Effects of oral montelukast on airway function in acute asthma

Effects of oral montelukast on pulmonary function and clinical symptoms in acute asthma exacerbations: a randomized, double-blind, placebo-controlled trial

Introduction

Montelukast is a leukotriene receptor antagonist that helps treat chronic asthma and allergic rhinitis by reducing inflammation and bronchoconstriction. However, oral montelukast's effectiveness in managing acute asthma attacks has yet to be completely identified.

Methods

This randomized, double-blind, placebo-controlled trial investigated the efficacy of oral montelukast in acute exacerbations of asthma. Seventy patients between 18 and 65 years of age with a primary diagnosis of asthma attack were included in the study and were randomly assigned to receive 10 mg of montelukast orally daily or placebo. Symptoms, signs, forced expiratory volume in 1 second (FEV1), and peak expiratory flow rate (PEFR) were evaluated.

Results

Our findings showed a statistically significant difference between montelukast and placebo regarding FEV1 (78.05 ± 7.84 vs. 72.05 ± 12.00, P = 0.016), PEFR (322.86 ± 28.95 vs. 290.86 ± 44.21, P = 0.003), and wheezing (P = 0.022) on the fifth day of treatment. Additionally, FEV1 and PEFR values were compared in two subgroups of patients, ICS users (ICSU) and non-ICS users (NICSU), in both the montelukast and placebo groups. In the montelukast group, while PEFR improved significantly for day 5 in both the ICSU (P = 0.007) and NICSU (P = 0.027) subgroups, FEV1 only improved in the ICSU (P = 0.009) subgroup compared to placebo.

Conclusion

The present study demonstrated that oral montelukast administered in acute asthma exacerbation could lead to better values of PEFR and FEV1 on pulmonary function and improvement of wheezing in terms of symptoms.

Effects of using montelukast during acute wheezing attack in hospitalized preschool children on the discharge rate and the clinical asthma score

BACKGROUND

In chronic asthma treatment, leukotriene receptor antagonists have been recommended, but it is not clear whether montelukast can be used in acute recurrent wheezing attacks in children.

OBJECTIVE

To investigate the safety and effectiveness of oral montelukast in addition to standard treatment in hospitalized children aged between 6 and 72 months with acute recurrent wheezing attacks.

METHOD

One hundred patients aged between 6 and 72 months who had wheezing attacks with clinical asthma scores (CAS) ≥3 and were hospitalized were included in this randomized, double-blind, placebo-controlled, parallel-group clinical trial. All the patients included in the study were given 0.15 mg/kg (maximum 5 mg) nebulized salbutamol (8 L/min and with 100% O₂ ) with 4 h of intervals, 1 mg/kg prednisolone (maximum 5 days), nebulized ipratropium bromide (total eight doses) with 6 h of intervals. In addition to this treatment, one group received 4 mg montelukast, and the other group received a placebo. The CAS of the patients were evaluated with 4-h intervals.

RESULTS

Total hospital length of stay (LOS) was not different between the montelukast and placebo groups (p = 0.981). There was no statistically significant difference between the two treatment groups in terms of discharge time, CAS, and oxygen saturation (p ≥ 0.05).

CONCLUSION

Adding montelukast to standard treatment in patients hospitalized for moderate-to-severe wheezing attacks did not affect hospital LOS and CAS.

Comparison of oral montelukast with oral ozagrel in acute asthma: A randomized, double-blind, placebo-controlled study

Background:

The need for more effective management of acute asthma has led to research on drugs which are otherwise approved for use in chronic asthma.

Objective:

To study and compare the effects of oral montelukast with oral ozagrel in acute asthma.

Materials and Methods:

One hundred and twenty patients with acute asthma were recruited for the study. Out of 120 study patients, forty each were randomized into placebo, montelukast, and ozagrel groups. After the first dose of the drug or placebo was administered, peak expiratory flow rate (PEFR), number of rescue medications and also vital signs were noted at 6 h, 12 h, 24 h, 48 h, and at discharge. In addition, same recordings were done on the morning (8 a.m. – 10 a.m.) following admission. The difference in mean PEFR of each group at above-mentioned time points was the primary endpoint whereas need for rescue medications the secondary end-point.

Results:

The respective mean PEFR recordings of the placebo, montelukast, and ozagrel groups at various time points were as follows: at 6 h (235.19 ± 3.18, 242.86 ± 3.26, 228.18 ± 3.25); at 12 h (254.37 ± 5.23, 265.62 ± 5.38, 242.99 ± 5.36); at 24 h (267.46 ± 7.41, 291.39 ± 7.61, 268.14 ± 7.58); and at 48 h (277.99 ± 7.35, 303.22 ± 7.56, 285.27 ± 7.53); and discharge (301.94 ± 7.07, 317.32 ± 7.27, 298.99 ± 7.23). The mean PEFR between the treatment groups were not statistically significant (P = 0.102). The mean PEFR in the three groups at 8–10 a.m. following admission was 257.60 ± 5.52, 264.23 ± 5.98, and 249.94 ± 5.96; P = 0.266. Total number of rescue doses needed were 7, 4, and 13, respectively (P = 0.67).

Conclusion:

Montelukast or ozagrel when added to the standard treatment of acute asthma does not result in any additional benefit.

Evaluating the role of leukotriene-modifying drugs in asthma management: Are their benefits 'losing in translation'?

Leukotrienes (LTs) initiate a cascade of reactions that cause bronchoconstriction and inflammation in asthma. LT-modifying drugs have been proved very effective to reduce inflammation and associated exacerbation however despite some illustrious clinical trials the usage of these drugs remains overlooked because the evidence to support their utility in asthma management has been mixed and varied between studies. Although, there are plenty of evidences which suggest that the leukotriene-modifying drugs provide consistent improvement even after just the first oral dose and reduce asthma exacerbations, the beneficial effect of these drugs has remained sparse and widely debated. And these beneficial effects are often overlooked because most of the clinical studies include a mixed population of asthmatics who do not respond to LT-modifiers equally. Therefore, in the present era of personalized medicine, it is important to properly stratify the patients and non-invasive measurements of biomarkers may warrant the possibility to characterize biological/pathological pathway to direct treatment to those who will benefit from it. Endotyping based on individual's leukotriene levels should probably ascertain a subgroup of patients that would clearly benefit from the treatment even though the trial fails to show overall significance. In this article, we have methodically evaluated contemporary literature describing the efficacy of LT-modifying drugs in the management of asthma and highlighted the importance of phenotyping the asthmatics for better treatment outcomes.

Comparison of oral montelukast with oral zileuton in acute asthma: A randomized, double-blind, placebo-controlled study

Background:

Leukotriene modifiers have an established role in the management of chronic asthma but their role in acute asthma is still under evaluation.

Objective:

To study and compare the effects of oral montelukast with oral zileuton in acute asthma.

Materials and Methods:

This study included 120 asthmatics and was conducted from September 2012 to March 2014. Patients were randomized into three different groups to receive montelukast or zileuton or placebo in addition to standard treatment for asthma exacerbation. Peak expiratory flow rate (PEFR) values, details of rescue medication and vital signs were recorded at 6 h, 12 h, 24 h, and 48 h of drug or placebo administration and at discharge. Additional recording was done in the morning (8–10 am) following admission. The primary endpoint was the mean PEFR of each group at these time points; the secondary end point being the need for rescue medications.

Results:

The mean PEFR recordings of the three study groups – placebo, montelukast, and zileuton – respectively, at various time points were as follows: at 6 h (223.25 ± 90.40, 199.00 ± 82.52, 233.75 ± 84.05; P = 0.240); at 12 h (271.00 ± 109.38, 251.50 ± 101.44, 309.50 ± 129.63; P = 0.048); at 24 h (288.25 ± 114.26, 269.00 ± 107.51, 324.50 ± 127.88; P = 0.080); and at 48 h (295.00 ± 114.80, 293.50 ± 113.24, 344.75 ± 119.91; P = 0.015); discharge (305.00 ± 118.56, 305.25 ± 119.51, 361.25 ± 119.70; P = 0.010). The mean PEFR for the three study groups at 8–10 am on the morning following admission was 268.75 ± 111.43, 252.50 ± 99.99, 306.75 ± 114.44; P = 0.047. Total rescue doses needed were 10, 1, and 0, respectively (P = 0.049).

Conclusion:

Zileuton is better than montelukast as an additional drug in acute asthma and results in significant improvement in lung function, and reduction in the need for rescue medications.

Leukotriene receptor antagonists in addition to usual care for acute asthma in adults and children

BACKGROUND

Acute asthma presentation in the emergency setting frequently leads to hospital admission. Currently available treatment options include corticosteroid therapy, beta(2)-agonists and oxygen. Antileukotriene agents are beneficial in chronic asthma as additional therapy to inhaled steroids. Their value when used orally or intravenously in the acute setting requires evaluation.

OBJECTIVES

To determine if the addition of a leukotriene receptor antagonist (LTRA) produces a beneficial effect in children and adults with acute asthma who are currently receiving inhaled bronchodilators and systemic corticosteroids.

SEARCH METHODS

We searched the Cochrane Airways Group's Specialised Register of trials with predefined terms. Searches are current to February 2012.

SELECTION CRITERIA

We included randomised trials comparing antileukotrienes and standard acute asthma care versus placebo and standard care in people with acute asthma of any age. We considered any dose and method of delivery of the leukotriene agent.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion in the review and extracted data. We then checked data and resolved disagreements by discussion. We contacted study authors where necessary to provide additional information and data.

MAIN RESULTS

Eight trials, generating 10 treatment-control comparisons, that recruited 1470 adults and 470 children met the entry criteria. These studies were of mixed quality, and there was heterogeneity in the severity of asthma exacerbation.For oral treatment, there was no significant difference in hospital admission between LTRAs and control in three trials on 194 children (risk ratio (RR) 0.86; 95% confidence interval (CI) 0.21 to 3.52). Using a broader composite outcome which measured requirement for additional care there was no significant difference between treatments (RR 0.87; 95% CI 0.60 to 1.28). Results demonstrated some indication of improvement in lung function with a significant difference in forced expiratory volume in one second (FEV(1)) favouring LTRAs in two trials on 641 adults (mean difference (MD) 0.08; 95% CI 0.01 to 0.14). There were insufficient data to assess this outcome in children. The most common adverse event described was headache; however, there was no significant difference between LTRAs and control (RR 0.81; 95% CI 0.22 to 2.99). Due to insufficient numbers, we were unable to conduct a subgroup analysis based on age.The combined results of two trials of intravenous treatment in 772 adults and one trial in 276 children demonstrated a reduction in the risk of hospital admission which was not quite statistically significant (RR 0.78; 95% CI 0.61 to 1.01). There was a statistically significant small difference in FEV(1) in the adult studies (MD 0.12; 95% CI 0.06 to 0.17), but not in the single trial in children (MD 0.01; 95% CI -0.06 to 0.08).

AUTHORS' CONCLUSIONS

Presently, the available evidence does not support routine use of oral LTRAs in acute asthma. Further studies are required to assess whether intravenous treatment can reduce the risk of hospital admission, and what the most appropriate dose regimen is. Additional research is also needed into safety and efficacy of additional doses for those on maintenance therapy, and larger paediatric trials are required to allow subgroup analysis. Prolonged studies would be required to establish other health economic outcomes in admitted patients.

Anti-leukotriene agents compared to inhaled corticosteroids in the management of recurrent and/or chronic asthma in adults and children

BACKGROUND

Anti-leukotrienes (5-lipoxygenase inhibitors and leukotriene receptors antagonists) serve as alternative monotherapy to inhaled corticosteroids (ICS) in the management of recurrent and/or chronic asthma in adults and children.

OBJECTIVES

To determine the safety and efficacy of anti-leukotrienes compared to inhaled corticosteroids as monotherapy in adults and children with asthma and to provide better insight into the influence of patient and treatment characteristics on the magnitude of effects.

SEARCH METHODS

We searched MEDLINE (1966 to Dec 2010), EMBASE (1980 to Dec 2010), CINAHL (1982 to Dec 2010), the Cochrane Airways Group trials register, and the Cochrane Central Register of Controlled Trials (Dec 2010), abstract books, and reference lists of review articles and trials. We contacted colleagues and the international headquarters of anti-leukotrienes producers.

SELECTION CRITERIA

We included randomised trials that compared anti-leukotrienes with inhaled corticosteroids as monotherapy for a minimum period of four weeks in patients with asthma aged two years and older.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the methodological quality of trials and extracted data. The primary outcome was the number of patients with at least one exacerbation requiring systemic corticosteroids. Secondary outcomes included patients with at least one exacerbation requiring hospital admission, lung function tests, indices of chronic asthma control, adverse effects, withdrawal rates and biological inflammatory markers.

MAIN RESULTS

Sixty-five trials met the inclusion criteria for this review. Fifty-six trials (19 paediatric trials) contributed data (representing total of 10,005 adults and 3,333 children); 21 trials were of high methodological quality; 44 were published in full-text. All trials pertained to patients with mild or moderate persistent asthma. Trial durations varied from four to 52 weeks. The median dose of inhaled corticosteroids was quite homogeneous at 200 µg/day of microfine hydrofluoroalkane-propelled beclomethasone or equivalent (HFA-BDP eq). Patients treated with anti-leukotrienes were more likely to suffer an exacerbation requiring systemic corticosteroids (N = 6077 participants; risk ratio (RR) 1.51, 95% confidence interval (CI) 1.17, 1.96). For every 28 (95% CI 15 to 82) patients treated with anti-leukotrienes instead of inhaled corticosteroids, there was one additional patient with an exacerbation requiring rescue systemic corticosteroids. The magnitude of effect was significantly greater in patients with moderate compared with those with mild airway obstruction (RR 2.03, 95% CI 1.41, 2.91 versus RR 1.25, 95% CI 0.97, 1.61), but was not significantly influenced by age group (children representing 23% of the weight versus adults), anti-leukotriene used, duration of intervention, methodological quality, and funding source. Significant group differences favouring inhaled corticosteroids were noted in most secondary outcomes including patients with at least one exacerbation requiring hospital admission (N = 2715 participants; RR 3.33; 95% CI 1.02 to 10.94), the change from baseline FEV(1) (N = 7128 participants; mean group difference (MD) 110 mL, 95% CI 140 to 80) as well as other lung function parameters, asthma symptoms, nocturnal awakenings, rescue medication use, symptom-free days, the quality of life, parents' and physicians' satisfaction. Anti-leukotriene therapy was associated with increased risk of withdrawals due to poor asthma control (N = 7669 participants; RR 2.56; 95% CI 2.01 to 3.27). For every thirty one (95% CI 22 to 47) patients treated with anti-leukotrienes instead of inhaled corticosteroids, there was one additional withdrawal due to poor control. Risk of side effects was not significantly different between both groups.

AUTHORS' CONCLUSIONS

As monotherapy, inhaled corticosteroids display superior efficacy to anti-leukotrienes in adults and children with persistent asthma; the superiority is particularly marked in patients with moderate airway obstruction. On the basis of efficacy, the results support the current guidelines' recommendation that inhaled corticosteroids remain the preferred monotherapy. 

Acute additive effect of montelukast and beclomethasone on AMP induced bronchoconstriction

Bronchial hyperresponsiveness to 5-adenosine mono-phosphate (AMP) is a marker of airway inflammation. Inhaled corticosteroids and antileukotrienes are used as anti-inflammatory drugs for the treatment of asthma. To find out if these two drugs exert their protection in an additive fashion, we compared the effects of acute treatment with inhaled beclomethasone (BDP) and montelukast (ML), alone or in combination, on methacholine and AMP induced bronchoconstriction. 15 asthmatic patients undertook methacholine and AMP challenges at baseline and after receiving ML or BDP, alone or in combination, in a randomized, double-blind, double-dummy placebo-controlled, crossover design. BDP pretreatment significantly increased the AMP PC(20) value (68.34+/-15.9mg/mL) as compared to placebo (22.87+/-5.7mg/mL). Combined treatment, BDP plus ML, afforded a further significant increase of AMP PC(20) (154.57+/-55.0mg/mL) as compared to each single treatment. The significant protection exerted by combined treatment as compared to each single active treatment was also demonstrated by the change of AMP PC(20) doubling dose as compared to placebo and each single active treatment. Our findings suggest that these two agents exert their acute additive protection against AMP induced bronchoconstriction acting on distinct inflammatory pathways and their combined use might provide greater protection against inflammatory response elicited by AMP than either drug alone.

[Critical analysis of asthma guidelines: are they really evidence-based?]

Recent years have seen a growing reliance on "evidence-based" guidelines or consensus statements, in which rigorous, explicit methods are used to translate the complex findings of scientific research into operational recommendations for medical care. Various factors can affect the validity of the conclusions they express, however. The purpose of this review was to compare the levels of evidence supporting treatments for acute asthma in adults according to 3 of the most important guidelines. It seems that even though these guidelines are based on an approach that is more or less rigorous, there are considerable gaps and inconsistencies that compromise their validity. Our main sources of information should therefore be those that apply the best research designs, namely randomized controlled trials or meta-analyses of such trials with consistent results and a low probability of bias.

Antileukotrienes as adjunctive therapy in acute asthma

The leukotriene receptor antagonists (LTRAs) are a comparatively new class of asthma drugs that exhibit both bronchodilator and anti-inflammatory properties. There is a substantial body of evidence for their benefit in the management of chronic asthma in both adults and children, and particularly in specific types of asthma such as exercise-induced and aspirin-sensitive asthma. Despite best practice using current treatment guidelines for the management of acute asthma, a significant proportion of patients require continued treatment and are unable to be discharged from the emergency department; many require a short course of oral corticosteroids. The relatively rapid onset of action of LTRAs after oral administration and their additive effect to beta(2)-adrenoceptor agonists led to the hypothesis that they might be of benefit in acute asthma. This review examines the available evidence for the effect of LTRAs in acute asthma. Although the evidence is limited, it suggests that treatment with LTRAs provides additional bronchodilator effect to nebulised and inhaled beta(2)-adrenoceptor agonists. Short-term therapy with LTRAs results in fewer treatment failures and readmissions for patients with acute asthma, and less need for additional therapies such as nebulisers and corticosteroids.

Oral montelukast treatment of preschool-aged children with acute asthma

BACKGROUND

Increased amounts of cysteinyl leukotrienes have been demonstrated in urine samples from asthmatic patients, particularly during exacerbations of asthma. Although the use of leukotriene receptor antagonists has been recommended in the treatment of chronic asthma, no guidelines are available regarding their use in the treatment of acute asthma.

OBJECTIVE

To investigate the safety and effectiveness of a 4-mg tablet of oral montelukast in addition to short-acting beta2-agonist bronchodilator as the initial treatment in mild to moderate asthma exacerbations in children between 2 and 5 years old.

METHODS

Fifty-one patients who were experiencing mild to moderate asthma exacerbation were included in a randomized, double-blind, placebo-controlled, parallel-group study. Each patient received either a 4-mg tablet of montelukast or placebo in addition to inhaled salbutamol and were followed up for 4 hours. The pulmonary index score, respiratory rate, and pulse were determined at baseline and throughout 4 hours after administration.

RESULTS

Compared with placebo, the pulmonary index scores and respiratory rates were significantly lower in the montelukast group starting at 90 minutes (P = .01). This difference persisted at 120, 180, and 240 minutes of the study (P = .008, P = .02, and P = .048, respectively). At the end of the first hour of treatment, oral steroid need was 20.8% and 38.5% in patients randomized to the montelukast and placebo groups, respectively (P = .22). Hospitalization rates were not different between the 2 treatment groups.

CONCLUSION

A single 4-mg tablet of montelukast had the potential to provide additive clinical benefit in mild to moderate acute asthma in preschool-aged children when administered concomitantly with short-acting beta2-agonist bronchodilators as the initial treatment.

Voltammetric determination of montelukast sodium in dosage forms and human plasma

The voltammetric behaviour of montelukast (MKST) was studied using cyclic voltammetry, direct current (DCt), differential pulse polarography (DPP) and alternating current (ACt) polarography. MKST exhibited well-defined cathodic waves over the range pH range 1-5. No anodic waves were produced over the same pH range. At pH 1, the analytical pH; the diffusion current constant (Id) was 2.2+/-0.01 microA l mmol-1. The current concentration plot was rectilinear over the range 2-20 microg ml-1 with correlation coefficient (n=10) of 0.9943. The lower limit of detection (S/N=2) was 0.2 microg ml-1 (3.41x10(-7) M). The wave has been characterised as being diffusion-controlled, although adsorption phenomenon played a limited role in the electrode reaction. The proposed method was successfully applied to the determination of MKST in commercial tablets, and results were in agreement with those given with a reference HPLC method. The method was further extended to the in vitro determination of the drug in spiked human plasma. The mean % recovery (n=5) was 101.38+/-3.85. The number of electrons transferred in the reduction process could be accomplished and a proposal of the electrode reaction was proposed.

Localization and upregulation of cysteinyl leukotriene-1 receptor in asthmatic bronchial mucosa

We have tested the hypothesis that the CysLT(1) receptor is expressed by a variety of bronchial mucosal immune cells and that the numbers of these cells increase in asthma, when stable and in exacerbations. We have applied in situ hybridization and immunohistochemistry to endobronchial biopsy tissue to identify and count inflammatory cells expressing CysLT(1) receptor mRNA and protein, respectively, and used double immunohistochemistry to identify the specific cell immunophenotypes expressing the receptor. Double-labeling demonstrated that bronchial mucosal eosinophils, neutrophils, mast cells, macrophages, B-lymphocytes, and plasma cells, but not T-lymphocytes, expressed the CysLT(1) receptor. The numbers of CysLT(1) receptor mRNA and protein positive inflammatory cells in nonsmoking, nonatopic control subjects without asthma were 13 and 16 mm(-2), respectively (median values; n = 15), and were significantly greater in stable asthma (50 and 43 mm(-2), respectively; n = 17; P < 0.001). Compared with stable asthma, there were further significant increases in subjects hospitalized for a severe exacerbation of their asthma (mRNA: median = 113 and protein: 156 mm(-2); n = 15; P < 0.002). For the combined data of both asthma subgroups, there were strong positive correlations between the increased numbers of CD45+ leukocytes and the greater numbers of cells expressing CysLT(1) receptor (mRNA: r = 0.60, P < 0.001; protein: r = 0.73, P < 0.0001). In conclusion, a variety of immunohistologically distinct inflammatory cells express the CysLT(1) receptor in the bronchial mucosa and both these and the total number of leukocytes increase in mild stable disease and increase further when there is a severe exacerbation of asthma.

Zafirlukast treatment for acute asthma: evaluation in a randomized, double-blind, multicenter trial

CONTEXT

Acute asthma causes nearly 2 million hospital emergency department (ED) visits in the United States annually, and hospitalization after an ED visit and relapse after ED discharge are common.

OBJECTIVE

To evaluate the adding of therapy with zafirlukast to standardized care for patients with acute asthma in the ED and a 28-day follow-up period.

DESIGN AND PATIENTS

A total of 641 patients presenting to the ED with acute asthma were randomized to receive either single-dose zafirlukast, 160 mg (Z160) [162 patients], zafirlukast, 20 mg (Z20) [158 patients]), or placebo (321 patients) as adjunct treatment to standard care in this double-blind, multicenter trial. Assessments, including spirometry and symptom scores, were obtained before each albuterol treatment and at 4 h. Patients who were discharged from the ED after 4 h continued outpatient therapy over a 28-day period and received either Z20 bid (276 patients) or placebo (270 patients) in addition to prednisone, albuterol, and their previous asthma medications. FEV(1) was measured at clinic visits on days 10 and 28. Patients recorded outpatient clinical data twice daily on a home diary card.

MAIN OUTCOME MEASURES

the effect of zafirlukast on relapse after ED discharge. Other assessments were the rate of extended care (ie, ED stay for > 4 h or hospitalization), FEV(1), and symptoms.

RESULTS

At the end of the outpatient period, 65 of 276 patients (23.6%) treated with zafirlukast and 78 of 270 patients (28.9%) treated with placebo relapsed (p = 0.047; absolute reduction, 5.3%; relative reduction, 18.3%). At the end of the ED period, 16 of 162 patients (9.9%) treated with Z160, 26 of 158 patients (16.5%) treated with Z20, and 48 of 321 patients (15.0%) treated with placebo required extended care (p = 0.052; absolute reduction with Z160 compared to placebo, 5.1%; relative reduction, 34%). These findings were supported by a significant improvement in FEV(1) and dyspnea in the ED with the use of Z160 therapy, and by greater improvement in FEV(1) and symptoms during the outpatient period for patients treated with Z20.

CONCLUSIONS

When added to standardized care, therapy with Z20 bid reduced the risk of relapse compared with placebo over a 28-day treatment period. One dose of Z160 in the ED also reduced the rate of extended care.

Anti-leukotriene agents compared to inhaled corticosteroids in the management of recurrent and/or chronic asthma in adults and children

BACKGROUND

Anti-leukotrienes agents are currently being studied as alternative first line agents to inhaled corticosteroids in mild to moderate chronic asthma.

OBJECTIVES

To compare the safety and efficacy of anti-leukotriene agents with inhaled glucocorticoids (ICS) and to determine the dose-equivalence of anti-leukotrienes to daily dose of ICS.

SEARCH STRATEGY

We searched MEDLINE (1966 to Aug 2003), EMBASE (1980 to Aug 2003), CINAHL (1982 to Aug 2003), the Cochrane Airways Group trials register, and the Cochrane Central Register of Controlled Trials (August 2003), abstract books, and reference lists of review articles and trials. We contacted colleagues and international headquarters of anti-leukotrienes producers.

SELECTION CRITERIA

Randomised controlled trials that compared anti-leukotrienes with inhaled corticosteroids during a minimal 30-day intervention period in asthmatic patients aged 2 years and older.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the methodological quality or trials and extracted trial data. The primary outcome was the rate of exacerbations requiring systemic corticosteroids. Secondary outcomes included lung function, indices of chronic asthma control, adverse effects and withdrawal rates.

MAIN RESULTS

27 trials (including 1 trial testing two protocols) met the inclusion criteria; 13 were of high methodological quality; 20 are published in full-text. All trials pertained to patients with mild to moderate persistent asthma. Only 3 trials focused on children and adolescents. Trial duration varied from 4 to 37 weeks. In most trials, daily dose of ICS was 400 mcg of beclomethasone or equivalent. Patients treated with anti-leukotrienes were 65% more likely to suffer an exacerbation requiring systemic steroids [Relative Risk 1.65; 95% Confidence Interval (CI) 1.36 to 2.00]. Twenty six (95% CI: 17 to 47) patients must be treated with anti-leukotrienes instead of inhaled corticosteroids to cause one extra exacerbation. Significant differences favouring ICS were noted in secondary outcomes where()the improvement in FEV(1) reached 130 mL [13 trials; 95% CI: 50, 140 mL ]. Other significant benefits of ICS were seen for symptoms, nocturnal awakenings, rescue medication use, symptom-free days, and quality of life. Anti-leukotriene therapy was associated with 160% increased risk of withdrawals due to poor asthma control. Twenty nine (95% CI 20 to 48) patients must be treated with anti-leukotrienes instead of inhaled corticosteroids to cause one extra withdrawal due to poor control. Risk of side effects was not different between groups.

REVIEWERS' CONCLUSIONS

Inhaled steroids at a dose of 400 mcg/day of beclomethasone or equivalent are more effective than anti-leukotriene agents given in the usual licensed doses. The exact dose-equivalence of anti-leukotriene agents in mcg of ICS remains to be determined. Inhaled glucocorticoids should remain the first line monotherapy for persistent asthma.

Addition of anti-leukotriene agents to inhaled corticosteroids for chronic asthma

BACKGROUND

Anti-leukotriene (AL) agents are being considered as 'add-on' therapy to inhaled corticosteroids (ICS), in chronic asthma.

OBJECTIVES

To examine the safety and efficacy of daily AL plus ICS compared to ICS alone, and determine the corticosteroid-sparing effect of AL when added to ICS in chronic asthma.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, CINAHL (until August 2003), reference lists of review articles and trials, contacted international headquarters of AL manufacturers and looked at American Thoracic Society and European Respiratory Society meeting abstracts (1998 to 2003).

SELECTION CRITERIA

Randomised placebo-controlled trials of asthmatics aged two years and older with at least one month intervention.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed quality and extracted data independently. Trials were grouped by asthma control at baseline (symptomatic or well-controlled) and dose of ICS in the control group (same or double).

MAIN RESULTS

Of 587 citations, 27 (25 adult and 2 paediatric) trials met inclusion criteria. Sixteen trials were published in full-text and 16 trials reported data in a way that allowed meta-analysis. In symptomatic patients, addition of licensed doses of anti-leukotrienes to ICS resulted in a non-significant reduction in the risk of exacerbations requiring systemic steroids: Relative Risk (RR) 0.64; 95% Confidence Interval (CI) 0.38 to 1.07). A modest improvement group difference in PEF was seen (Weighted Mean Difference (WMD) 7.7 L/min; 95% CI 3.6 to 11.8 L/min) together with decrease in use of rescue short-acting beta2-agonist use (WMD 1 puff/week; 95%CI 0.5 to 2). With only 3 trials comparing the use of licensed doses of anti-leukotrienes with increasing the dose of inhaled glucocorticoids, no firm conclusion can be drawn about the equivalence of both treatment options. In ICS-sparing studies of patients who were well controlled at baseline, addition of anti-leukotrienes produced no overall difference in dose of inhaled glucocorticoids (WMD -21 mcg/d, 95%CI -65, 23 mcg/d), but it was associated with fewer withdrawals due to poor asthma control (RR 0.63, 95% CI 0.42 to 0.95).

REVIEWERS' CONCLUSIONS

The addition of licensed doses of anti-leukotrienes to add-on therapy to inhaled glucocorticoids brings modest improvement in lung function. Although addition of anti-leukotrienes to inhaled glucocorticoids appears comparable to increasing the dose of inhaled steroids, the power of the review is insufficient to confirm the equivalence of both treatment options. Addition of anti-leukotrienes is associated with superior asthma control after glucocorticoid tapering; although the glucocorticoid-sparing effect cannot be quantified at present, it appears modest.