it is more inclusive
est dose of inhaled corticosteroids to achieve than ABPA or SAFS, not being focused on to-
a control of disease this might not be serious tal IgE and not restricted to severe asthmatics
problem in clinical practice. In severe cases only. The recommendation supports close pa-
low dose continuous or intermittent oral cor- tient s follow up due to detecting and prevent-
ticosteroids (OCS) are necessary to achieve ing long term lung damage17.
control.
Furthermore, unlike SAFS, AFAD dis-
Since OCS are seen as a last resort in tinguishes between sensitisation to thermotol-
asthma therapeutic algorithms, anti-T2 bio- erant and non-thermotolerant fungi5.
logical therapy is a possible option in AFAD
treatment. Evidence on omalizumab, but also Literature
mepolizumab, benralizumab and dupilumab
are based mostly on case series and reports. 1. Wardlaw AJ, Rick EM, Ozyigit LP, et
Favourable reported responses include signif- al. New Perspectives in the Diagno-
icant reduction in OCS burden, reduction sis and Management of Allergic Fungal
in acute exacerbations, improvement in lung Airway Disease, J Asthma Allergy. 2021
function and improvement in patients out- May 25:14:557-73.
comes120–23.
2. Denning DW, O’Driscoll BR, Hogabo-
The place of antifungal therapy in AFAD am CM, et al. The link between fun-
remains uncertain. Whilst open studies have gi and severe asthma: a summa-
often reported a benefit, placebo controlled, ry of the evidence. Eur Respir J. 2006
blinded studies have shown either no benefit Mar;27(3):615-26.
or a modest improvement at best compared
to standard of care, which these days proba- 3. Denning DW, Pashley C, Hartl D, et al.
bly includes biological therapy. Clinical prac- Fungal allergy in asthma-state of the art
tice would suggest that in the majority of pa- and research needs. Clin Transl Allerg.
tients with AFAD the benefits of azole therapy 2014 Apr 15:4:14. doi: 10.1186/2045-
are not outweighed by side effects. However, 7022-4-14.
where fungal bronchitis is present, particular-
ly in the context of difficult to treat exacerba- 4. Knutsen AP, Bush RK, Demain JG, et
tions, they are an important adjunct to thera- al. Fungi and allergic lower respiratory
py and can lead to a dramatic improvement tract diseases. J Allergy Clin Immunol.
in symptoms in relatively short time. Positive 2012 Feb;129(2):280-3.
sputum fungal culture seems to be a useful bi-
omarker of a response to antifungal therapy 5. Pashley CH, Wardlaw AJ. Allergic fun-
even in the case of Candida species if it is per- gal airways disease (AFAD): an under-
sistent5. There are no definitive guidelines on recognized asthma endotype. Myco-
how long a course should be, but clinical rec- pathologia. 2021 Oct;186(5):609-22.
6. Agarwal R, Chakrabarti A, Shah A,
e. Allergic bronchopulmonary asper-
gillosis: review of literature and pro-
recommends that three months is necessary
To a large extent management of AFAD is and usually sufficient. Repeated courses are aspergillus sensitisation and severe asthma clinical outcomes
similar to the management of the underlying sometimes necessary.
airway disease with personalised approach.
An approach toward treatment of T2 treat- Conclusions
able trait (eosinophilic pattern of disease) in-
cludes inhaled corticosteroids. They are a cor- The term AFAD has a liberal definition, based
nerstone of therapy. There exist a theoretical on the presence of IgE sensitisation to thermo-
risk of augmentation od fungal colonisation, tolerant fungi and evidence of fungal-relat-
but with the approach toward using the low- ed lung damage23. As such it is more inclusive
est dose of inhaled corticosteroids to achieve than ABPA or SAFS, not being focused on to-
a control of disease this might not be serious tal IgE and not restricted to severe asthmatics
problem in clinical practice. In severe cases only. The recommendation supports close pa-
low dose continuous or intermittent oral cor- tient s follow up due to detecting and prevent-
ticosteroids (OCS) are necessary to achieve ing long term lung damage17.
control.
Furthermore, unlike SAFS, AFAD dis-
Since OCS are seen as a last resort in tinguishes between sensitisation to thermotol-
asthma therapeutic algorithms, anti-T2 bio- erant and non-thermotolerant fungi5.
logical therapy is a possible option in AFAD
treatment. Evidence on omalizumab, but also Literature
mepolizumab, benralizumab and dupilumab
are based mostly on case series and reports. 1. Wardlaw AJ, Rick EM, Ozyigit LP, et
Favourable reported responses include signif- al. New Perspectives in the Diagno-
icant reduction in OCS burden, reduction sis and Management of Allergic Fungal
in acute exacerbations, improvement in lung Airway Disease, J Asthma Allergy. 2021
function and improvement in patients out- May 25:14:557-73.
comes120–23.
2. Denning DW, O’Driscoll BR, Hogabo-
The place of antifungal therapy in AFAD am CM, et al. The link between fun-
remains uncertain. Whilst open studies have gi and severe asthma: a summa-
often reported a benefit, placebo controlled, ry of the evidence. Eur Respir J. 2006
blinded studies have shown either no benefit Mar;27(3):615-26.
or a modest improvement at best compared
to standard of care, which these days proba- 3. Denning DW, Pashley C, Hartl D, et al.
bly includes biological therapy. Clinical prac- Fungal allergy in asthma-state of the art
tice would suggest that in the majority of pa- and research needs. Clin Transl Allerg.
tients with AFAD the benefits of azole therapy 2014 Apr 15:4:14. doi: 10.1186/2045-
are not outweighed by side effects. However, 7022-4-14.
where fungal bronchitis is present, particular-
ly in the context of difficult to treat exacerba- 4. Knutsen AP, Bush RK, Demain JG, et
tions, they are an important adjunct to thera- al. Fungi and allergic lower respiratory
py and can lead to a dramatic improvement tract diseases. J Allergy Clin Immunol.
in symptoms in relatively short time. Positive 2012 Feb;129(2):280-3.
sputum fungal culture seems to be a useful bi-
omarker of a response to antifungal therapy 5. Pashley CH, Wardlaw AJ. Allergic fun-
even in the case of Candida species if it is per- gal airways disease (AFAD): an under-
sistent5. There are no definitive guidelines on recognized asthma endotype. Myco-
how long a course should be, but clinical rec- pathologia. 2021 Oct;186(5):609-22.
6. Agarwal R, Chakrabarti A, Shah A,
e. Allergic bronchopulmonary asper-
gillosis: review of literature and pro-
