🫁 ABPA Treatment: Why Are Steroids First, Even if They Can Increase Fungal Growth?

If you’ve been diagnosed with Allergic Bronchopulmonary Aspergillosis (ABPA), you may have heard that treatment often starts with oral steroids like prednisolone. But ABPA is triggered by a reaction to the Aspergillus fungus — so why use a treatment that might actually let that fungus grow more?

It’s a great question. This guide explains why steroids are still often the first step, what other treatments are available, and when they might be used.

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🌿 What Is ABPA?

ABPA is not an infection — it’s an allergic immune reaction in the lungs to the fungus Aspergillus fumigatus. This overreaction causes:

• Lung inflammation

• Mucus plugging

• Breathlessness and wheezing

• Possible long-term lung damage (e.g., bronchiectasis)

People with asthma or cystic fibrosis are more likely to develop ABPA.

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💊 Why Are Steroids Usually the First Treatment?

🔥 The key problem in ABPA is inflammation, not the fungus itself.

Steroids like prednisolone are often used first because they:

• Act quickly to calm the allergic immune reaction

• Reduce inflammation and mucus

• Help relieve symptoms fast (wheezing, tight chest, breathlessness)

• Prevent long-term damage if started early

Even though steroids may allow some fungal growth, their fast action against inflammation is often more important — especially in flare-ups.

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🍄 What About Antifungal Treatments?

Antifungals like itraconazole or posaconazole reduce the amount of Aspergillus in the lungs. This helps to:

• Reduce allergic triggers

• Prevent future flare-ups

• Lower the need for steroids

However, antifungals:

• Take weeks to work

• Don’t control inflammation well on their own during a flare

• Can have side effects and interact with other medications

➡️ That’s why they are often used after steroids, or alongside them — especially in people who flare up often or need steroids long term.

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🧬 What About Biologics?

Biologic therapies like:

• Omalizumab (anti-IgE)

• Dupilumab (blocks IL-4 and IL-13)

• Mepolizumab (anti-IL-5)

…are used to help regulate the immune system in patients who:

• Can’t tolerate steroids

• Have frequent relapses

• Need ongoing treatment despite antifungals

Biologics can help:

• Reduce steroid use

• Lower flare frequency

• Improve asthma control

But they’re not yet approved as first-line treatments and are generally reserved for more complex or persistent cases.

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✅ What Happens If My Symptoms Are Mild?

Good question. In mild ABPA (e.g. stable breathing, low IgE, no major lung damage), specialists may:

• Monitor closely before starting any treatment

• Try antifungals alone, especially if steroid use is risky

However, regular follow-up is essential to make sure inflammation doesn’t silently worsen.

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🔄 Typical ABPA Treatment Steps

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🧘 Staying Well with ABPA

• Follow your treatment plan closely

• Keep lungs clear with mucus clearance techniques

• Avoid damp, mouldy environments

• Keep up with regular check-ups and lung tests

• Let your team know if symptoms return

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🗨️ In Summary

Steroids are still first-line because they work fast to stop inflammation.
Antifungals and biologics are important longer-term options that help reduce fungal triggers and flare-ups — and may reduce or even replace steroids over time.

Every ABPA patient is different, and your care should be tailored to you.

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