Inhaled corticosteroids or montelukast as the preferred primary long-term treatment for pediatric asthma?

According to current guidelines, inhaled corticosteroids (ICS) are the preferred primary long-term treatment for asthmatic children of all age groups, but leukotriene receptor antagonists can be considered to be an alternative treatment for mild persistent asthma. In this article, all randomized double-blind efficacy studies comparing the long-term (>4-week) treatment using a leukotriene receptor antagonist with an inhaled corticosteroid in asthmatic children were critically reviewed. In school-aged children, five reports with an adequate study design were available. All of these studies compared montelukast with inhaled fluticasone. The meta-analysis of the two main outcome measures, forced expiratory volume in 1 s (weighted mean difference, 4.6% predicted, 95% confidence interval: 3.5–5.5) and asthma control days (respectively, 5.6%, 4.3–6.9) demonstrated the superiority of fluticasone over montelukast. Many other clinical and pulmonary outcomes also consistently showed that low-dose inhaled fluticasone was more effective than montelukast in the long-term management of mild to moderate persistent asthma. A more favorable response to fluticasone over montelukast was associated with more severe disease or markers of allergic inflammation. About a quarter of patients benefited more from montelukast than fluticasone. In children under school age, no comparative studies were available. However, long-term montelukast treatment was found to be effective in placebo-controlled studies in asthmatic children aged >2 years. These findings support the present international recommendations for ICS as the preferred first-line controller therapy for mild to moderate persistent childhood asthma. If montelukast is selected as a monotherapy and asthma is not adequately controlled within 4–6 weeks, the treatment should be discontinued and the preferred medication initiated. Supported by the Academy of Finland. The author has no conflict of interest in connection with this paper. An erratum to this article can be found at     

Montelukast vs. inhaled low-dose budesonide as monotherapy in the treatment of mild persistent asthma: a randomized double blind controlled trial

BACKGROUND: Guidelines recommend daily controller therapy for mild persistent asthma. Montelukast has demonstrated consistent benefit in controlling symptoms of asthma and may be an alternative, orally administered, nonsteroidal agent for treating mild asthma. Aim: To determine whether montelukast is as effective as budesonide in controlling mild persistent asthma as determined by FEV(1). METHODS: Between November 2003 to October 2005, participants aged 5-15 years with recently diagnosed mild persistent asthma (n = 62) were randomized to oral montelukast (5 mg daily) [N(1) = 30] or inhaled budesonide (400 microg per day in two doses) [N(2) = 32] in a single center, double-blind study. RESULTS: Baseline demographic and spirometric parameters were comparable. The median (95% confidence interval) percentage predicted FEV(1) was similar in the two groups after 12 weeks of treatment (budesonide: 76.70 (67.96-90.53%), montelukast: 75 (67.40-88.47)%; p = 0.44). There was similar improvement in spirometric parameters and clinical symptom scores in both the groups. There was no statistically significant difference between the groups in the need for rescue drugs as well as side effects reported by parents. CONCLUSION: Montelukast is as effective as inhaled budesonide in the treatment of mild persistent asthma in children aged 5-15 years. Montelukast may be used as an alternative to low dose inhaled corticosteroids for management of mild persistent asthma.     

Montelukast — evaluation in 6 to 14 years old children with persistent asthma — pediatric montelukast study group

Objective : The suffering of children with asthma as a persistent illness is present in approximately 10% of the total population. The prevalent treatment regimens available has been the inhaled coticosteroids and short acting bronchodialators. Though the therapies are rational and well accepted but at the cost of side effects on chronic use. The changing definitions and guidelines with regard to asthma have given a classified slot to newer treatments like leukotriene receptor antagonists (LTRAs). The aim of the present study was to study the efficacy and tolerability of montelukast in the treatment of Indian pediatric patients aged 6 to 14 years with chronic asthma.Methods: It was a prospective, open, non-comparative multicentric study. 881 Children (Mean age 11.83± 3.12 years) were included. Patients fulfilling the inclusion criteria were given one mouth dissolving 5 mg montelukast tablet daily in the evening for 30 days.Results : There was an overall improvement in all the efficacy parameters. The daytime total asthma score decreased from 9.55 ± 1.52 to 3.59 ±2.10. The average number of asthma attacks over the last 4 weeks decreased from 1.14± 1.19 to 0.28±0.57. The number of nocturnal awakenings fell from 1.54±0.78 to 0.43±0.54. FEV, (L) (Predicted J improved by 21.18%). PEFR (LJmin.) improved by 34.69%). Approximately 45% physicians rated the treatment as excellent, 30% as very good, 18% as good, 7% as fair and none as poor.Conclusion: Montelukast administered once daily improved efficacy end-points and was well tolerated in pediatric patients with chronic persistent asthma establishing itself as a valuable treatment option to current asthma therapies in 6 to 14 years old patients.     

Update on leukotriene receptor antagonists in preschool children wheezing disorders

ABSTRACT: Asthma is the most common chronic disease in young children. About 40% of all preschool children regularly wheeze during common cold infections. The heterogeneity of wheezing phenotypes early in life and various anatomical and emotional factors unique to young children present significant challenges in the clinical management of this problem. Antiinflammatory therapy, mainly consisting of inhaled corticosteroids (ICS), is the cornerstone of asthma management. Since Leukotrienes (LTs) are chemical mediators of airway inflammation in asthma, the leukotriene receptor antagonists (LTRAs) are traditionally used as potent anti-inflammatory drugs in the long-term treatment of asthma in adults, adolescents, and school-age children. In particular, montelukast decreases airway inflammation, and has also a bronchoprotective effect. The main guidelines on asthma management have confirmed the clinical utility of LTRAs in children older than five years. In the present review we describe the most recent advances on the use of LTRAs in the treatment of preschool wheezing disorders. LTRAs are effective in young children with virus-induced wheeze and with multiple-trigger disease. Conflicting data do not allow to reach definitive conclusions on LTRAs efficacy in bronchiolitis or post-bronchiolitis wheeze, and in acute asthma. The excellent safety profile of montelukast and the possibility of oral administration, that entails better compliance from young children, represent the main strengths of its use in preschool children. Montelukast is a valid alternative to ICS especially in poorly compliant preschool children, or in subjects who show adverse effects related to long-term steroid therapy.     

Montelukast added to budesonide in children with persistent asthma: a randomized, double-blind, crossover study

OBJECTIVE: We tested the hypothesis that adding montelukast to budesonide would improve asthma control in children with inhaled glucocorticoid-dependent persistent asthma. STUDY DESIGN: In a multicenter, randomized, double-blind, crossover study, we compared the benefit of adding montelukast, 5 mg, or placebo once daily to budesonide, 200 microg, twice daily. RESULTS: After a 1-month run-in with budesonide, 200 microg, twice daily, 279 children were randomized to montelukast or placebo. The mean +/- SD age was 10.4 +/- 2.2 years, the mean forced expiratory volume in 1 second (FEV(1)) was 77.7% +/- 10.6% predicted, and reversibility was 18.1% +/- 12.9%. Compared with adding placebo to budesonide, adding montelukast produced significant improvements in mean percent change from baseline FEV(1) (P =.062 [P =.010 for per-protocol analysis]), mean absolute change from baseline FEV(1) (P =.040), mean increase from baseline in morning (P =.023) and evening (P =.012) peak expiratory flows, decrease in exacerbation days by approximately 23% (P <.001), decreased beta2-agonist use (P =.013), and reduced blood eosinophil counts (P <.001). The treatments did not differ significantly with regard to safety. CONCLUSIONS: Montelukast, 5 mg, added to budesonide improved asthma control significantly, indicated by a small additive effect on lung function and a clinically relevant decrease in asthma exacerbation days.     

吸人糖皮质激素与口服孟鲁司特治疗咳嗽变异型哮喘的疗效比较及随访研究

目的 比较吸入糖皮质激素(ICS)和口服白三烯调节剂(LTM)对儿童咳嗽变异型哮喘(CVA)的疗效,探讨儿童CVA的最佳治疗方案,并探讨CVA发展为典型哮喘的相关危险因素.方法 将84例年龄(3.9±1.2)岁(2～6岁)的CVA患儿随机分为ICS组(42例)和LTM组(42例).ICS组患儿通过定量气雾剂+储雾罐规律吸人二丙酸倍氯米松200 μg/d维持治疗,LTM组患儿每晚口服孟鲁司特5 mg维持治疗,治疗时间6个月,停用试验药物治疗后继续随访18个月.结果 ICS组平均止咳天数为(14±9)d,LTM组平均止咳天数为(13±9)d,两组问比较差异无统计学意义(Z=1.12,P=0.25).在24个月的研究观察期间,ICS组出现喘息的比率(7.1%)明显低于LTM组(33.3%)(x2=8.92,P=0.003).喘息组患儿湿疹和变应性鼻炎的患病率分别为47.1%和58.8%,明显高于无喘息组(分别为19.4%和31.3%)(x2分别为4.16和4.40,P均＜0.05).多因素逐步回归分析结果显示,湿疹和变应性鼻炎是CVA发展为典型哮喘的危险因素,OR值分别为7.668和3.855(P分别为0.002和0.049),而规律吸入ICS是有效的保护因素,其OR值为0.128(P=0.008).结论 CVA患者可转化为典型哮喘,接受ICS治疗的患儿出现喘息的比率低于接受LTM治疗的患儿,湿疹和过敏性鼻炎是CVA发展为典型哮喘的危险因素.     

按哮喘预测指数分组治疗在5岁以下喘息儿童中的应用

目的 观察按哮喘预测指数（asthma predictive index, API）分组治疗在5 岁以下喘息儿童中的应用价值。方法 239 例5 岁以下喘息患儿,API 阳性组126 例,API 阴性组113 例,分别随机分为糖皮质激素吸入治疗组（ICS 治疗组）及孟鲁司特钠治疗组（LTRA 治疗组）。治疗开始4 周内2 组所用药物种类和剂量相同,在疾病稳定期（第4 周后）ICS 治疗组仅使用布地奈德混悬液雾化吸入治疗,LTRA 治疗组仅使用孟鲁司特钠口服治疗,评估记录各组患儿不同时间点哮喘症状评分。结果 API 阳性组及阴性组在治疗后的前4 周,ICS和LTRA 2 种方法均有效,哮喘症状评分与治疗前比较差异有统计学意义,但2 个治疗组间比较差异无统计学意义;在治疗24 周时,2 种治疗方法仍有效,但API 阳性组中LTRA 治疗组较ICS 治疗组更有效;在API 阴性组中,LTRA 治疗组与ICS 治疗组疗效比较差异无统计学意义。结论 5 岁以下的儿童喘息,在疾病稳定期,可根据不同的API 分组,选择不同治疗方案,以达到更有效地控制喘息的目的。     

Advances in the management of childhood asthma

For children with daily asthma symptoms, the most effective preventative therapy is inhaled corticosteroids (ICS). Most children experience good symptom control on relatively low doses (<400 μg/day). If frequent symptoms persist despite treatment with ICS 400 μg/day, beneficial add-on therapies include long-acting beta-2 agonists, leukotriene receptor antagonists and slow-release theophyllines. These should be tried sequentially before the dose of ICS is increased.Non-atopic children with episodic viral-triggered wheezing are extremely unlikely to respond to regular ICS. They might best be treated with ‘when-required’ high-dose beta-2 agonists with or without oral steroids.Children with frequently recurrent or chronic non-specific coughing are unlikely to have asthma. However, a clear response of symptoms to a trial of inhaled steroids and relapse when stopping therapy remains useful in identifying those with true cough-variant asthma.It remains to be seen how effective anti-IgE antibody therapy will be.     

That ICS should be first line therapy for asthma--con

Asthma is a heterogeneous disease and it is therefore unrealistic to expect that inhaled corticosteroids (ICS) would be appropriate first line preventer therapy for all children with asthma. There is good theoretical and clinical trial evidence demonstrating that leukotriene receptor antagonists (LTRAs) are more effective than ICS for viral induced wheezing and equivalent to ICS for mild persistent asthma in children. LTRAS do not have the systemic adverse effects of ICS, are generally well tolerated and their once daily oral administration enhances adherence. LTRAs should therefore be first line preventer therapy for children with frequent intermittent or mild persistent asthma while ICS should be reserved as first line treatment for children with moderate to severe persistent asthma. Given the skew in paediatric asthma severity towards the milder end, this effectively means that LTRAs should be tried first in 2 of every 3 children with asthma requiring preventer treatment.     

A randomized controlled trial on the effect of montelukast on sputum eosinophil cationic protein in children with corticosteroid-dependent asthma

Previous adult studies demonstrated the clinical efficacy of an additional treatment with leukotriene receptor antagonists on steroid-dependent asthma, but there is little knowledge about anti-inflammatory add-on effects within the lung. In this study, we hypothesized that steroid-treated children exhibit a decrease in bronchial inflammation in induced sputum under additional treatment with montelukast. Twenty-five asthmatic children aged 6 to 14 y, who had been taking inhaled corticosteroids (400-800 microg/d budesonide) regularly for at least 12 wk, were randomized to receive additional treatment with either montelukast (5 mg orally, once daily) or placebo over a 4-wk period. As primary efficacy variable, eosinophil cationic protein (ECP) in induced sputum as direct measurement of bronchial inflammation was assessed before and after treatment. To assure a baseline level of inflammation, an ECP concentration above 100 microg/L was required. Sputum eosinophil count, concentration of exhaled nitric oxide, urinary excretion of eosinophil protein X, and quality-of-life items were considered as secondary outcome variables. After treatment with montelukast, ECP in sputum was significantly reduced (montelukast: median -975 microg/L [5 to 95% confidence interval: -4295 to 583 microg/L]; placebo: 561 microg/L [-1335 to 3320 microg/L]; p < 0.01) and the quality-of-life score had significantly improved (p < 0.05) compared with placebo. Partly explained by low baseline levels, no statistically significant change in concentration of exhaled nitric oxide (p > 0.05), urinary excretion of eosinophil protein X (p > 0.05), or eosinophil count (p > 0.05) was found. In conclusion, add-on treatment with montelukast can suppress sputum ECP in children with steroid-dependent asthma, while at the same time an improvement in quality of life items occurs.     

Current management of allergic asthma in children

Asthma in children is characterized by recurring symptoms such as wheezing, breathlessness, and cough, by airflow obstruction and bronchial hyperresponsiveness, and by underlying inflammation. The presence of allergic sensitization, and allergic rhinitis in particular, is strongly associated with asthma. The goal of management of asthma is to achieve and maintain control of the clinical manifestations of the disease. This can be obtained by drug treatment, education of patients and care givers, and, in allergic asthma, by allergen avoidance and specific immunotherapy. The drugs used in asthma can be classified as controllers - such as inhaled corticosteroids (ICS) and leukotriene receptor antagonists - or relievers (bronchodilators to be used during acute exacerbations of asthma). ICS are the most effective anti-inflammatory controllers for the management of persistent asthma in children of all ages, but there is no consensus about the optimal starting dose. Dose-response studies reported marked and rapid improvement in clinical symptoms and lung function at low doses of ICS, and mild asthma is well controlled by such doses in most children, this ensuring good safety. If there is no improvement with the initial low dose of ICS, an increased ICS dose or additional therapy with leukotriene receptor antagonists or long-acting inhaled β2-agonists should be considered. When asthma is caused by allergy to aeroallergens, specific immunotherapy must be taken into account, in its two forms of subcutaneous or sublingual immunotherapy. The former has complete evidence of efficacy, but the sublingual route is safer and more easily accepted by children.     

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目的观察白三烯(LTs)受体拮抗剂(孟鲁司特钠)在儿童腺样体肥大(AH)治疗中的疗效,探讨LTs受体拮抗剂用于治疗儿童AH的临床可行性。方法收集2007年1月至2010年12月在广州医学院第二附属医院就诊的上气道咳嗽综合征合并腺样体肥大和(或)并有过敏性鼻炎的患儿,分为观察组116例和对照组52例,各组均予对症治疗及按需使用抗生素,在此基础上观察组给予LTs受体拮抗剂(孟鲁司特钠)治疗16周。观察治疗前后各组患儿咳嗽持续天数、呼吸相关睡眠障碍症状指标评分及腺样体/鼻咽比值(A/N比值)的改变。结果治疗16周后:(1)观察组呼吸相关睡眠障碍症状指标评分、咳嗽天数,A/N比值分别由(12.31±2.58)分、(52.59±11.87)d、0.77±0.04下降至(5.68±3.30)分、(19.99±11.14)d、0.64±0.07,治疗前后差异有统计学意义(P<0.001)。对照组治疗前后上述各指标差异无统计学意义(P>0.05)。观察组与对照组在治疗前上述各指标差异无统计学意义,治疗后各指标间差异有统计学意义(P<0.001);(2)对观察组中的上气道咳嗽综合征合并单纯AH及AH合并过敏性鼻炎(AH-AR)...     

Long-term management of asthma

Long-term management of asthma includes identification and avoidance of precipitating factors of asthma, pharmacotherapy and home management plan. Common precipitating factors include viral upper respiratory infections, exposure to smoke, dust, cold food and cold air. Avoidance of common precipitating factors has been shown to help in better control of asthma. Pharmacotherapy is the main stay of treatment of asthma. Commonly used drugs for better control of asthma are long and short acting bronchodilators, mast cell stabilizers, inhaled steroids, theophylline and steroid sparing agents. After assessment of severity most appropriate medications are selected. For mild episodic asthma the medications are short acting beta agonists as and when required. For mild persistent asthma: as and when required bronchodilators along with a daily maintenance treatment in form of low dose inhaled steroids or cromolyn or oral theophylline or leukotriene antagonists are required. Moderate persistent asthma should be treated with inhaled steroids along with long acting beta agonists for symptom control. For severe persistent asthma the recommended treatment includes inhaled steroids, long acting beta agonists with or without theophylline. If symptoms are not well controlled, a minimal dose of oral prednisolone preferably on alternate days may be needed in few patients. Patients should be followed up every 8–12 weeks. On each follow up visit patients should be examined by a doctor, compliance to medications should be checked and actual inhalation technique is observed. Depending on the assessment, medications may be decreased or stepped up. For exercise induced bronchoconstriction: cromolyn, short or long acting beta agonists or leukotriene antagonists may be used. In children with seasonal asthma, maintenance treatment according to assessed severity should be started 2 weeks in advance and continued throughout the season. These patients should be reassessed after discontinuing the treatment. Parents should be given a written plan for management of acute exacerbation at home     

孟鲁司特钠单用于轻度持续哮喘患儿疗效和安全性的随机双盲安慰剂对照试验

目的：研究孟鲁司特钠单用于治疗5~14岁轻度持续哮喘患儿的疗效和安全性。方法：采用安慰剂随机双盲对照试验,对首诊诊断为轻度持续哮喘患儿,采用调查问卷方式采集患儿基线数据,经过2周安慰剂洗脱期,随机分为治疗组和对照组,分别睡前咀嚼口服孟鲁司特钠或安慰剂5 mg·d-1,疗程均为12周。在入组后4、8和12周记录哮喘日记卡内容：日间和夜间哮喘症状评分、β2受体激动剂使用频率、最大呼气峰流速（PEF）、因哮喘急性发作而需急诊或住院治疗的次数等;于治疗后12周检测肺功能指标：FEV1%预计值、FEF25%~75%。结果：2009年9月至2010年9月上海交通大学附属第一人民医院儿科哮喘专科门诊的轻度持续哮喘患儿安慰剂组纳入42例,孟鲁司特钠组纳入89例,至观察终点安慰剂组35例,孟鲁司特钠组77例进入分析。与安慰剂组相比,孟鲁司特钠组的PEF明显改善（P<0.05）;每周日间和夜间哮喘症状平均评分、每月因哮喘发作而需急诊或住院就诊率和每周平均β2受体激动剂使用次数均下降,差异有显著统计学意义（P<0.01）;治疗后12周孟鲁司特钠组FEV1%、FEF25%~75%较安慰剂组显著提高（P<0.05）;研究期间两组患儿均未观察到不良反应事件。结论：孟鲁司特钠单独用于轻度持续性哮喘患儿具有良好的疗效,不良反应少,患儿依从性高。     

Periodic use of inhaled steroids in children with mild persistent asthma: what are pediatricians recommending?

Although asthma treatment guidelines recommend daily inhaled corticosteroid (ICS) use for all persistent asthma, pediatricians may recommend alternative treatment plans for children with mild persistent disease. The authors administered a survey of pediatricians to describe prescribing patterns for mild persistent asthma. More than 99% of providers agreed that periodic ICS could be effective for some asthma patients. Overall, 129/251 providers (51%) reported prescribing daily ICS to most patients with mild persistent asthma, whereas 78 (31%) reported recommending periodic ICS for most such patients. Providers with patient populations > or = 25% black were significantly less likely to report prescribing daily ICS (odds ratio, 0.3; 95% confidence interval, 0.2-0.6) for mild persistent asthma. Further research is needed on the effectiveness of periodic ICS use for children with mild persistent asthma and on underlying reasons for differing provider practice patterns.     

哮喘儿童吸入糖皮质激素疗效与白三烯水平的相关性探讨

目的：探讨哮喘儿童半胱氨酰白三烯合成与分泌水平与吸入糖皮质激素（ICS）疗效个体差异的相关性。方法：32例5～12岁已规律使用ICS 6个月以上非急性发作期哮喘儿童,按病情控制程度分为ICS控制良好组（14例）与ICS控制不良组（18例）,取10例健康儿童作为对照组,比较3组儿童外周血多形核白细胞(PMNL)白三烯C4合成酶（LTC4S ）mRNA表达与尿白三烯E4（LTE4）分泌水平。LTC4S mRNA表达水平以qCt值表示,qCt值与基因表达水平呈负相关。结果：哮喘儿童组PMNL LTC4S mRNA 表达（qCt值:1.12±0.27）明显高于对照组（qCt值:1.42±0.12）,P<0.05。ICS控制不良组PMNL LTC4S mRNA表达水平最高（qCt值:1.03±0.17）,与ICS控制良好组（qCt值:1.24±0.33）和健康对照组(qCt值:1.42±0.12)比较差异均有显著性意义（分别P<0.05和P<0.01）。3组间尿LTE4比较差异无显著性意义。结论：哮喘儿童外周血LTC4S mRNA表达水平增高,且规范使用ICS控制不良患儿显著高于ICS控制良好患儿,提示体内白三烯水平增高可能与ICS控制不良有关。［中国当代儿科杂志,2009,11（6）：441-444］     

Effects of montelukast on symptoms and eNO in children with mild to moderate asthma

BACKGROUND: Asthma is a chronic inflammatory airway disease. Exhaled nitric oxide (eNO) is a marker reflecting airway inflammation. This study was conducted to investigate whether montelukast, a leukotriene receptor antagonist, could be used for the management of asthma and how fast the montelukast sodium decreased airway inflammation as demonstrated by eNO levels. METHODS: Twenty children aged 6-14 years (mean age: 9.2 +/- 2.4 years; mean weight 30 +/- 4.6 kg) with mild to moderate asthma were recruited for the study. They received montelukast plus an inhaled short-acting beta2 agonist as open and uncontrolled therapy. Asthma score (AS) and peak expiratory flow rate (PEFR) and eNO concentrations were measured at pretreatment (0 week) and post-treatment (1 and 2 weeks) as well as 2 weeks after withdrawal of therapy. RESULTS: In one week, the eNO levels (33.3 +/- 15.5 p.p.b. vs 14.8 +/- 8.6 p.p.b.; P < 0.05), and AS (4.2 +/- 1.3 vs 1.8 +/- 1.3; P < 0.05) decreased rapidly, and PEFR (206.9 +/- 69.7 L/min vs 236.2 +/- 69.8 L/min; P < 0.05) increased. Concurrent beta2 agonist use decreased from a mean +/- SD of 2.2 +/- 0.4-1.3 +/- 0.3 puffs per weeks (P < 0.05). After the withdrawal of treatment for 2 weeks, the eNO levels (29.2 +/- 16.1 p.p.b) rebounded again, although the improvements in AS (1.1 +/- 1.3) and PEFR (245.0 +/- 91.3 L/min) persisted. CONCLUSION: Oral montelukast sodium treatment of these children with mild to moderate asthma effectively improved asthmatic symptoms and suppressed airway inflammation in 1 week, suggesting that this leukotriene antagonist combined with short-acting beta2 agonists may provide effective treatment option in mild to moderate childhood asthma. Larger, controlled, and double-blinded studies are needed to confirm these preliminary open uncontrolled observations.     

Suppression of plasma matrix metalloproteinase-9 following montelukast treatment in childhood asthma

BACKGROUND: Montelukast and ketotifen are commonly prescribed anti-inflammatory medications used in the treatment of childhood asthma. METHODS: To investigate the modulation effect of montelukast and ketotifen, the levels of exhaled nitric oxide (eNO) and plasma matrix metalloproteinase-9 (MMP-9) were analyzed in a group of 30 children with mild persistent asthma. RESULTS: Patients on montelukast therapy for 8 weeks had significantly decreased levels of eNO and plasma MMP-9, which were associated with improved symptoms and enhanced peak expiratory flow but not significantly associated with increased level of tissue inhibitor metalloproteinase-1 (TIMP-1). In contrast, treatment with ketotifen produced no significant changes in these parameters until 4-6 weeks into the therapy and no effect on plasma MMP-9. CONCLUSION: Leukotriene antagonists, such as montelukast, may be better non-steroidal anti-inflammatory drugs for preventing airway inflammation in mild childhood asthma.     

Inhaled corticosteroids should be the first line of treatment for children with asthma

Although montelukast is claimed to be preferable to inhaled corticosteroids in children with asthma and allergic rhinitis, virus-induced exacerbations, exercise induced asthma, and in those experiencing difficulties with inhalation therapy, there is no scientific evidence to support any of these claims. In comparative trials and systematic reviews, inhaled corticosteroids are clearly more effective than montelukast in reducing asthma exacerbations, improving lung function, symptom scores, and rescue medication use. The effects on exercise induced bronchoconstriction appear to be similar. Because of their superior efficacy and excellent long-term efficacy and safety profile, inhaled corticosteroids are the treatment of first choice for the maintenance therapy of childhood asthma, irrespective of age or clinical phenotype.