Leukotriene Receptor Antagonists in Asthma Treatment

Ann Intern Med 2015 Sept 22
ICS #1 for persistent asthma, with LTRAs as alternative therapy (NAEPP guidelines)
If low-dose ICS not controlling, then add LABA or double ICS dose, LRTA alternatively.
No previous meta-analyses of LRTAs vs placebo
Systematic review of 50 trials (n = 9872 adult and peds patients)
Meta-analysis of 34 trials
Montelukast most often used in the trials
– 40% lower risk of asthma exacerbations requiring systemic steroids or urgent visits (compared to placebo).
– add-on LTRAs to ICS, no differences for exacerbations seen cf placebo.
– add-on and monotherapy reduced rescue med use and nighttime symptoms
– add-on only improved daytime sxs
– FEV1 rose by 0.11 L (mean) with monotherapy, 0.12 L with add-on
– no change in QOL scores
Take-home:  LTRAs are effective for asthma vs placebo, but inferior to ICS.
(It is also known that LTRAs are not as effective as LABAs.)
Best to save LTRAs for those who cannot use or don’t benefit from ICS or LABA.

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