Background
In children with mild-moderate persistent asthma, identification of phenotypic predictors to guide selection of a controller regimen is essential.
Objective
Identify phenotypic characteristics retaining predictive value for the difference in treatment responses between twice daily fluticasone and once-daily montelukast.
Methods
Data from the Pediatric Asthma Controller Trial (PACT) were assessed with multivariate analysis. Outcomes included the change in asthma control days (ACDs), FEV1, peak expiratory flow and time to first asthma exacerbation measured over a one-year treatment period.
Results
The mean age was 9.6 +/- 2.1 years, 60% were male, 50% had a parental history of asthma and 78% had positive aeroallergen skin prick tests. The mean %-predicted pre-bronchodilator FEV1 was 97.8 +/-12.9, median PC20 was 0.93 mg/ml and median exhaled nitric oxide (eNO) was 25.2 ppb. A history of parental asthma best predicted the expected treatment benefit with fluticasone compared to montelukast in terms of gain in ACDs (adjusted p=0.02) and time to first exacerbation (adjusted p=0.05). Elevated baseline eNO predicted the differential treatment response for fluticasone regarding the gain in ACDs (adjusted p=0.01). Prior inhaled corticosteroid (ICS) use (adjusted p=0.01) and low PC20 (adjusted p=0.03) each predicted the expected treatment benefit with fluticasone over montelukast regarding time to first exacerbation. No phenotypic characteristics predicted treatment benefits for montelukast over fluticasone for either outcome.
Conclusions
Physicians treating children with parental history of asthma, elevated eNO, low PC20, or history of ICS use can expect the best long-term outcomes with ICS therapy, as compared to treatment with leukotriene receptor antagonists.
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