ARTICLE IN PRESS Respiratory Medicine (2005) 99, 653
LETTER TO THE EDITOR Recovery time following bronchial challenge Van der Woude et al.1 have demonstrated that compared to placebo, the Borg score returned significantly quicker to baseline value after inhalation of formoterol, salmeterol and salbutamol. These results were observed following methacholine challenge during which the forced expiratory volume in 1 s (FEV1) was required to fall by at least 30%. While expected, these findings may only be of relevance to patients with mild asthma who are steroid naı¨ve or who use regular inhaled corticosteroids alone. In everyday clinical practice, many asthmatics with moderate-to-severe disease—especially those with impaired FEV1—are maintained on combined inhaled corticosteroid plus long-acting b2-agonist preparations. Despite the theoretical compliance benefit, it is important to note that regular use of the longacting b2-agonist moiety is known to blunt the effects of salbutamol.2 In other words, patients using regular long-acting b2-agonists experience a more prolonged recovery despite acute salbutamol administration. Several studies have demonstrated that prior administration of a leukotriene CysLT1-receptor antagonist significantly shortens the time taken to recover following bronchial challenge,3–5 with the implication that cysteinyl leukotrienes are integral pro-inflammatory mediators in maintaining the bronchoconstrictor response. Indeed, the ‘real-life’ implication of this was observed in a study by Camargo et al.6 In this double-blind, parallel group controlled trial, 210 patients with acute asthma were randomised to receive either montelukast or placebo along with conventional therapy. Patients given active drug had a significantly more rapid improvement in FEV1 over a 2-h period and received less inhaled b2-agonist compared to placebo. In conclusion, it is important to bear in mind that the findings of van der Woude et al. should only be applied to patients who do not use regular longacting b2-agonist. Moreover, use of a leukotriene CysLT1-receptor antagonist such as montelukast is DOI of original article 10.1016/j.rmed.2004.03.001
an effective means of shortening the recovery time following an acute episode of bronchoconstriction, irrespective of prior use of long-acting b2-agonist. Whether leukotriene CysLT1-receptor antagonists should be used along with standard therapy in emergency departments to quicken the time taken to recover remains to be seen.
References 1. van der Woude HJ, Postma DS, Politiek MJ, et al. Relief of dyspnoea by b2-agonists after methacholine-induced bronchoconstriction. Respir Med 2004;98:816–20. 2. Lee DK, Jackson CM, Currie GP, et al. Comparison of combination inhalers vs inhaled corticosteroids alone in moderate persistent asthma. Br J Clin Pharmacol 2003;56: 494–500. 3. Brannan JD, Anderson SD, Gomes K, et al. Fexofenadine decreases sensitivity to and montelukast improves recovery from inhaled mannitol. Am J Respir Crit Care Med 2001;163: 1420–5. 4. Currie GP, Haggart K, Lee DK, et al. Effects of mediator antagonism on mannitol and adenosine monophosphate challenges. Clin Exp Allergy 2003;33:783–8. 5. Currie GP, Lee DK, Haggart K, et al. Effects of montelukast on surrogate inflammatory markers in corticosteroid-treated patients with asthma. Am J Respir Crit Care Med 2003;167: 1232–8. 6. Camargo Jr. CA, Smithline HA, Malice MP, et al. A randomized controlled trial of intravenous montelukast in acute asthma. Am J Respir Crit Care Med 2003;167:528–33.
Graeme P. Currie, Edward Paterson Department of Respiratory Medicine, Chest Clinic C, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, Scotland, UK E-mail address:
[email protected] Wendy J. Anderson Department of Respiratory Medicine, Antrim Hospital, Bush Road, Antrim BT41 2QB, Northern Ireland, UK Daniel K.C. Lee Department of Respiratory Medicine, Ipswich Hospital, Heath Road, Ipswich IP4 5PD, England, UK
0954-6111/$ - see front matter & 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.rmed.2004.10.010