SELECTED ARTICLES FROM THE RECENT LITERATURE 2004

10/11/04

Desloratadine vs montelukast in the treatment of chronic idiopatic urticaria

Summary
Background - Antihistamines (AH) remain the first therapeutic approach to control the manifestations of chronic idiopathic urticaria (CIU). However, AH treatment is sometimes not sufficient and in some cases of CIU, barely effective at all. A few small studies have assessed the therapeutic effects of leukotriene antagonists such as montelukast (Mont) or zafirlukast in CIU, either as monotherapy or in combination with AH agents, with conflicting results.

Findings - Di Lorenzo et al of the Univ. of Palermo in Italy compared the clinical efficacy of: Group (a) desloratadine (Desl), a non-sedating AH, 5 mg/day; Group (b) Mont, 10 mg/day; Group(c), a combination of these 2 drugs or Group (d) placebo, in a randomized, double-blind, parallel group study of 160 CIU patients with negative autologous serum skin tests and no evidence of worsening with aspirin or food additive challenge.

After 6 weeks of these treatments, the total urticaria symptom scores and number of hives were significantly lower in Groups a, b, and c, the active treatment groups, than in placebo- treated CIU patients. However, pruritus and several other symptoms were significantly less in the 2 groups receiving Desl (alone or in combination with Mont) while those treated with Mont alone exhibited symptoms not significantly different than seen in placebo treated patients. Perhaps, most important, only the members of groups (a) and (c) who had received Desl (alone or with Mont) all continued the 6 weeks of study medication. In contrast, 27 of 40 patients treated with Mont alone and 35 of 40 treated with placebo alone discontinued the study medications early in the study period because of uncontrolled CIU. Furthermore, there was no difference in efficacy of the Desl alone vs Desl plus Mont therapy.

Reference
J Allergy Clin Immunol 2004;114:619-25

Editor's Comments
These findings in a sizable (n=160) group of CIU patients make a fairly convincing case that Mont adds little in the way of efficacy in CIU, either as monotherapy or as additive benefit to Desl treatment. It can be questioned why Mont was ineffective here while showing some efficacy as “add-on” therapy in earlier smaller studies. Indeed, a very recent report (Clin Exp Allergy. 2004;34:1401-7) described a moderate additive benefit when Mont was used with Desl in a fairly sizable unselected CIU population One possibility is that the CIU patients in the study described above were selected to have negative autologous serum skin test and aspirin challenge tests. Perhaps it is the 30-40% of CIU patients with positive “auto-immune” skin test reactivity who may be helped more by LA. Some clinicians are impressed that the LA agent zafirlukast may be more effective than Mont in CIU .

 

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