Adding antifungals to oral steroids for ABPA in cystic fibrosis was not linked to better outcomes

Design

Retrospective cohort with inverse probability of treatment weighting

Population

3,096 people with cystic fibrosis and incident ABPA, 2006–2022

Primary outcome

FEV1 slope, time to pulmonary exacerbation and ABPA relapse

Effect

OCS alone FEV1% slope +0.24 (0.09–0.38); no benefit with antifungal alone or combination

This retrospective cohort followed 3,096 people with cystic fibrosis and a first diagnosis of allergic bronchopulmonary aspergillosis between 2006 and 2022, using inverse probability weighting to compare first treatments: oral corticosteroids alone, antifungals alone, or both.

Three-quarters received treatment. Oral steroids alone were associated with a small improvement in FEV1 slope after starting (0.24 percentage points, 95% CI 0.09–0.38). Neither antifungals alone nor the combination were associated with better lung function, fewer pulmonary exacerbations or fewer ABPA relapses than steroids alone. Larger centres and patients with prior exacerbations started antifungals sooner.

Antifungals are widely added in ABPA despite little evidence for their role in cystic fibrosis, and they bring drug interactions — notably with CFTR modulators — and liver toxicity. This observational analysis does not support adding them routinely. It cannot exclude benefit in subgroups, such as patients who cannot reduce steroids.

• Oral corticosteroids remain first-line treatment for ABPA in cystic fibrosis.
• Routine addition of an azole antifungal was not associated with better outcomes in this cohort.
• Azoles interact with CFTR modulators; check doses and interactions before co-prescribing.
• Consider antifungals selectively, for example to reduce steroid dependence, rather than routinely.

Why it matters

A common add-on may be adding interaction risk without measurable gain.

Don't overread it

This is observational; it cannot show that antifungals never help in ABPA.

The statistics, in plain English

Weighting balances measured differences between treatment groups, but patients given antifungals may have been sicker in unmeasured ways. 'No significant difference' here means the data cannot show a benefit, not that one is impossible.

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