Addition of anti-leukotriene agents to inhaled corticosteroids for chronic asthma
Evidence Summaries Level of Evidence = B
The addition of licensed doses of anti-leukotrienes to add-on therapy to inhaled glucocorticoids appears to bring modest improvement in lung function.
A Cochrane review 1 included 16 trials in the meta-analysis. In symptomatic patients, addition of licensed doses of anti-leukotrienes to ICS resulted in a non-significant reduction in the risk of exacerbations requiring systemic steroids: Relative Risk (RR) 0.64; 95% Confidence Interval (CI) 0.38 to 1.07). A modest improvement group difference in PEF was seen (Weighted Mean Difference (WMD) 7.7 l/min; 95% CI 3.6 to 11.8 l/min) together with decrease in use of rescue short-acting beta2-agonist use (WMD 1 puff/week; 95% CI 0.5 to 2). With only 3 trials comparing the use of licensed doses of anti-leukotrienes with increasing the dose of inhaled glucocorticoids, no firm conclusion can be drawn about the equivalence of both treatment options. In ICS-sparing studies of patients who were well controlled at baseline, addition of anti-leukotrienes produced no overall difference in dose of inhaled glucocorticoids (WMD –21 µg/d, 95%CI –65, 23 µg/d), but it was associated with fewer withdrawals due to poor asthma control (RR 0.63, 95% CI 0.42 to 0.95).
Authors' conclusion: Although addition of anti-leukotrienes to inhaled glucocorticoids appears comparable to increasing the dose of inhaled steroids, the power of the review is insufficient to confirm the equivalence of both treatment options. Addition of anti-leukotrienes is associated with superior asthma control after glucocorticoid tapering; although the glucocorticoid-sparing effect cannot be quantified at present, it appears modest.
Comment: The quality of evidence is downgraded by sparse data.
1. Ducharme F, Schwartz Z, Hicks G, Kakuma R. Addition of anti-leukotriene agents to inhaled corticosteroids for chronic asthma. Cochrane Database Syst Rev 2004;(2):CD003133. [PMID:15106191]
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