In poorly controlled asthmatic children, what works best?
Ans: Long-acting beta agonists (the ones with the warning*) are more effective than either monteleukast (Singulair) or doubled dosing inhaled corticosteroids.
To put things into perspective, about 7 million U.S. children have asthma; the prevalence is more than doubling over the past 2 decades; this group suffers 500,000 hospitalizations, 10.5 million physician-office visits, 3,500 deaths and millions of missed school days yearly,
A study, called Best Add on Therapy Giving Effective Responses (BADGER), compared the effectiveness of 3 separate stepped-up treatment regimes in 182, 6 to 18 year old children who had mild to moderate persistent asthma that wasn't being controlled on low-dose inhaled corticosteroids.
Results Almost all the children responded differently, but 45% did their best with the long-acting beta agonist, salmeterol, 28% with the leukotriene receptor antagonist, montelukast, and 27% with double dosing an inhaled corticosteroid, fluticasone. Certain patient characteristics were correlated to the most effective stepped-up treatment—African-Americans were equally likely to respond best to LABA step-up or corticosteroid step-up, but not montelukast; For white patients, LABA therapy was the best and inhaled corticosteroids was less effective. LABA was preferable for asthma patients who did not have eczema,
"Step-up Therapy for Children with Uncontrolled Asthma Receiving Inhaled Corticosteroids." See the New England Journal of Medicine online, March 2, 2010.
* Note: The recent safety advisory from the US Food and Drug Administration (FDA) on the use of long-acting beta agonists (LABAs) "should be viewed with extreme caution" American Academy of Allergy, Asthma and Immunology (AAAAI) 2010 Annual Meeting. Presented March 1, 2010.
Predicting asthma control under everyday** practice conditions
Research design and methods: A subgroup of 1380 patients with initially inadequately controlled asthma was defined from a cohort of 1893 asthmatic patients (mean age 45.3 +/- 19.2 years) recruited by 281 office-based physicians who participated in a previously-conducted asthma control survey in Switzerland. Multiple regression techniques were used to identify predictors of improved asthma control, defined as an absolute decrease of 0.5 points or more in the Asthma Control Questionnaire between the baseline (V1) and follow-up visit (V2).
Results: Asthma control between V1 and V2 improved in 85.7%. Add-on treatment with montelukast was reported in 82.9% of the patients. Patients with worse asthma control at V1 and patients with good self-reported adherence to therapy had significantly higher chances of improved asthma control (OR = 1.24 and 1.73, 95% CI 1.18-1.29 and 1.20-2.50, respectively).
Compared to adding montelukast and continuing the same inhaled corticosteroid/fixed combination (ICS/FC) dose, the addition of montelukast to an increased ICS/FC dose yielded a 4 times higher chance of improved asthma control (OR = 3.84, 95% CI 1.58-9.29). Significantly, withholding montelukast halved the probability of achieving improved asthma control (OR = 0.51, 95% CI = 0.33-078).
The probability of improved asthma control was almost 5 times lower among patients in whom FEV(1) was measured compared to those in whom it was not (OR = 0.23, 95% CI = 0.09-0.55). Patients with severe persistent asthma also had a significantly lower probability of improved control (OR = 0.15, 95% CI = 0.07-0.32), as did older patients (OR = 0.98, 95% CI = 0.97-0.99).
Subgroup analyses which excluded patients whose asthma may have been misdiagnosed and might in reality have been chronic obstructive pulmonary disease (COPD) showed comparable results.
Conclusions: Under conditions of everyday clinical practice, the addition of montelukast to ICS/FC and good adherence to therapy increased the likelihood of achieving better asthma control at the follow-up visit, while older age and more severe asthma significantly decreased it.
** Observations made iin Switzerland
Taegtmeyer AB, Steurer-Stey C, Price DB, Wildhaber JH, Spertini F, Leuppi JD. "Predictors of asthma control in everyday clinical practice in Switzerland" Curr Med Res Opin (Sep 2009) [last accessed Sept. 16, 2009]