Clinical effectiveness of inhaled corticosteroids versus montelukast in children with asthma: prescription patterns and patient adherence as key factors

Objectives: To examine the real-life effectiveness of inhaled corticosteroids (ICS) versus leukotriene receptor antagonists (LTRA) monotherapy in children with mild or moderate asthma. Methods: Using medical and drug records, we accrued a cohort of 227 children aged 2-17 years, prescribed daily LTRA or ICS monotherapy. LTRA-treated children were matched on age, gender, and previous acute-care visits in a 1: 3 ratio to ICS-treated children. Outcomes included rescue oral corticosteroids, prescription duration and dispensing, acute-care visits, hospital admissions, and beta(2)-agonist use. Results: More ICS- than montelukast-treated children had persistent asthma (73 vs. 50%) and fewer had good asthma control (35 vs. 61%) at baseline, suggesting residual confounding by indication. Physician prescriptions covered 62% of the follow-up period for ICS compared to 97% for montelukast (mean group difference [MGD]: -17%, 95% CI: -28%, -7%). In pharmacies, patients claimed 51 vs. 74% of prescribed ICS and montelukast, respectively (MGD = -12% [-20%, -4%]). Consequently, dispensed ICS and montelukast covered 24% and 38% of follow-up period, respectively (MGD = -14% [-22%, -6%]). No group differences in oral corticosteroids (RR = 1.10 [0.66, 1.84]) and acute-care visits (RR = 1.79 [0.96, 3.34]) were observed. ICS-treated children experienced more hospital admissions (RR = 3.63 [1.20, 11.03]) and needed more frequently rescue beta(2)-agonist use of >= 4 doses per week (RR = 2.54 [1.23, 5.23]). Conclusions: When compared to LTRA, the prescription of ICS monotherapy did not significantly reduce rescue oral corticosteroids or acute care visits and was associated with a higher rate of hospital admission for asthma and rescue beta(2)-agonist use. The findings may be due to paradoxical shorter ICS prescription duration and lower patient adherence, despite more persistent asthma and poorer control than in LTRA-treated children.