Once daily oral controller therapy with low dose theophylline or montelukast was not effective in poorly controlled asthma

Inhaled corticosteroids (ICSs) are first choice medications for initiating maintenance controller therapy in patients with mild persistent asthma (Step 2, Global INitiative for Asthma [GINA]).1 Their effectiveness in improving asthma control and reducing exacerbations and asthma mortality is supported by clinical and epidemiological studies over the past 3 decades. Adding long acting - agonists (LABAs) (Step 3, GINA) or leukotriene receptor antagonists to ICSs improves clinical outcomes more than do ICSs alone.2 The study by the ALA-ACRC compared the addition of oral montelukast, theophylline, or placebo to existing treatment regimens in patients with poorly controlled asthma. The results reinforce current guidelines showing little role for montelukast or theophylline in this setting. Most patients were white women, with mean age of 40 years and asthma onset at mean age of 21 years. Of concern are the 18 of patients on LABA monotherapy without ICSs. Hence, generalising these results to other populations should be done with caution. Where does this leave montelukast and theophylline in overall asthma management? Montelukast is still first line anti-inflammatory controller therapy in children in whom oral or non-steroidal medications are preferred. It is also effective for reducing rates of episodic viral induced asthma exacerbations in preschool children3 and managing exercise induced asthma in cases where ICSs are ineffective.4 In some countries, theophyllines are a low cost alternative to ICSs. A subgroup analysis in the study by the ALA-ACRC showed improved asthma control, symptoms, and lung function in patients taking theophylline without ICSs. However, it is not clear whether the reduced cost of theophylline in this setting may be offset by other direct (emergency presentation, hospital admission) or indirect (school or work absenteeism) costs of asthma and longer term asthma outcomes in comparison with ICS therapy.