Tailored asthma therapy on the horizon

UK researchers report that montelukast therapy is more effective than salmeterol in children with asthma who have a particular genotype - a finding that could pave the way for personalized asthma management.

The authors had previously found in a large study that children with asthma who took salmeterol and inhaled corticosteroids had an increasing likelihood of exacerbations according to how many copies they had of the Arg¹⁶ allele located in the ß₂ receptor gene (ADRB2).

In this study, 62 children who were regularly taking inhaled corticosteroids and had a history of poor asthma control were randomly assigned to receive montelukast 5 or 10 mg once daily or salmeterol 50 µg twice daily, alongside their usual fluticasone treatment. They were also allowed to take salbutamol 200 µg as rescue medication when required. All the children were homozygous for the Arg¹⁶ allele.

Children assigned to the montelukast group had a significantly greater decline in the number of days away from school due to asthma over the course of a year of treatment than those given salmeterol, so that, on average, patients in the salmeterol group took 0.4 more days off per quarter.

Salbutamol use was also significantly reduced in the montelukast group compared with the salmeterol group. Daily usage was reported by 18% of patients in the montelukast group after 12 months, compared with 36% at the start of the study . By comparison, salbutamol was consistently used by around one third of the salmeterol group throughout the study.

The authors also report that both early morning and nocturnal symptoms improved significantly more among patients treated with montelukast than among salmeterol-treated patients, and that quality of life scores were significantly better.

Brian Lipworth (University of Dundee, UK) and colleagues say their findings help to explain some of the variation in the efficacy of salmeterol in children with asthma, and could change how they are treated.

"Those children possessing susceptible Arg¹⁶ ß₂ receptor genotype may experience better asthma control with the addition of montelukast rather than salmeterol as second-line controller medication, in addition to inhaled corticosteroids," they write in Clinical Science.

Stephen Holgate, from the University of Southampton in the UK, commenting on the study in a press briefing, described it as small but impressive: "It will undoubtedly encourage further, larger studies to be undertaken to confirm the findings in different children and adult asthmatic populations. The gene-based test is not yet available to doctors, but should become so if larger trials are equally positive."

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