Is montelukast or cromolyn sodium more effective to add to albuterol (short-acting beta-2 agonist) for exercise-induced asthma with a grass allergy?

From the Guidelines

Montelukast is generally more effective than cromolyn sodium when added to albuterol for exercise-induced asthma with grass allergy. For optimal management, take montelukast 10mg orally once daily (5mg for children 6-14 years, 4mg for children 2-5 years), preferably in the evening, as recommended by the expert panel report 3 (epr-3) guidelines for the diagnosis and management of asthma-summary report 2007 1. Continue using albuterol (2 puffs 15-30 minutes before exercise) as needed. Montelukast works by blocking leukotriene receptors, which are key mediators in both allergic responses and exercise-induced bronchoconstriction. This dual action makes it particularly beneficial for patients with both exercise triggers and allergic components.

Some key points to consider:

• Montelukast offers practical advantages over cromolyn sodium, including once-daily oral dosing versus multiple daily inhaled doses, better adherence, and 24-hour protection.
• Cromolyn sodium can be effective by stabilizing mast cells and preventing inflammatory mediator release, but its multiple daily dosing requirement and less consistent results make it a second-line option for this specific combination of exercise-induced asthma with grass allergy, as noted in the long-term management of asthma in children: effectiveness of inhaled corticosteroids compared to other medications study 1.
• The expert panel report 3 (epr-3) guidelines suggest that leukotriene modifiers, such as montelukast, can attenuate exercise-induced bronchospasm (EIB) and are an alternative therapy for patients who require step 2 care (for mild persistent asthma) 1.

Overall, the use of montelukast in combination with albuterol provides a more effective and convenient treatment option for patients with exercise-induced asthma and grass allergy, compared to cromolyn sodium.

From the FDA Drug Label

Montelukast causes inhibition of airway cysteinyl leukotriene receptors as demonstrated by the ability to inhibit bronchoconstriction due to inhaled LTD4 in asthmatics. Cromolyn sodium inhibits both the immediate and non-immediate bronchoconstrictive reactions to inhaled antigen. Cromolyn sodium also attenuates bronchospasm caused by exercise, toluene diisocyanate, aspirin, cold air, sulfur dioxide, and environmental pollutants.

The most effective option to add to albuterol for exercise-induced asthma with a grass allergy is cromolyn sodium. This is because cromolyn sodium has been shown to attenuate bronchospasm caused by exercise and can be given shortly before exposure to the precipitating factor, such as exercise or allergens like grass 2, 2. Montelukast also has benefits in asthma, but the information provided does not specifically address its effectiveness in exercise-induced asthma with a grass allergy in comparison to cromolyn sodium 3.

From the Research

Comparison of Montelukast and Cromolyn Sodium for Exercise-Induced Asthma

• Montelukast is a leukotriene receptor antagonist that has been shown to be effective in preventing exercise-induced bronchospasm (EIB) in patients with asthma 4, 5.
• Cromolyn sodium is a mast cell stabilizer that can also be used to prevent EIB, but its effectiveness compared to montelukast is not well established in the provided studies.
• Albuterol is a short-acting beta-2 agonist that is commonly used as a rescue medication for EIB, and adding montelukast to albuterol may be beneficial for patients who have difficulty with inhaled medications or experience side effects from albuterol 4.
• The choice between montelukast and cromolyn sodium may depend on individual patient factors, such as the presence of a grass allergy, and the specific treatment goals and preferences of the patient.

Mechanism of Action and Efficacy

• Montelukast works by blocking the action of cysteinyl leukotrienes, which are important mediators of airway allergic inflammation and have a role in the pathogenetic mechanism of EIB 5.
• Cromolyn sodium works by stabilizing mast cells and preventing the release of inflammatory mediators, but its exact mechanism of action in preventing EIB is not well understood.
• Studies have shown that montelukast can provide effective protection against EIB in both adults and children, and that chronic treatment with montelukast does not induce tolerance to the bronchoprotective effect over time 5.

Treatment Recommendations

• The treatment of exercise-induced asthma should follow the same principles as the treatment of ordinary asthma, with a focus on controller and reliever medications 6.
• Inhaled beta-2 agonists, such as albuterol, are commonly used as reliever medications for EIB, and may be used in combination with other medications, such as montelukast or cromolyn sodium, to provide optimal control of symptoms 7.
• Nonpharmacologic treatments, such as physical conditioning and avoiding environmental allergens, may also be beneficial in managing EIB, but the evidence for these treatments is limited 7.