Montelukast vs. Beclomethasone for Asthma

Abstract & Commentary

Synopsis: Both agents provided clinical benefit to patients with chronic asthma that suggests their use as controller medications for this condition.

Source: Malmstrom K, et al, for the Montelukast/Beclomethasone Study Group. Ann Intern Med 1999;130:487-495.

Montelukast, a once-daily oral leukotriene, was compared with inhaled beclomethasone, 200 mcg, twice daily over a 12-week treatment period in 895 chronic asthmatic patients using a double-blind, double-dummy, placebo-controlled design. Both agents improved peak expiratory flow rates and quality of life. Both agents also increased the number of asthma-controlled days and decreased nocturnal awakenings and asthma exacerbations compared to placebo. Over the 12-week study, the side effect profile was similar and no different from placebo.

Beclomethasone had a greater mean clinical benefit, as measured by FEV1, which was 13.1% compared to an FEV1 of 7.4% with montelukast, and a daytime symptoms score of -0.62 for beclomethasone, compared to -0.41 for montelukast. However, montelukast has a faster onset of action and greater initial effect. Thus, both agents provided clinical benefit to patients with chronic asthma that suggests their use as controller medications for this condition.

Comment by Sheldon L. Spector, MD

Inhaled corticosteroids are the most frequently prescribed controller medications in the treatment of asthma. They are recommended in virtually every asthmatic patient, except the most mild, due to their anti-inflammatory properties and long-term benefit.1,2

Although antileukotrienes are also anti-inflammatory, they were recommended in the 1997 NHLBI guidelines only for mild, persistent asthma.3 Current usage includes more severe patients,4 so a head-to-head comparison as described in the study by Malmstrom and associates is welcomed. In fact, a recent study by Nathan and colleagues demonstrated a better effect with more moderate patients using another antileukotriene.5 Currently, there are no comparison studies between antileukotrienes or of other antileukotrienes with different inhaled cortocosteroids. In the present study, beclomethasone had some clinical advantages; however, montelukast has a faster onset of action and greater initial effect.

Although compliance was good for both groups, the literature supports better compliance with an oral medication and once-daily therapy.6 Moreover, it is not clear if a subgroup of patients would respond better to antileukotrienes than inhaled corticosteroids. A combination of inhaled corticosteroids with the antileukotriene would also be attractive in view of their different modes of action and the potential ability to reduce high-dose corticosteroid aerosols and thereby decrease the chance for steroid side effects.

References

1. National Asthma Education Program. 1991. Guidelines for the Diagnosis and Management of Asthma. Washington, D.C.: U.S. Dept. of Health and Human Services. Publication No. 91-3042:48.

2. Spector S, Nicklas R. J Allergy Clin Immunol 1995; 96(5):707-870.

3. National Asthma Education and Prevention Program. Expert Panel Report II: Guidelines for the Diagnosis and Management of Asthma. February 1997.

4. Spector SL. Drugs 1997;54(3):369-384.

5. Nathan RA, et al, and the ACCOLATE Trialists Group.

6. Spector SL, et al. J Allergy Clin Immunol 1986;77: 65-70.

Which of the following statements is false?

a. Montelukast has a faster onset of action and greater initial effect.

b. Inhaled corticosteroids are the most frequently prescribed controller medications in the treatment of asthma.

c. Both montelukast and beclomethasone improved peak expiratory flow rates and quality of life.

d. None of the above