Montelukast and Nasal Corticosteroids to Treat Pediatric Obstructive Sleep Apnea: A Systematic Review and Meta‐analysis

Abstract

Objective To systematically review the literature on anti-inflammatory medications for treating pediatric obstructive sleep apnea and perform meta-analysis of the available data. Data Sources PubMed/MEDLINE and 4 additional databases. Review Methods Three authors independently and systematically searched through June 28, 2018, for studies that assessed anti-inflammatory therapy for treatment of pediatric obstructive sleep apnea (OSA). Data were compiled and analyzed using Review Manager 5.3 (Nordic Cochrane Centre). Results After screening 135 studies, 32 were selected for review with 6 meeting inclusion criteria. In total, 668 patients aged 2 to 5 years met inclusion criteria for meta-analysis. Of these, 5 studies (166 children) that evaluated montelukast alone as treatment for pediatric OSA found a 55% improvement in the apnea-hypopnea index (AHI) (mean [SD] 6.2 [3.1] events/h pretreatment and 2.8 [2.7] events/h posttreatment; mean difference [MD] of −2.7 events/h; 95% confidence interval [CI], –5.6 to 0.3) with improvement in lowest oxygen saturation (LSAT) from 89.5 (6.9) to 92.1 (3.6) (MD, 2.2; 95% CI, 0.5-4.0). Two studies (502 children) observing the effects of montelukast with intranasal corticosteroids on pediatric OSA found a 70% improvement in AHI (4.7 [2.1] events/h pretreatment and 1.4 [1.0] events/h posttreatment; MD of −4.2 events/h; 95% CI, –6.3 to −2.0), with an improvement in LSAT from 87.8 (3.1) to 92.6 (2.2) (MD, 4.8; 95% CI, 4.5-5.1). Conclusions Treatment with montelukast and intranasal steroids or montelukast alone is potentially beneficial for short-term management of mild pediatric OSA.

Treatment of Obstructive Sleep Apnea in Children: Handling the Unknown with Precision

“…A subsequent RCT study by our research group relied on the important observation that corticosteroids markedly inhibit adenotonsillar tissue proliferation and inflammation in an in vitro model and corroborated previous findings while expanding their scope to less severely affected patients, thereby expanding the decision tree in pediatric OSA to include anti-inflammatory therapy in lieu of T&A in younger patients with mild OSA [54][55][56]. Other studies have further confirmed the efficacy of intranasal corticosteroids, either alone or in combination with other anti-inflammatory agents [57][58][59].…”

Efficacy of Adenoidectomy for the Treatment of Mild Sleep Apnea in Children

“…For example, a recent meta-analysis demonstrated a significant improvement in both AHI and nadir oxygen saturation following 3 to 4 months of treatment with montelukast. 15 Use of anti-inflammatories in the treatment of mild OSA in children has also been shown to improve quality of life. 6 However, there are increasing concerns regarding the behavioral and mental health side effects of montelukast, leading the US Food and Drug Administration to recently issue a black box warning.…”

New treatments for obstructive sleep apnea in children

“…They have been safely used in children with asthma and allergic rhinitis on the basis of their anti‐inflammatory action. In a systematic review and meta‐analysis on 668 patients aged 2‐5 years, five studies that evaluated Montelukast alone found a 55% improvement in OAHI and improvement in mean lowest oxygen saturation from 89.5%‐92.1% . In a prospective, double‐blind randomized trial, Goldbart et al found that oral montelukast (4‐5 mg daily) for 12 weeks reduced the severity of nonsevere OSA and tonsillar hypertrophy vs placebo …”

“…The review showed that after 12 weeks of treatment with intranasal steroids and oral montelukast, 62% of patients had a normalization of sleep findings with follow‐up PSG . In the systematic review and meta‐analysis mentioned above, two studies that used a combination of Montelukast and intranasal corticosteroids found a 70% improvement in AHI, and the mean lowest oxygen saturation improved from 87.8%‐92.6% . Kheirandish et al found that the success rate of the intranasal steroid and oral montelukast was 80.5%, thus decreasing the number of children needing surgical intervention.…”