44. Anti-leukotrienes as monotherapy in the young asthmatic:

In a recent review article, Inoue et al comment that early introduction of inhaled steroids is recommended for control of symptoms, improved quality of life and inhibition of airway remodeling in childhood asthma. While evidence for the above exists in school age and older children, further investigation is required to determine whether the disease concept and role of early intervention apply equally to infants and very young children. Unfortunately symptomatic infants and toddlers do not appreciate that the stated lack of evidence confounds the development of practice guidelines at this age, and they require symptomatic relief to the same extent as their older counterparts. How then to treat this age group? Green and Weinberg have recently proposed that montelukast should be added to the armamentarium, even as first line monotherapy, for the management of pre-school asthmatics aged 2-5 years. This product has recently been licensed for use in young asthmatics and is available as a pleasant-tasting chewable tablet for once-daily administration. Advantages over inhaled agents for this age group are obvious, but inhaled steroids will still be required if montelukast fails to control symptoms. In noting the recommendations to consider use of this agent one should also note two systematic reviews on the subject, in particular the Cochrane review that indicated that in comparison with inhaled steroids there would be one extra exacerbation requiring systemic steroids for every 26 patients treated with anti-leukotrienes, and one extra withdrawal for poor asthma control for every 29 patients treated with anti-leukotrienes.


Read more:
Allergol Int 2004;53:309-14
Pediatrics 2001;108:1-10
BMJ 2003;326:621
Cochrane Database Syst Rev 2004:CD002314