Can we predict montelukast treatment failure in step-down therapy for controlled asthma?

Although many physicians and patients want to replace low dose inhaled steroids with montelukast in controlled patients with mild asthma, there are insufficient data to predict montelukast failure. A study by Drummond et al (J Asthma 2011 Oct 27 [Epub ahead of print]) provides a piece of the puzzle. Using the 165 participants in the Leukotriene or Corticosteroid or Corticosteroid-Salmeterol Study (LOCCS) trial who were stepped down from low-dose ICS to montelukast, the authors attempted to predict the risk of montelukast treatment failure during step-down. Characteristics independently associated with montelukast treatment failure included early asthma onset (<10 years), need for steroid burst in the last year, and low pre-bronchodilator FEV₁. They constructed a montelukast failure index that may prove to be helpful for clinical practice, but it needs further validation.

Another piece to the LABA debate in asthma: The age of the patient

The US Food and Drug Administration assessed the risks of LABAs in asthma using a meta-analysis of controlled clinical trials in patients 4 to 11, 12 to 17, 18 to 64, and older than 64 years old (McMahon AW et al., Pediatrics 2011;128:e1147-e1154). They studied how age affected a composite index of asthma-related deaths, intubations, and hospitalizations, as well as the effects of concomitant inhaled corticosteroid (ICS) use. For all ages, the composite event incidence difference was 6.3 events per 1000 patient-years when patients using LABAs were compared to those not using LABAs. The greatest difference in serious asthma-related events attributable to LABAs was observed among children — 30.4 events per 1000 patient-years [95% CI: 5.7-55.1] in the 4- to 11-year age group. In all age groups, results for the subgroup of patients with concomitant ICS use were similar to the overall results. The authors conclude that “Additional data are needed to assess risks of LABA use for children with simultaneous ICS use.”