In patients with angioedema-predominant chronic spontaneous urticaria (CSU), addition of the leukotriene receptor antagonist (LTRA) montelukast to background daily antihistamine therapy was shown to improve symptoms in a significant proportion of individuals, and led to disease resolution in approximately two-thirds of patients, according to the results of a retrospective chart published by the Journal of Allergy and Clinical Immunology: In Practice.
A total of 49 patients were evaluated in at the Johns Hopkins Asthma and Allergy Center in Baltimore, Maryland, between 2008 and 2017. Of these patients, 11 were lost to follow-up; therefore, their therapeutic response could not be evaluated. A total of 38 patients were included in the analysis, with 24 receiving montelukast as part of their treatment regimen; 14 did not receive montelukast or any other LTRA. All patients were receiving 4 times the usual dose of antihistamines with the exception of a few participants in whom this higher dose could not be tolerated. Montelukast was administered at a daily dose of 10 mg.
The severity of each patient’s disease was graded with the use of an 8-point Likert scale, with a higher number denoting worse disease. The Likert scale was used at the time of initial clinical encounter, at the time of peak disease state, and at follow-up visits, when applicable, or after a change in medication regimen. Of the patients treated with montelukast, the investigators evaluated disease severity and frequency of episodes from before to after prescription of the agent. In patients who were not treated with montelukast, the investigators compared symptoms from the initial visit, when other add-on therapies were initiated, to the time after initiation of these treatments. The researchers also evaluated whether participants experienced “no improvement,” “some improvement” (ie, any decrease in disease severity or frequency, but without complete resolution), or “complete resolution” of disease.
The age, sex, duration of disease, and severity of disease at initial visit were similar in both groups. Overall, 92% (22 of 24) of the montelukast-treated patients experienced some improvement in their symptoms with addition of the agent compared with 50% (7 of 14) of those who were not treated with montelukast, a difference that was statistically significant (P =.006). Moreover, a higher proportion of individuals treated with montelukast experienced complete resolution of disease in the follow-up period, which ranged from 4 months to 3 years.
Of the patients in the montelukast treatment group, a significant improvement in within-individual disease severity and frequency was observed (P <.001). Overall, >70% of those who reported improvement in their symptoms experienced the improvement within the first 6 months of treatment, with 2 participants reporting improvement after 12 months of treatment.
The investigators concluded that the results of this study support the fact that it may be beneficial to consider the use of montelukast as a second-line agent in patients with angioedema-predominant CSU. Limitations of the study include the retrospective nature and that all patients were from a single provider’s clinic. Because this is a single-site study, the main LTRA used at other centers might not necessarily be montelukast. It is hoped that the findings of this analysis will encourage future prospective studies on this topic.
Akenroye AT, McEwan C, Saini SS. Montelukast reduces symptom severity and frequency in patients with angioedema-predominant chronic spontaneous urticaria [published online May 5, 2018]. J Allergy Clin Immunol Pract. doi:10.1016/j.jaip.2018.04.026