Children with mild to moderate persistent asthma who have low pulmonary function and/or elevated signs of allergic inflammation should be treated with inhaled corticosteroids.
Other asthmatic children could receive a trial of either inhaled corticosteroids (ICSs) or leukotriene receptor antagonists (LTRAs) with an assessment of response.
Those are the key conclusions of a study that sought to determine whether responses to fluticasone and montelukast are the same for all children with asthma or whether some pediatric patients who do not respond to one medication may respond to the other.
“There is increasing evidence that children respond differently to the various treatment options for asthma,” James Kiley, Ph.D., director of the division of lung diseases at the National Heart, Lung, and Blood Institute, said in a statement.
“If we can pinpoint in advance which children will do better with a certain type of therapy, we can improve their lives more quickly and save them the risk of trying medications that are less effective for them. This study adds important information for identifying which children are more likely to respond well to inhaled corticosteroids,” the NHLBI statement continued.
For the study, Stanley J. Szefler, M.D., and his associates administered fluticasone and montelukast separately for 8 weeks to 126 children aged 6-17 years with mild to moderate persistent asthma (J. Allergy Clin. Immunol. 2005;115:233-42).
Response was defined as achieving a 7.5% or greater improvement on a single measurement of forced expiratory volume in 1 second (FEV1) after 8 weeks of treatment on each drug.
Of the 126 children, 17% responded to both medications, 23% responded to fluticasone alone, 5% responded to montelukast alone, and 55% responded to neither medication.
Certain factors predicted responses to one medication but not to the other. For example, compared with children who failed to respond to either medication, those who responded to fluticasone alone had lower pulmonary function and methacholine PC20 values at baseline, as well as higher exhaled nitric oxide levels, total eosinophil counts, IgE levels, and eosinophil cationic protein levels.
“Our findings thus suggest that children with higher levels of eosinophilic airway inflammation might respond to ICSs but not to LTRAs,” the investigators wrote. “The group that responded to montelukast alone, although small in proportion (5%), was younger in age and had a shorter duration of disease. Perhaps leukotriene-driven inflammation is an important feature of asthma in young children, or perhaps this represents a specific phenotype of the disease.”
The investigators added that children who responded to both medications had significantly lower levels of pulmonary function and higher levels of urinary leukotriene E4 at baseline, compared with those who failed to respond to either medication.
“These data reveal an asthma phenotype with impaired lung function and overexpressed leukotriene production that is responsive to both ICSs and LTRAs,” they wrote.
The investigators said the main limitation of the study was the reliance on a single FEV1 measurement.
They concluded that the overall findings “suggest that asthma therapy might soon move from the current approach based on mean responses in populations to one in which the treatment that is most likely to expeditiously achieve a favorable response is identified for each individual patient on the basis of her or his phenotypic and possibly genotypic characteristics.”
GlaxoSmithKline Inc. and Merck & Co. Inc. donated the drugs and placebo agents used in the study.