Prolonged Itraconazole Therapy as Sole Treatment for Patients with Allergic Fungal Rhinosinusitis

Abstract

BackgroundCurrently, the mainstay of treatment for allergic fungal rhinosinusitis (AFRS) is surgical debridement along with topical or systemic steroids. However, prolonged systemic steroid therapy comes with side effects and is also sometimes contraindicated. Systemic antifungals have been used earlier as an adjunct to steroids or in refractory cases, but they have not been used as the sole primary treatment.ObjectiveTo study the effectiveness of sole Itraconazole therapy in patients with AFRS by comparison of clinical, radiological, and biochemical parameters before and after treatment.MethodsThirty‐four patients diagnosed with localized sino‐nasal AFRS were recruited and started on the tablet Itraconazole 200 mg orally twice daily for 3 months with q2weekly monitoring of liver function tests. The baseline clinical, radiological, and biochemical parameters were then compared with those after completion of 3 months of Itraconazole therapy.ResultsThere was significant difference between all the parameters—clinical: SNOT‐22 score (p < 0.001) and Meltzer endoscopy score (p < 0.001), radiological: Lund‐Mackay score (p = 0.004) and 20‐point CT score (p = 0.002), and biochemical: serum total IgE (p < 0.001), Aspergillus‐specific IgE (p < 0.001), and absolute eosinophil count (p < 0.001). The clearance of the disease was more in anterior sinuses than the posterior ones.ConclusionProlonged Itraconazole can be given as sole therapy in AFRS, especially in patients for whom steroids are contraindicated or in those who are awaiting surgery. It can result in symptomatic and radiological improvement, but surgery still remains the definitive treatment option for AFRS for complete clearance of disease.Level of Evidence3 Laryngoscope, 2023

Randomized Control Study to Analyse the Efficacy Budesonide Nasal Douching on Allergic Fungal Rhinosinusitis

“…In the study by Barsha et al, conducted during the COVID-19 period, the focus on preoperative administration of systemic itraconazole as a solo agent sheds light on the potential efficacy of systemic antifungal therapy in reducing the burden of AFRS. Systemic itraconazole may have a significant impact on various dimensions of the disease, potentially improving symptoms and preparing patients for surgery, even amidst challenging circumstances{16–18}. Moreover, diving deeper into the review of medical management, the study by Verma et al{19}, which investigated the combination of systemic steroids with itraconazole in a randomized controlled trial, further bolsters the case for combination therapy.…”

“…Systemic medical therapy will consist of oral prednisolone 1 mg/kg/day in tapering doses (1 mg/kg for the first 7 days, 0.8 mg/kg from 8 th to 14 th day, 0.6 mg/kg from 15-22 nd day, 0.4 mg/kg from 23-28 th day & 0.2 mg/kg from 29 th -42 nd day of treatment {8}. Tablet Itraconazole will be prescribed 400mg PO BD on the first day & it will be followed by 200 mg/day till 6 weeks {16}. The topical nasal douches will be based on budesonide.…”