Voriconazole for chronic pulmonary aspergillosis: a prospective multicenter trial

Abstract

Early evidence suggests the efficacy of voriconazole for chronic pulmonary aspergillosis (CPA). We conducted a prospective, open, multicenter trial to evaluate the efficacy and safety of voriconazole for proven CPA in minimally or non-immunocompromised patients. Patients had CPA confirmed by chest computed tomography (CT) and/or endoscopy, positive Aspergillus culture from a respiratory sample, and positive serologic test for Aspergillus precipitins. Patients received voriconazole (200 mg twice daily) for a period of 6–12 months and were followed for 6 months after the end of therapy (EOT). The primary endpoint was global success at 6 months, defined as complete or partial (≥50 % improvement) radiological response and mycological eradication. Forty-one patients with confirmed CPA were enrolled. All patients had A. fumigatus as the etiologic agent. By EOT, five patients had died from comorbidities and seven had discontinued voriconazole due to toxicity. The global success rate at 6 months was 13/41 (32 %): 10/19 (53 %) for chronic necrotizing aspergillosis and 3/22 (14 %) for chronic cavitary aspergillosis ( p = 0.01). The respective success rates at EOT were 58 and 32 %. Clinical symptoms and quality of life also improved during treatment. Voriconazole is effective for CPA, with acceptable toxicity. The response rate is higher and obtained more rapidly in necrotizing than cavitary forms. Electronic supplementary material The online version of this article (doi:10.1007/s10096-012-1690-y) contains supplementary material, which is available to authorized users.

Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management

“…Oral triazole therapy for CCPA is now considered the standard of care. Oral voriconazole is also effective for CCPA with an acceptable tolerability in several studies as primary therapy (SoR A and QoE II) or after itraconazole (either because of failure or intolerance) (SoR A and QoE II) [15,30,[89][90][91][92]. A retrospective cohort study supports the evidence that oral posaconazole may be a potential alternative treatment (SoR B and QoE II) [59].…”

“…Some cases of SAIA have responded to long-term oral itraconazole in some cohort studies [31,86,87,93,94]. A prospective multicentre study of CPA patients treated with voriconazole confirmed data obtained in a preliminary study showing that voriconazole efficacy was significantly greater in patients with SAIA than in those with CCPA [15,90,95].…”

“…As a general recommendation, outpatient oral triazole therapy likely provides some therapeutic benefit in cases of progressive and/or symptomatic CPA. Quality of life measures, such as the St. George's Respiratory Questionnaire [84,85] or the Respiratory Symptoms Score [15], may guide the decision-making process.…”

“…Subsequently criteria for the diagnosis and categorisation of patients were proposed in 2003 [10], and later refinements to the criteria and classification of the disease were proposed [12,13]. Several prospective treatment studies were undertaken [14][15][16]. The global burden of CPA following pulmonary TB ( prevalence of 1.74 million), complicating allergic bronchopulmonary aspergillosis (ABPA) (CPA prevalence of 411 000) and sarcoidosis (CPA prevalence of 72 000) have been estimated [17][18][19], showing the extent of the problem internationally.…”

Pulmonary solid tumor with coexisting pulmonary aspergillosis: case reports and literature review

“…Optimal treatment of pulmonary aspergillosis complicated with noncavitary lung tumor has not yet been established; whether antifungal treatment is overtreatment remains controversial. Antifungal treatment including itraconazole or voriconazole have efficacy for CPA and cavitary CPA (20)(21)(22)(23)(24). However, no studies have evaluated the significance of antifungal treatment for aspergillosis coexisting with lung carcinomas.…”