Jartti Tuomas
Department of Pediatrics, Turku University Hospital, Kiinamyllynkatu 4-6, 20520 Turku, Finland.
Eur J Pediatr. 2008 Jul;167(7):731-6. doi: 10.1007/s00431-007-0644-3. Epub 2008 Jan 24.
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.
根据当前指南，吸入性糖皮质激素（ICS）是各年龄组哮喘儿童首选的长期主要治疗药物，但白三烯受体拮抗剂可被视为轻度持续性哮喘的替代治疗药物。在本文中，对所有比较白三烯受体拮抗剂与吸入性糖皮质激素用于哮喘儿童长期（>4周）治疗的随机双盲疗效研究进行了严格审查。在学龄儿童中，有五项研究设计充分的报告。所有这些研究都将孟鲁司特与吸入性氟替卡松进行了比较。对两项主要结局指标进行的荟萃分析显示，1秒用力呼气量（加权平均差异为预测值的4.6%，95%置信区间：3.5-5.5）和哮喘控制天数（分别为5.6%，4.3-6.9）表明氟替卡松优于孟鲁司特。许多其他临床和肺部结局也一致表明，低剂量吸入性氟替卡松在轻度至中度持续性哮喘的长期管理中比孟鲁司特更有效。与孟鲁司特相比，对氟替卡松的更有利反应与更严重的疾病或过敏性炎症标志物有关。约四分之一的患者从孟鲁司特中获益多于氟替卡松。在学龄前儿童中，没有可用的比较研究。然而，在年龄>2岁的哮喘儿童的安慰剂对照研究中发现，长期使用孟鲁司特治疗是有效的。这些发现支持了目前国际上关于ICS作为轻度至中度持续性儿童哮喘首选一线控制疗法的建议。如果选择孟鲁司特作为单一疗法，且在4-6周内哮喘未得到充分控制，则应停用该治疗并开始使用首选药物。
