By Dr. Paul Ehrlich
A new British study published in The New England Journal of Medicine has gotten a lot of pickup lately. I looked briefly at the study a few days ago and intended a much longer analysis, but the last straw was an article in The Nation. I figure that when an asthma story makes it into the pages of that distinguished political publication, I should respond.
The gist of the study, as The Nation describes it, is, “Researchers at Britain’s University of East Anglia (UEA) followed 650 chronic asthma patients for two years, and found that drugs called leukotriene receptor antagonists (LTRAs) ‘managed the disease equally successfully.’”
It goes on to quote lead author David Price of the University of Aberdeen and UEA :“We hope these findings will increase the options for healthcare professionals when prescribing for this common but disruptive disease…We found that adherence to treatment was vastly improved — by as much as 60 percent — when patients were given the once-a-day LTRA tablets and patients did not have to worry about using appropriate inhaler technique.”
The trouble with this story is the way it has been handled by reporters, many of whom would probably like to believe, as would many parents and patients, that there is an alternative to inhaled corticosteroids.
Patients and many doctors have been searching for this particular grail for a long time. When you read even the summary of this article on the NEJM website, however, the claims are pretty modest:
Study results at 2 months suggest that LTRA was equivalent to an inhaled glucocorticoid as first-line controller therapy and to LABA as add-on therapy for diverse primary care patients. Equivalence was not proved at 2 years. The interpretation of results of pragmatic research may be limited by the crossover between treatment groups and lack of a placebo group (emphasis added).
I can fully imagine that there are going to be patients and parents who will show their doctors these articles and demand to go on LTRAs and get off steroids. And their doctors, who don’t know any better, may acquiesce. But allergists have been there before.
LTRAs, which are marketed as Singulair and Accolate were once hailed as wonder drugs, but the bloom is off the rose. As we wrote in our book:
Every time referrals to our offices dry up from one doctor or another, it usually coincides with some new drug release, but over time, new patients start to trickle in as the miracle starts to wear off.
This was certainly the case with a drug called Singulair, which pediatricians loved because it could be taken orally—you sometimes have to hold a kid down to teach him to use an inhaler—and because it had no steroids. But while a useful drug, its great wave of popularity crested as it showed its limitations; it was not the panacea it first appeared to be. Many patients still needed the combination of treatments allergists offer.
I have a feeling that the comparable efficacy cited in this study is based in part on the issue of compliance. Is a once-a-day LTRA as effective as ICS? If you don’t take the ICS as directed, maybe. What patients really need, as Larry and I harp on, is to be compliant. Programs that reinforce this discipline pay off. We need more of them.