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(Chest. 2001;120:2116-2117.)
© 2001 American College of Chest Physicians

Perimenstrual Asthma Exacerbations and Positioning of Leukotriene-Modifying Agents in Asthma Management Guidelines

Norman L. Dean, MD, FCCP

Chapel Hill, NC

Correspondence to: Norman L. Dean, MD, FCCP, PO Box 4886, Chapel Hill, NC 27515; e-mail: mgdeanesq{at}nc.rr.com

To the Editor:

The excellent review in CHEST (May 2001) by Salvi et al,1 discussing the combined anti-inflammatory and bronchodilating effects of leukotriene-modifying agents and their positioning in asthma management guidelines, is both timely and needed in updating guidelines for asthma therapy. Perimenstrual exacerbations of persistent asthma, in addition to exercise- and aspirin-induced asthma, is an example of a subset of asthma better controlled by the addition of a leukotriene-modifying agent to a regimen containing inhaled steroids. Forty percent of asthmatic female patients have perimenstrual exacerbations of asthma uncontrolled by steroid therapy.2 Female asthmatics have an increase in bronchial reactivity to adenosine monophosphate and dysregulation of ß2-receptors concomitant with fluxes of estrogen and progesterone during the transition from the luteal to the follicular phase of the menstrual cycle.3 Studies2 3 4 5 have noted the inability of therapeutic steroids to inhibit clinical perimenstrual exacerbations of persistent asthma. The efficacy of leukotriene-modifying agents in preventing perimenstrual exacerbations and concomitant increases in leukotrienes have been cited in two reports.4 5 Additional studies examining the role of leukotriene-modifying agents in perimenstrual asthma exacerbations and on the neuroendocrine immune system are needed.

The combined anti-inflammatory and bronchodilating properties of leukotriene modifiers described by Salvi and colleagues1 highlight both the early (step 2) role for these controller agents as well as a role in all stages of severity of persistent asthma. Leukotriene modifiers, particularly in perimenstrual-, exercise-, and aspirin-triggered asthma and asthma with comorbid rhinitis, merit consideration as an addition to inhaled steroid therapy as a controller targeting inflammation not adequately controlled by steroids.

References

  1. Salvi, SS, Krishna, MT, Holgate, S, et al (2001) The anti-inflammatory effects of leukotriene-modifying drugs and their use in asthma. Chest 119,1533-1546[Abstract/Free Full Text]
  2. Skobeloff, EM, Spivey, WH, Silverman, R, et al (1996) The effect of the menstrual cycle on asthma presentations in the emergency department. Arch Intern Med 156,1837-1840[Abstract]
  3. Tan, KS, McFarlane, LC, Lipworth, BJ (1997) Loss of normal cyclical ß2-adrenoreceptor regulation and increased premenstrual responsiveness to adenosine monophosphate in stable female asthmatics. Thorax 52,608-611[Abstract]
  4. Nakasato, H, Ohrui, T, Sekizawa, K, et al (1999) Prevention of severe premenstrual asthma attacks by leukotriene receptor antagonists. J Allergy Clin Immunol 104,585-588[Medline]
  5. Dean, N, Sadat, A, Nunnery, S, et al (2001) Montelukast provides superior efficacy for perimenstrual asthma exacerbations not controlled by inhaled steroids [abstract]. Chest 120,208S



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