Paper
Is voriconazole more efficacious than itraconazole in children with acute exacerbation of allergic bronchopulmonary aspergillosis? A systematic review of literature and evidence-based guideline recommendation
Published Sep 1, 2023 · Sanjay Bafna, Hardeep Kaur, Pawan Kalyan
Journal of Pediatric Pulmonology
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Abstract
Background: Oral steroid therapy is accepted as the standard treatment of allergic bronchopulmonary aspergillosis (ABPA). Additional antifungal agents have been studied in clinical trials among adult patients with acute ABPA exacerbation. However, the optimal antifungal agent has not been identified. Some recent studies suggested that voriconazole could be used in adults with ABPA, instead of itraconazole. Objectives: We undertook this systematic review of literature to determine if voriconazole is more efficacious than itraconazole in children with acute exacerbation of ABPA, to develop an evidence-based guideline recommendation. Methods: We undertook a stepwise search for preexisting guidelines, followed by search for systematic reviews. As no relevant guideline or systematic review was identified, we conducted a new systematic review of randomized controlled trials (RCTs) comparing voriconazole versus itraconazole in acute ABPA exacerbation. The evidence was collated, critically appraised, and synthesized. We then worked through the Evidence to Decision (EtD) framework, to formulate a recommendation, using the Grading of Recommendations Assessment, Development, and Evaluation approach. Results: There were neither preexisting guidelines nor systematic reviews addressing the question. Search for RCT yielded 26 unique publications, of which 24 were not relevant. Only two relevant RCTs were identified, but neither compared voriconazole versus itraconazole. They compared either antifungal agent versus steroid therapy. Therefore, we compared voriconazole versus itraconazole indirectly, concluding that both had similar efficacy. Additional considerations of cost, need for monitoring, and potential reduction in equity, weighed against voriconazole. Conclusion: There is no robust evidence comparing voriconazole versus itraconazole in children with asthma experiencing ABPA exacerbation. Indirect comparison through low-quality evidence facilitated a conditional recommendation against using voriconazole.
There is no robust evidence comparing voriconazole versus itraconazole in children with asthma experiencing ABPA exacerbation, and a conditional recommendation against using voriconazole due to cost, monitoring, and equity concerns.
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