According to the results of a small randomised controlled trial, the addition of oral montelukast to standard treatment for an acute asthma exacerbation increased peak expiratory flow (PEF) measurements the morning after admission.

The authors note that leukotriene receptor antagonists (LTRAs) have an established role in the management of chronic asthma, and that they may provide benefit additional to that of current treatment in acute asthma.  They briefly discuss the two largest studies of LTRAs in acute asthma – one looked at IV montelukast and the other oral zafirlukast.  Their study is to their knowledge the first looking at patients with an acute asthma exacerbation of a severity that required hospitalisation and who received an LTRA in addition to maximal treatment as set out by the British Thoracic Society (BTS).

The single-centre study randomised a total of 87 adults (aged 18-50 years) with acute asthma requiring hospitalisation (and a PEF ≤75% of their known best or predicted) to montelukast 10mg or placebo on admission and every evening thereafter for 4 weeks (when they were reviewed as outpatients).  All subjects received oral prednisolone 40mg at presentation and daily thereafter, and initial treatment with nebulised salbutamol (5mg at least every 6 h) and nebulised ipratropium (500mcg every 6 h).  Additional oxygen, intravenous magnesium and/or aminophylline and further nebulised salbutamol were prescribed if indicated.  The primary end point was the difference in PEF between active and placebo treatment the morning following admission.

Primary endpoint data were analysed for 73 patients – 37 randomised to montelukast (mean baseline PEF of 227.6l/min; 47.6% predicted) and 36 to placebo (baseline PEF of 240.3 l/min; 49.6% predicted).  The morning after admission, patients who received montelukast achieved a PEF of 389.6 l/min (81.4% predicted) compared with 332.3 l/min (69.8% predicted) for placebo (mean difference between treatment groups of 57.4 l/min; p=0.046).