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Oral antifungals may benefit severe asthma patients

Patients who suffer from severe asthma may benefit from oral antifungal therapy, according to researchers at the University of Manchester.

The study (PDF, 407K), published in the American Journal of Respiratory and Critical Care Medicine (2009;179:11), recruited 58 patients who had both severe asthma and allergic sensitivity to at least one of seven common fungi. The patients were randomised to receive either oral itraconazole 200mg twice daily or placebo.

The primary end point was a comparison of the change in Asthma Quality of Life Questionnaire score for the two groups. The AQLQ is scored on a scale of 1 to 7, with 7 representing an excellent quality of life.

The itraconazole group had a higher increase in AQLQ score of 0.85 (95 per cent confidence interval 0.28–1.41) compared with -0.01 (95 per cent confidence interval -0.43–0.42) for the placebo group (P=0.014).

This compares favourably, say the authors, with a rise of 0.15 with regular salbutamol, 0.55 with long acting beta-2 agonist therapy and 0.42 with anti-IgE therapy.

An improvement in the AQLQ score of at least 0.75 was seen in 54 per cent of the itraconazole group compared with 18 per cent of the placebo group (P=0.013).

The rhinitis score improved (-0.43) in the antifungal group and deteriorated (0.17) in the placebo group (P=0.013). Total serum IgE decreased in the antifungal group by 27 per cent and increased in the placebo group by 12 per cent (P=0.001). However, morning peak flow did not improve significantly in the treatment group (-0.22L versus -0.02L; P=0.22).

After 32 weeks of treatment 41 patients remained in the study. Adverse events requiring discontinuation occurred in 17 patients, 11 of whom were in the antifungal group. The reported adverse events included nausea, oedema, breathlessness, joint pains, muscle weakness and Cushingoid symptoms.

The authors stress that the sample size for this study was small and that larger studies are required to assess more accurately the impact of antifungal therapy on lung physiology and to confirm the results.

The author of the study, David Denning, said: “This study indicates that fungal allergy is important in some patients with severe asthma, and that oral antifungal therapy is worth trying in difficult-to-treat patients. Clearly itraconazole will not suit everyone and is not always helpful, but when it is the effect is dramatic.

“These findings open the door to a new means of helping patients with severe asthma, and raise intriguing questions related to fungal allergy and asthma.”

Citation: The Pharmaceutical Journal URI: 10045019

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