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Antileukotrienes

The leukotriene receptor antagonists (LRTAs) montelukast and zafirlukast (available since 1998) have anti-inflammatory and bronchodilator properties.1 They block the effects of cysteinyl leukotrienes in the airways which can get released in response to antigens, aspirin or exercise. They have long half-lives.

Indications

They are effective in mild to moderate asthma when used alone or with an inhaled steroid and may be of benefit in exercise-induced asthma and in those with concomitant rhinitis.2 3 Montelukast is no more effective than a standard dose of inhaled corticosteroid but the two drugs appear to be additive. They are less effective in severe asthma.
LRTAs may be indicated in several clinical situations:4

  1. In step 2 of the British Guidelines, they can be used as an alternative to inhaled steroids in patients taking short-acting beta-agonists. They are less effective than inhaled steroids and should not be given as the sole preventive in patients taking long-acting beta-agonists (LABAs).
  2. In step 3 they can be used as an adjunct to inhaled steroids if a LABA has failed to control symptoms. LABA but not LTRA may also be associated with blunting of the reliever response to salbutamol in the presence of bronchoconstriction. LRTAs confer a bronchoprotective effect (e.g. against allergen or exercise) which, unlike LABAs, is not subject to tolerance, even when combined with inhaled steroid. A single dose of a LRTA is effective within one hour and protects for at least 12 hours.5
  3. In step 4 LRTAs can be used as an adjunct to inhaled steroids, LABAs and other therapies.2
  4. LRTAs can reduce eye and nose symptoms as effectively as antihistamines. Combined with an antihistamine is more effective than either alone, but this combination is still less effective than intranasal steroids.6 However, they would seem a logical choice for patients with seasonal rhinitis and asthma.
  5. They have theoretical benefit in aspirin-intolerant asthma, since they are important mediators of this type of asthma, and they can improve symptoms inadequately controlled with steroids but they do not necessarily protect from severe reactions if exposed to aspirin or NSAID. However, they would be a logical choice for patients with asthma, aspirin intolerance and nasal polyposis.
Unwanted effects
  • Montelukast and zafirlukast are generally well tolerated.
  • Unwanted effects include gastrointestinal symptoms (nausea, abdominal pain), headache and skin rashes.
  • Transient, asymptomatic elevations in liver transaminases may occur with zafirlukast but not with conventional doses of montelukast.
  • Rarely, zafirlukast causes severe hepatotoxicity, so the drug is contraindicated in patients with liver impairment.
  • Very rarely, Churg-Strauss syndrome, a systemic eosinophilic vasculitis, has been reported in patients receiving leukotriene receptor antagonists, usually when cortocosteroid therapy is reduced or withdrawn.


Document References
  1. Currie GP, Devereux GS, Lee DK, et al; Recent developments in asthma management.; BMJ. 2005 Mar 12;330(7491):585-9.
  2. British Guideline on the management of asthma, SIGN and British Thoracic Society (2003 - update 2007); (2003 - update 2005)
  3. British National Formulary British Medical Association and Royal Pharmaceutical Society of Great Britain. London.
  4. No authors listed; Leukotriene receptor antagonists--an update.; Drug Ther Bull. 2005 Nov;43(11):85-8. [abstract]
  5. Coreno A, Skowronski M, Kotaru C, et al; Comparative effects of long-acting beta2-agonists, leukotriene receptor antagonists, and a 5-lipoxygenase inhibitor on exercise-induced asthma.; J Allergy Clin Immunol. 2000 Sep;106(3):500-6. [abstract]
  6. Pullerits T, Praks L, Ristioja V, et al; Comparison of a nasal glucocorticoid, antileukotriene, and a combination of antileukotriene and antihistamine in the treatment of seasonal allergic rhinitis.; J Allergy Clin Immunol. 2002 Jun;109(6):949-55. [abstract]

Internet and Further Reading AcknowledgementsEMIS is grateful to Dr Laurence Knott for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2007.
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Document Version: 1
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Last Updated: 9 Aug 2007
Review Date: 8 Aug 2008


















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