What are the risk factors for Chronic Pulmonary Aspergillosis returning once antifungal therapy has been stopped?

Chronic pulmonary aspergillosis (CPA) can be a scary disease. People can be on antifungal drugs for a very long time, sometimes indefinitely. This can be worrying. Is it ever possible to come off antifungal drugs? Will the fungus ever go away? If the drugs are stopped, might the fungus come back again?

A recent research paper from the National Aspergillosis Centre has attempted to find some answers.

The researchers wanted to know how many people with CPA relapsed once their antifungal treatment was stopped. They also wanted to know what the risk factors for relapse might be. Understanding these risk factors might help to manage the disease better and might tell us which patients are at a low risk of relapse. This means that for these patients, treatment could be stopped earlier and so antifungal resistance, toxicity and cost could be reduced.

The scientists looked at people with aspergillosis who were treated at the National Aspergillosis Centre between 2009 and 2017. They identified at 102 people whose antifungal treatment (mainly voriconazole) was stopped during this period.

In 21% of people, CPA came back (21 out of 102 people). The key risk factors for relapse were the involvement of both lungs and, to a lesser extent, the presence of an aspergilloma.

In a different study of patients with CPA who were mainly treated with itraconazole, presence of disease in more than one lobe on CT scan, younger age and longer duration of treatment to achieve remission were associated with a higher risk of relapse.

Even though the authors found that CPA came back for 21% of people in this study, the chance of relapse is a very difficult thing to predict. Many people with CPA have other conditions which affect their health such as bacterial infections, non-tuberculous mycobacterial infections or COPD. Doctors might look at information from scans, microbiology or blood test results to help inform them as to whether relapse is likely, or they might rely on whether a person seems to be ‘getting worse’ clinically.

That said, this study showed that where both lungs are affected and an aspergilloma is present, the likelihood of relapse is increased, although it should be noted that antifungals were stopped mainly because of side effects or resistance development, and not because of achieving remission of disease.

The full paper is available on the Aspergillus Website.

This is a figure from the research paper showing that people with bilateral aspergillosis (i.e. aspergillosis involving both lungs) are more likely to relapse that people with aspergillosis involving one lung (unilateral disease). The green line is for both lungs, the blue line is for one lung.
This is a figure from the research paper showing that people with bilateral aspergillosis (i.e. aspergillosis involving both lungs) are more likely to relapse that people with aspergillosis involving one lung (unilateral disease). The green line is for both lungs, the blue line is for one lung.

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