Steroids are better than montelukast in acute asthma exacerbations in children

Clinical question In children stabilized in emergency departments (EDs) for acute asthma exacerbations, does short-term maintenance with steroids result in better outcomes than maintenance with montelukast?

Bottom line In children discharged from the ED with mild to moderately severe exacerbations of asthma, treatment with steroids results in fewer treatment failures than treatment with montelukast (Singulair). (Level of evidence = 1b)

Synopsis Children older than 2 years presenting to an ED between 8 AM and midnight with a mild to moderate exacerbation of asthma were initially treated with nebulized albuterol with ipratropium and a dose of a steroid (2 mg/kg prednisone [maximum dose of 60 mg] or a 5-mg dose of prednisolone). Children who stabilized within 8 hours were randomized to receive 5 days of prednisone/prednisolone (1 mg/kg/d) plus placebo or montelukast (4 mg, 5 mg, and 10 mg in children aged 2-5 years, 6-14 years, and 5-17 years, respectively) plus placebo. All children also used inhaled albuterol and fluticasone. Of 1,417 children seen in the emergency department for asthma exacerbations, 747 met the inclusion criteria and only 134 participated in the study (4 failed to complete it). Treatment failure occurred in 7.9% of children taking steroids compared with 22.4% of children taking montelukast. Compared with montelukast, one would need to use steroids in seven children (95% CI, 4-52) to prevent one treatment failure. Three children taking montelukast reported adverse events (facial swelling, vomiting and diarrhea, abdominal and leg pain) compared with none of the children taking steroids.

Schuh S, Willan AR, Stephens D, et al. Can montelukast shorten prednisolone therapy in children with mild to moderate acute asthma? A randomized controlled trial. J Pediatr. 2009;155(6):795-800.