SELECTED ARTICLES FROM THE RECENT LITERATURE 2007

September 11, 2007

Non-corticosteroid therapy for long-term asthma treatment

Summary
Background - Inhaled corticosteroids (ICS) are a mainstay of the chronic treatment of persistent asthma (PA). However, non-ICS agents are frequently tried as monotherapy or to reduce the ICS dose required for control of PA.

Findings - Kelly of the Univ of New Mexico reviewed recent studies comparing the efficacy of non-ICS agents in the treatment of PA. The author concluded:

  1. Neither inhaled long acting beta agonists (LABA) or omalizumab (anti-IgE antibody) should be used as monotherapy for PA.
  2. There are overall no significant differences in the efficacy of cromolyn. Theophylline or leukotriene antagonists (e.g. - montelukast) in mild-moderate PA. However, there is often significant difference in the response of individual asthmatic patients to one or the other of these agents. There are no reliable genetic or other markers in an individual patient to predict the clinical efficacy of one of these agents.
  3. Addition of LABA to the ICS treatment of moderate-severe PA usually leads to fewer acute asthma exacerbations and better pulmonary function at a lower ICS dose than when ICS is used as monotherapy. The other non-ICS agents are not as effective as LABA as adjuncts to ICS therapy. Therefore, added LABA remain the adjunctive therapy of choice when PA is not adequately controlled on low to medium ICS dosage.
  4. Omalizumab has not been compared adequately with other adjunctive non-ICS agents. However, one study showed an added benefit of omalizumab therapy in PA not controlled on ICS plus LABA.

Reference
Exp Opin Pharmacoth 2007;8:2077-87

Editor's Comments
The conclusions in this report are generally in line with that expressed in most recent reviews. However, I think that LA agents are usually more effective than cromolyn, particularly in adults. The FDA has mandated a "black box" warning about the chronic use of LABA in PA because of increased asthma- related mortality associated with it use (seen mainly in African-Americans).
Omalizumab use has been limited to more severe PA, particularly since recent reports of anaphylactic reactions to this agent.

 

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