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

Leukotriene modifiers in the treatment of asthma in children

“…If indicated, an increased ICS dose or additional therapy with LTRAs or LABAs should be considered Effect in older children begins to disappear as soon as treatment is discontinued New evidence does not support a disease-modifying role after cessation of treatment in preschool children LTRA (dose depends on age) Alternative first-line treatment for persistent asthma Evidence supports LTRA as initial controller therapy for mild asthma in children Younger age (<10 years) and high levels of urinary leukotrienes predict favourable response Therapy for patients who cannot or will not use ICS Useful also as add-on therapy to ICS: different and complementary mechanisms of action Manifold randomized, controlled studies indicate that LTRAs are inferior to long-acting beta2-agonists as add-on therapy in symptomatic patients using low-to-moderate doses of ICS [Ducharme et al 2006;Ringdal et al 2003]. However, some large studies have been published that demonstrate that LTRAs can provide similar efficacy in terms of exacerbation reduction [Ducharme et al 2004]. …”

Leukotriene receptor antagonists - an update

“…Only four of the 13 trials used currently licensed doses of leukotriene receptor antagonists and also provided data on the number of patients experiencing an asthma exacerbation requiring systemic corticosteroid, the primary endpoint for meta-analysis. After treatment lasting 4-16 weeks, the number of such exacerbations did not differ significantly between those given a leukotriene receptor antagonist (22 exacerbations in 493 patients) and the control group (35 exacerbations in 495 patients; RR 0.64, 95% CI 0.38-1.07) 18. Compared with control, addition of a leukotriene receptor antagonist brought about small improvements in various secondary clinical endpoints (e.g.…”

“…A recent systematic review identified 27 randomised placebo-controlled trials (two in children) in which addition of a leukotriene receptor antagonist to regular inhaled cortico-steroid was compared to continued treatment with inhaled corticosteroid alone (the control) 18. In 13 trials, all patients remained on an unchanged dose of inhaled corticosteroid (typically 400-800?g BDP daily, or equivalent) throughout the trial.…”

“…Seven other randomised trials compared the addition of a leukotriene receptor antagonist to inhaled corticosteroid (200-800?g BDP daily, or equivalent) with doubling the inhaled corticosteroid dose 18. Here, only two studies (involving a total of 1,179 patients) used licensed doses of montelukast or zafirlukast and reported the number of exacerbations requiring systemic corticosteroids.…”

Asthma control in adults

“…Inhaled corticosteroids are generally the most effective drugs in adults with asthma, w19 and they remain the mainstay of regular treatment in chronic asthma (www.ginasthma.com). 2 11 Leukotriene receptor antagonists can be a useful alternative for patients unable or unwilling to take inhaled corticosteroids and have an additive effect to low or moderate dose inhaled corticosteroids 12. Phosphodiesterase 4 inhibitors provide another alternative.…”