BMJ 2003;326:621 ( 22 March )

Papers

Inhaled glucocorticoids versus leukotriene receptor antagonists as single agent asthma treatment: systematic review of current evidence

Francine M Ducharme, associate professor. 

Departments of Paediatrics and of Epidemiology and Biostatistics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada

Francine.ducharme{at}muhc.mcgill.ca

Objective: To compare the safety and efficacy of anti-leukotrienes and inhaled glucocorticoids as monotherapy in people with asthma.
Design: Systematic review of randomised controlled trials comparing anti-leukotrienes with inhaled glucocorticoids for 28 days or more in children and adults.
Main outcome measure: Rate of exacerbations that required treatment with systemic glucocorticoids.
Results: 13 trials (12 in adults, one in children) met the inclusion criteria; all were in people with mild and moderate asthma. Leukotriene receptor antagonists were compared with inhaled glucocorticoids at a daily dose equivalent to 400-450 µg beclometasone dipropionate. Patients treated with leukotriene receptor antagonists were 60% more likely to suffer an exacerbation requiring systemic glucocorticoids (relative risk 1.6, 95% confidence interval 1.2 to 2.2; number needed to treat 27, 13 to 81). A 130 ml greater improvement (80 ml to 170 ml) in forced expiratory volume in one second and a 19 l/min greater increase (14 l to 24 l) in morning peak expiratory flow rate were noted in favour of inhaled glucocorticoids. Differences in favour of inhaled glucocorticoids were also observed for nocturnal awakenings, use of rescue beta 2 agonists, and days without symptoms. Risk of side effects was no different between groups, but leukotriene receptor antagonists were associated a 2.5-fold increase risk of withdrawals due to poor asthma control (relative risk 2.5, 1.8 to 3.5).
Conclusions: Inhaled glucocorticoids doses equivalent to 400 µg/day beclometasone are more effective than leukotriene receptor antagonists in the treatment of adults with mild or moderate asthma. There is insufficient evidence to conclude on the efficacy of anti-leukotrienes in children.

What is already known on this topic
In 2000 a Cochrane systematic review tentatively concluded that control of asthma was better in patients treated with inhaled glucocorticoids as single agents than with anti-leukotrienes

The 2002 Global Initiative for Asthma guidelines still classify the role of anti-leukotrienes as "under investigation"

What this study adds
Anti-leukotrienes as single agent are less effective than low doses of inhaled glucocorticoids for patients with mild and moderate persistent asthma




© 2003 BMJ Publishing Group Ltd
Add to CiteULike CiteULike   Add to Complore Complore   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Reddit Reddit   Add to StumbleUpon StumbleUpon   Add to Technorati Technorati    What's this?

Relevant Article

Low dose inhaled glucocorticoid is superior to anti-leukotrienes
BMJ 2003 326: 0. [Full Text] [PDF]

This article has been cited by other articles:

  • del Giudice, M. M., Pezzulo, A., Capristo, C., Alterio, E., Caggiano, S., de Benedictis, D., Capristo, A. F. (2009). Leukotriene modifiers in the treatment of asthma in children. Ther Adv Respir Dis 3: 245-251 [Abstract]  
  • Joos, S, Miksch, A, Szecsenyi, J, Wieseler, B, Grouven, U, Kaiser, T, Schneider, A (2008). Montelukast as add-on therapy to inhaled corticosteroids in the treatment of mild to moderate asthma: a systematic review. Thorax 63: 453-462 [Abstract] [Full text]  
  • Bousquet, J., Wahn, U., Meltzer, E. O., Fox, H., Hedgecock, S., Thomas, K., Fowler-Taylor, A. (2008). Omalizumab: an anti-immunoglobulin E antibody for the treatment of allergic respiratory diseases. ERR 17: 1-9 [Abstract] [Full text]  
  • FitzGerald, J M, Gibson, P G (2006). Asthma exacerbations {middle dot} 4: Prevention.. Thorax 61: 992-999 [Abstract] [Full text]  
  • Currie, G. P., Lee, D. K. C., Srivastava, P. (2005). Long-Acting Bronchodilator or Leukotriene Modifier as Add-on Therapy to Inhaled Corticosteroids in Persistent Asthma?. Chest 128: 2954-2962 [Abstract] [Full text]  
  • Becker, A., Lemiere, C., Berube, D., Boulet, L.-P., Ducharme, F. M., FitzGerald, M., Kovesi, T., on behalf of The Asthma Guidelines Working Group o, (2005). Summary of recommendations from the Canadian Asthma Consensus Guidelines, 2003. CMAJ 173: S3-S11 [Full text]  
  • (2005). Pharmacotherapy -- first-line maintenance therapy. CMAJ 173: S28-S32 [Full text]  
  • Currie, G.P., Srivastava, P., Dempsey, O.J., Lee, D.K.C. (2005). Therapeutic modulation of allergic airways disease with leukotriene receptor antagonists. QJM 98: 171-182 [Abstract] [Full text]  
  • Lee, E., McNally, D. L, Zuckerman, I. H (2004). Evaluation of a Physician-Focused Educational Intervention on Medicaid Children with Asthma. The Annals of Pharmacotherapy 38: 961-966 [Abstract] [Full text]  
  • Riccioni, G., Di Ilio, C., D'Orazio, N. (2004). Pharmacological Treatment of Airway Remodeling: Inhaled Corticosteroids or Antileukotrienes?. Annals of Clinical & Laboratory Science 34: 138-142 [Abstract] [Full text]  
  • (2003). OTHER ARTICLES NOTED (25 Apr 2003 to 18 Jul 2003). Evid. Based Nurs. 6: e1-12 [Full text]  

Rapid Responses:

Read all Rapid Responses

Errata
Rod C Hall
bmj.com, 21 Mar 2003 [Full text]
Outcome selection for meta-analysis
Cathy M Jackson, et al.
bmj.com, 24 Mar 2003 [Full text]
Why glucocorticoids are better than leukotriene receptor antagonists
G.N. Malavige
bmj.com, 25 Mar 2003 [Full text]
Reply to Electronic Responses
Francine M. Ducharme, et al.
bmj.com, 15 Apr 2003 [Full text]
FURTHER ASSESSMENT OF THE EQUIVALENCE OF ANTI-LEUKOTRIENES AND ICS
Peter G. Polos, et al.
bmj.com, 30 May 2003 [Full text]
Reply to “Further assessment of the equivalency of anti-leukotrienes and ICS”
Francine M. Ducharme
bmj.com, 11 Jun 2003 [Full text]
Access jobs at BMJ Careers
Whats new online at Student BMJ