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Antifungal — ABPA / Chronic Pulmonary Aspergillosis Pregnancy: Contraindicated — teratogenic; use voriconazole or amphotericin B for invasive aspergillosis in pregnancy under specialist guidance

Itraconazole (Respiratory)

Brand names: Sporanox

Adult dose

Dose: 200 mg twice daily for 4–6 months (ABPA); 200 mg twice daily long-term (chronic pulmonary aspergillosis — CPA)
Route: Oral (capsule with food and acid; solution fasted)
Frequency: Twice daily
Max: 400 mg/day
First-line azole antifungal for allergic bronchopulmonary aspergillosis (ABPA) — steroid-sparing effect; reduces exacerbations and IgE. Also used for chronic pulmonary aspergillosis (CPA) and subacute invasive aspergillosis. Monitor itraconazole trough levels (target 0.5–4 mg/L) — erratic bioavailability.

Paediatric dose

Dose: 3–5 mg/kg/day mg/kg
Route: Oral solution (preferred — better bioavailability)
Frequency: Once or twice daily
Max: 200 mg twice daily
BNFc: specialist use for ABPA and fungal infections in children — licensed from 1 year for some indications (oral solution)

Dose adjustments

Renal

No dose adjustment for capsules; avoid IV formulation if eGFR <30

Hepatic

Use with caution; avoid in significant hepatic impairment — hepatotoxicity risk

Paediatric weight-based calculator

BNFc: specialist use for ABPA and fungal infections in children — licensed from 1 year for some indications (oral solution)

Clinical pearls

  • ABPA: diagnostic criteria include central bronchiectasis, high serum IgE (>1000 IU/mL), positive Aspergillus RAST/precipitins, eosinophilia; itraconazole reduces steroid requirements and frequency of exacerbations
  • Itraconazole + CFTR modulators: major pharmacokinetic interaction — azoles dramatically increase ivacaftor levels; use voriconazole where possible (also an interaction but better characterised); always consult CF centre
  • Trough levels: check at 4–6 weeks of treatment (target 0.5–4 mg/L for capsules; 0.5–2 mg/L for solution); capsule bioavailability is highly variable
  • Capsule absorption: requires gastric acid — take with food; patients on PPIs have markedly reduced absorption; switch to solution or voriconazole if inadequate levels
  • Voriconazole alternative: better bioavailability and CNS penetration; preferred for invasive aspergillosis; consider in patients with inadequate itraconazole levels
  • NICE CG: itraconazole recommended for ABPA steroid-sparing therapy — reduces exacerbations and long-term steroid burden

Contraindications

  • Heart failure — CONTRAINDICATED (negative inotrope)
  • Pregnancy (teratogenic)
  • Co-administration with QT-prolonging drugs metabolised by CYP3A4

Side effects

  • Hepatotoxicity
  • QT prolongation
  • Heart failure exacerbation
  • Nausea
  • Drug interactions (potent CYP3A4 inhibitor)
  • Peripheral neuropathy (prolonged use)

Interactions

  • CFTR modulators (ivacaftor, Kaftrio) — major interaction; reduce ivacaftor dose significantly when co-prescribing
  • Statins — suspend during treatment
  • Warfarin — increased INR significantly

Monitoring

  • Itraconazole trough levels (target 0.5–4 mg/L)
  • LFTs (monthly)
  • Total IgE and eosinophil count (ABPA response)
  • Spirometry
  • Drug interactions review

Reference: BNFc; BNF 90; BNFc; Stevens et al. NEJM 2000 (itraconazole ABPA); ESCMID/ECMM/ERS Aspergillosis Guidelines 2018; NICE guideline. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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