Tools for Practice Outils pour la pratique


#154 Pills vs. Puffers: Leukotriene receptor antagonists for childhood asthma


CLINICAL QUESTION
QUESTION CLINIQUE
 #154 Are leukotriene receptor antagonists (LTRAs) effective in pediatric asthma?

BOTTOM LINE
RÉSULTAT FINAL
 Using leukotriene receptor antagonists instead of inhaled corticosteroids as monotherapy will lead to one more exacerbation in every 21 patients. Asadd-on to inhaled corticosteroids, leukotriene receptor antagonists are inferior to long acting beta-agonists (LABAs), and show similar outcomes to increased dosesof inhaled corticosteroids (ICS). Data is limited and not supportive of use in children ≤5 years.  


CFPCLearn Logo

Reading Tools for Practice Article can earn you MainPro+ Credits

La lecture d'articles d'outils de pratique peut vous permettre de gagner des crédits MainPro+

 Join Now S’inscrire maintenant

Already a CFPCLearn Member? Log in

Déjà abonné à CMFCApprendre? Ouvrir une session


EVIDENCE
DONNÉES PROBANTES
  • Randomized Controlled Trials (RCTs) report many outcomes, particularly surrogate endpoints like FEV1. We focused on objective clinical outcomes. 
    • Three systematic reviews of RCTs: ICS superior to LTRAs for mild/moderate asthma.1-3 
      • Largest Cochrane review (19 trials, 3,333 children):1 LTRA had statistically significantly more asthma exacerbations requiring oral corticosteroids (18.8%) versus ICS (13.3%), Number Needed to Harm (NNH)=21. 
    • Three systematic reviews assess LTRA as step-up therapy to ICS (4-16 weeks).3,4,5 Exacerbation compared in one RCT each: 
      • LTRA+ICS versus ICS same dose:6  
        • 279 children, no difference. 
      • LTRA+ICS low dose versus ICS moderate dose:7  
        • 165 children, no difference.  
      • LTRA+ICS versus LABA+ICS:7 
        • 167 children, no difference.   
        • Composite endpoint (exacerbations, asthma control days and FEV1) found LTRA inferior to LABA, NNH=6. 
      • Network meta-analysis (35 RCTs) found ICS+LABA best, ICS+LTRAs, medium/high-dose ICS and low-dose ICS tied for second, LTRA alone and placebo last.8 
    • RCTs comparing LTRAs to placebo report conflicting results.9,10
Context: 
  • Children age ≤5 years are included in few RCTs and fail to show consistent benefit.11,12   
    • Guidelines state LTRA “are not advocated and/or should be avoided” until further evidence in this age group. 
  • LTRAs were the second most commonly prescribed drug in children aged 0-11 from 2007-2009 (USA).14 
  • Parental concern about ICS safety, including growth effects, may impact decision making and compliance.15 No difference between LTRA and ICS in rates of adverse events, but more patients on LTRAs withdrew from studies due to poor asthma control.1 
  • LTRAs have demonstrated some benefit in various subgroups including allergic rhinitis,16,17 exercise induced bronchospasm,18 and specific genotypes.19 Limited research suggests superior outcomes with ICS in these groups.16-19 

Latest Tools for Practice
Derniers outils pour la pratique
program image
December 6, 2024

#379 Bumpin’ Up the Protection? RSV Vaccine in Pregnancy

How effective and safe is the respiratory syncytial virus (RSV) vaccine (AbrysvoTM) when given during pregnancy?
Read Lire 0.25 credits available Crédits disponibles
program image
November 22, 2024

#378 Tony Romo-sozumab: Winning touchdown in osteoporosis or interception for the loss?

What is the efficacy and safety of romosozumab in postmenopausal women with osteoporosis?
Read Lire 0.25 credits available Crédits disponibles
program image
November 8, 2024

#377 How to slow the flow IV: Combined oral contraceptives

In premenopausal heavy menstrual bleeding due to benign etiology, do combined oral contraceptives (COC) improve patient outcomes?
Read Lire 0.25 credits available Crédits disponibles
January 18, 2016

This content is certified for MainPro+ Credits, log in to access

Ce contenu est certifié pour les crédits MainPro+, Ouvrir une session
Author(s)
Auteur(s)
  • Chris Novak BSc
  • Christina Korownyk MD CCFP

1. Chauhan BF, Ducharme FM. Cochrane Database Syst Rev. 2012; 5:CD002314.

2. Massingham K, Fox S, Smaldone A. J Pediatr Health Care. 2014; 28(1):51-62.

3. Castro-Rodriguez JA, Rodrigo GJ. Arch Dis Child. 2010; 95(5):365-70.

4. Chauhan BF, Ben Salah R, Ducharme FM. Cochrane Database Syst Rev. 2013; 10:CD009585.

5. Chauhan BF, Ducharme FM. Cochrane Database Syst Rev. 2014; 1:CD003137.

6. Simons FE, Villa JR, Teper AM, et al. J Pediatr. 2001; 138(5):694-8.

7. Lemanske RF, Mauger DT, Sorkness CA, et al. N Engl J Med. 2010; 362(11):975-85.

8. Zhao Y, Han S, Shang J, et al. J Asthma. 2015; 52(8):846-57.

9. Knorr B, Matz J, Bernstein JA, et al. JAMA. 1998; 279(15):1181-6.

10. Weiss KB, Gern JE, Johnston NW. Ann Allergy Asthma Immunol. 2010; 105(2):174-81.

11. Nwokoro C, Pandya H, Turner S, et al. Lancet Respir Med. 2014; 2(10):796-803.

12. Valovirta E, Boza ML, Robertson CF, et al. Ann Allergy Asthma Immunol. 2011; 106(6):518-26.

13. Ducharme FM, Dell SD, Radhakrishnan D, et al. Can Respir J. 2015; 22:135-43.

14. Gu Q, Dillon CF, Burt LI. Available at: http://www.cdc.gov/nchs/data/databriefs/db42.htm. (Last accessed September 14, 2015)

15. Chan PW, DeBruyne JA. Pediatr Int. 2000; 42(5):547-51.

16. Philip G, Nayak AS, Berger WE, et al. Curr Med Res Opin. 2004; 20(10):1549-58.

17. Wilson AM, Dempsey OJ, Sims EJ, et al. Clin Exp Allergy. 2001; 31(4):616-24.

18. Parsons JP, Hallstrand TS, Mastronarde JG, et al. Am J Respir Crit Care Med. 2013; 187(9):1016-27.

19. Nwokoro C, Pandya H, Turner S, et al. Lancet Respir Med. 2014; 2(10):796-803.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.