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(Chest. 2002;121:1382.)
© 2002 American College of Chest Physicians

Bronchodilator Reversibility to Albuterol Predicts Bronchodilator Response to Salmeterol

Brian J. Lipworth, MD and Catherine M. Jackson, MBChB

Ninewells Hospital and Medical School Dundee, Scotland

Correspondence to: Brian J. Lipworth, MD, Professor of Allergy and Pulmonology, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland DD1 9SY; e-mail: b.j.lipworth{at}dundee.ac.uk

To the Editor:

We read with interest the recent study by Fish et al (August 2001)1 showing that adding salmeterol to inhaled corticosteroid achieved superior control as compared to adding montelukast. However it is likely that the results were biased toward the long-acting ß2-agonist as patients were required as an inclusion criteria to have at least 12% increase in FEV1 in response to albuterol. It is therefore perhaps not surprising that for the primary end point of morning peak expiratory flow (PEF), salmeterol exhibited significantly greater bronchodilator efficacy as compared to montelukast. It is also worth noting that both treatments significantly improved the primary outcome variable compared to baseline, and that even allowing for the biased inclusion criteria, there was only a 13 L/min mean difference in morning PEF. One has to question the clinical relevance of this mean difference of 13 L/min, given that the mean baseline value was 370 L/min, and that most PEF meters are calibrated to the nearest 10 L/min.

This study provides no information on other relevant clinical efficacy markers, such as protection against bronchoconstrictor stimuli in the presence of increased bronchomotor tone, using bronchial challenge techniques. For example, studies comparing salmeterol and montelukast as add-on therapy have demonstrated greater and more sustained protection against adenosine monophosphate or exercise challenge.2 3 Moreover, the addition of a leukotriene antagonist to concomitant inhaled corticosteroid therapy confers additive anti-inflammatory effects that are not seen with long-acting ß2-agonists.3 4 5 6 7 8 9

References

  1. Fish, JE, Israel, E, Murray, JJ, et al (2001) Salmeterol powder provides significantly better benefit than montelukast in asthmatic patients receiving concomitant inhaled corticosteroid therapy. Chest 120,423-430[Abstract/Free Full Text]
  2. Storms, WW, Bird, S, Firriolo, KM, et al (2001) The effect of short-acting ß-agonist bronchodilatation in patients on montelukast or salmeterol [abstract]. J Allergy Clin Immunol 107(Suppl 2),S316
  3. Wilson, AM, Dempsey, OJ, Sims, EJ, et al (2001) Evaluation of salmeterol or montelukast as second-line therapy for asthma not controlled with inhaled corticosteroids. Chest 119,1021-1026[Abstract/Free Full Text]
  4. Lipworth, BJ, Dempsey, OJ, Aziz, I, et al (2000) Effects of adding a leukotriene antagonist or a long-acting ß2-agonist in asthmatic patients with the glycine-16 ß2-adrenoceptor genotype. Am J Med 109,114-121[CrossRef][ISI][Medline]
  5. Fowler, SJ, Dempsey, OJ, Wilson, AM, et al (2001) Effects of adding either a leukotriene receptor antagonist or theophylline to a low or medium dose of inhaled corticosteroid in patients with persistent asthma. J Allergy Clin Immunol 107(Suppl 2),S266-S267
  6. Tamaoki, J, Kondo, M, Sakai, N, et al (1997) Leukotriene antagonist prevents exacerbation of asthma during reduction of high-dose inhaled corticosteroid: The Tokyo Joshi-Idai Asthma Research Group. Am J Respir Crit Care Med 155,1235-1240[Abstract]
  7. Laviolette, M, Malmstrom, K, Lu, S, et al (1999) Montelukast added to inhaled beclomethasone in treatment of asthma: Montelukast/Beclomethasone Additivity Group. Am J Respir Crit Care Med 160,1862-1868[Abstract/Free Full Text]
  8. Roberts, JA, Bradding, P, Britten, KM, et al (1999) The long-acting ß2-agonist salmeterol xinafoate: effects on airway inflammation in asthma. Eur Respir J 14,275-282[Abstract]
  9. McIvor, RA, Pizzichini, E, Turner, MO, et al (1998) Potential masking effects of salmeterol on airway inflammation in asthma. Am J Respir Crit Care Med 158,924-930[Abstract/Free Full Text]




This Article
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