Anti‐fungal agents in the treatment of chronic pulmonary aspergillosis: Systematic review and a network meta‐analysis

Abstract

Background Oral itraconazole and voriconazole are currently recommended in the initial management of chronic pulmonary aspergillosis (CPA). However, only a few studies have compared outcomes with different anti‐fungal agents (AFAs) in treating CPA. Herein, we perform a network meta‐analysis comparing the efficacy of different AFAs in CPA. Methods We searched the PubMed and EmBase databases to identify studies (either randomised‐controlled trials [RCTs] or observational) reporting treatment outcomes with AFAs in patients of CPA. The study quality was assessed using the Newcastle‐Ottawa scale (NOS). We performed a network meta‐analysis to compare the relative efficacy of different AFAs in treating CPA. The primary outcome was a favourable response to treatment with AFAs. Results We found ten studies (718 patients) investigating different AFAs (oral AFAs [n = 5], intravenous AFAs [n = 5]) in the treatment of CPA. There were four RCTs and six observational studies. The studies using oral agents reported long‐term outcomes (>12 weeks), while those with intravenous agents provided only short‐term outcomes (<6 weeks). We found one study of posaconazole and none with isavuconazole for treating CPA. Amongst the oral agents, itraconazole was significantly better than supportive care and was ranked as the best oral AFA on network rank analysis. We found all intravenous AFAs to be equally effective. Intravenous echinocandins and voriconazole were ranked best for achieving a favourable treatment response. Conclusion Oral itraconazole may be preferred over other azoles as the initial therapy for CPA. Amongst the intravenous agents, echinocandins and voriconazole may be preferred over amphotericin B. Randomised‐controlled trials comparing different AFAs, especially the newer AFAs, are urgently needed.

Identification of distinct immunophenotypes in chronic pulmonary aspergillosis using cluster analysis

“…Finally, no serological marker is available to assess the treatment response or relapse in CPA. 1,9,20 In cluster 2, treatment response could also be monitored by serially measuring serum total IgE, like ABPA. 18 Our study has a few limitations.…”

Efficacy of Intrabronchial Voriconazole Instillation for Inoperable Pulmonary Aspergilloma: A Pilot Randomized Controlled Trial

“…The recurrence of hemoptysis is due to the presence of aspergilloma that keeps on eroding the vessels in wall of the cavity and formation of new collateral vessels. The drugs available against Aspergillosis include the polyene (amphotericin B), the azoles (itraconazole and voriconazole), and echinocandins [24]. Systemic use of antifungals has several limitations such as nephrotoxicity, unpredictable oral absorption, need for drug-level monitoring, a long duration of treatment, limited concentration in the aspergilloma cavity, and relapse after discontinuation [25].…”

Chronic Pulmonary Aspergillosis During Convalescence From Severe COVID-19 Treated With Oral Itraconazole: A Report of Two Cases

“…One of the limitations of this report is that we could follow the clinical courses in both cases for only less than two months and CPA usually requires treatment for at least six months [ 11 ]. One network-centric meta-analysis has recently reported that ITCZ is the best oral antifungal agent for the initial treatment of CPA [ 12 ]. Further studies on CPA treatment following COVID-19 are required.…”