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@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
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.
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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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