What drugs are being developed to reduce steroid intake

Here’s a breakdown of what’s already available and what’s on the horizon:

🧬 Biologics – the biggest game-changer

These are antibody-based therapies that target specific immune pathways, rather than suppressing the whole immune system like steroids do.

✅ Already used off-label or in trials for ABPA:

1. Omalizumab (Xolair)

• Targets IgE (the allergy antibody that’s sky-high in ABPA)

• Already licensed for severe allergic asthma

• Studies show it reduces exacerbations, improves lung function, and helps taper off steroids

• Limitations: expensive, dosing based on IgE levels and weight (difficult in patients with very high IgE)

2. Mepolizumab (Nucala)

• Targets IL-5, which drives eosinophil activity

• Approved for eosinophilic asthma

• Used in some ABPA patients, especially when eosinophils remain high

• Can help reduce steroid use and fungal exacerbations

3. Benralizumab (Fasenra)

• Also targets IL-5 receptor – causes direct depletion of eosinophils

• Similar benefits to mepolizumab but may act faster

• Small studies and case reports show promise in ABPA and chronic pulmonary aspergillosis with eosinophilia

4. Dupilumab (Dupixent)

• Blocks IL-4 and IL-13, key drivers of Th2 inflammation

• Approved for asthma, atopic dermatitis, and nasal polyps

• Early evidence suggests it may benefit ABPA patients, especially those with co-existing nasal polyps or eczema

• Could be ideal for steroid-sparing in allergic fungal disease

💊 Antifungals as steroid-sparing agents

Already in use, but still being optimized:

• Itraconazole

• Voriconazole

• Posaconazole

• Isavuconazole (being explored more recently, better tolerated in some patients)

These reduce fungal burden, which helps turn down the immune overreaction—letting steroids be tapered or even avoided in some patients.

🔬 In Development or Under Investigation

🧪 Tezepelumab

• Blocks TSLP (thymic stromal lymphopoietin) – an early signal in allergic inflammation

• In trials for severe asthma

• May be helpful in ABPA down the line – trials are ongoing

🧪 Anti-IL-33 and Anti-ST2 therapies

• IL-33 is another “alarmin” involved in allergic responses

• Still in early stages, but being watched closely for steroid-sparing potential in allergic lung diseases

🌍 Other Strategies Being Studied

• Inhaled antifungals (e.g., inhaled voriconazole or amphotericin B) – may reduce systemic side effects

• Vaccines against Aspergillus – still early stage

• Mucolytics and anti-inflammatory antibiotics (e.g., azithromycin) as steroid-sparing support in some patients

🤔 What You Can Do Now

• If you’re struggling with steroid side effects or dependency, it’s totally reasonable to ask your respiratory team:

  • “Am I a candidate for a biologic like omalizumab or mepolizumab?”

  • “Is my antifungal therapy optimized?”

  • “Would a switch to inhaled or combination therapy help reduce my steroid use?”