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




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Relevant Article

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

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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]
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