60% of Patients with Severe Asthma with Fungal Sensitization (SAFS) Respond to Oral Antifungal Therapy

Some patients with severe asthma are sensitized to one or more fungi, a clinical entity categorized as severe asthma with fungal sensitization (SAFS). It is not known whether SAFS responds to antifungal therapy. Studies with the antifungal agent itraconazole showed benefit in allergic bronchopulmonary aspergillosis and the authors decided to give it a try in SAFS as well.

58 patients with severe asthma sensitized to at least one of seven fungi by skin prick or specific IgE testing were recruited. All had total IgE less than 1,000 IU/ml and negative Aspergillus precipitins. They were treated with oral itraconazole (200 mg twice daily) or placebo for 32 weeks, with follow-up for 16 weeks.


Various fungi including Penicillium and Aspergillus spp. growing in axenic culture. Image source: Wikipedia, Dr. David Midgley Cultures: Dr. David Midgley University of Sydney, Australia, Creative Commons Attribution ShareAlike 2.5 License.

Approximately 60% of patients with severe asthma with fungal sensitization (SAFS) responded to antifungal therapy as judged by large improvements in quality of life, reduced rhinitis, decrease in total serum IgE levels, and improved morning peak expiratory flow.

However, the FEV1 did not improve during the 16-week course of antifungal therapy. In addition, 5 patients in the antifungal group (the total number of patients was 58) developed adverse events requiring discontinuation of itraconazole.

Itraconazole (marketed as Sporanox by Janssen Pharmaceutica) is a triazole antifungal agent invented in 1984. Elevated alanine aminotransferase levels are found in 4% of people taking itraconazole. On average, 180 generic capsules cost $360. If a patient is prescribed three capsules twice daily for 3 months, the patient would spend more than $1,080 (more than 540 capsules).

Severe asthma - differential diagnosis and management (click to enlarge the image).

Regarding the mold/asthma link, certain findings have been found consistently: 1. the mold has to be visible, 2. the mold has to be in the room where they live, 3. the patient does not have to be allergic to mold to have symptoms because the some molds release irritant volatile compounds in the air.

Which of the following sampling devices is the "sampler of choice" for outdoor aeroallergens?

A. Andersen sampler

B. Hirst-type sampler

C. Cyclone sampler

D. Rotorod sampler

Answer: B

References:
Severe Asthma With Fungal Sensitization May Respond to Oral Antifungal Therapy. Medscape, 12/2008.
Randomized Controlled Trial of Oral Antifungal Treatment for Severe Asthma with Fungal Sensitization. David W. Denning et al. American Journal of Respiratory and Critical Care Medicine Vol 179. pp. 11-18, (2009).
Itraconazole, from Wikipedia, the free encyclopedia.
Image source, top right: Wikipedia, public domain.

Related:
Specific IgE Response to Trichophyton and Asthma Severity. Hirofumi Matsuoka et al. CHEST April 2009 vol. 135 no. 4 898-903.
An approach to recalcitrant, severe asthma - AAAAI Ask the Expert, 2011.