Do you consider dual biologic therapy in patients with ABPA that remain steroid dependent despite the use of omalizumab?

The treatment of ABPA can be so challenging, but this is something that I have not seriously considered at this point. Unfortunately, in general, the evidence for biologics in the treatment of ABPA currently is heterogeneous. Furthermore, many studies are descriptive case reports/series or based on retrospective chart reviews which are prone to bias. The best evidence supporting the use of biologics exists in asthma with several biologics approved for severe disease as monotherapy. However, the safety of concomitant use of multiple biologics even in asthma is unknown. This is an area of ongoing debate amongst asthma leaders and there are no guidelines for this. Dr Praveen Akuthota, a leading expert in eosinophilic lung disease, at ATS 2023 argued against the use of dual biologics to treat severe asthma citing that while these biologics have different targets, the efficacy in their combination is limited because they all still target T2 response. To me, the evidence for combining biologics in ABPA is not there yet. Furthermore, the cost may be another prohibitive factor when considering this approach.

Many cases are not always clear-cut ABPA and overlap in the spectrum of eosinophilic asthma; for such patients might be worth switching biologics from omalizumab to another one (which is also more effective for asthma); at least worth a try.