What is the best treatment for asthma with frequent daytime and nocturnal symptoms?

From the Guidelines

For asthma patients with frequent daytime and nocturnal symptoms, the recommended treatment is a low-dose inhaled corticosteroid (ICS) as controller medication plus a short-acting beta-agonist (SABA) as needed for rescue, with consideration of adding a long-acting inhaled beta2-agonist to the ICS if symptoms persist 1. The treatment approach should prioritize controlling airway inflammation and providing symptom relief.

• Key considerations include:
  • Proper inhaler technique to ensure effective medication delivery
  • Use of a spacer device with metered-dose inhalers
  • Regular follow-up (every 1-6 months) to assess symptom control and adjust therapy as needed 1
  • Stepping up therapy if symptoms are not well controlled, which may involve increasing the dose of ICS or adding other long-term control medications
  • Considering alternative diagnoses if lack of control persists despite adequate treatment and adherence The goal of treatment is to achieve and maintain good asthma control, minimizing symptoms and reducing the risk of exacerbations.
• Treatment options should be tailored to the individual patient's needs and circumstances, taking into account factors such as symptom severity, medication adherence, and potential side effects 1. A short course of oral systemic corticosteroids may be considered to gain rapid control for patients whose asthma frequently interrupts sleep or normal daily activities 1.

From the FDA Drug Label

The efficacy of SINGULAIR for the chronic treatment of asthma in adults and adolescents 15 years of age and older was demonstrated in two (U. S. and Multinational) similarly designed, randomized, 12-week, double-blind, placebo-controlled trials in 1576 patients The patients studied were mild and moderate, non-smoking asthmatics who required approximately 5 puffs of inhaled β-agonist per day on an “as-needed” basis The co-primary endpoints in these trials were FEV1 and daytime asthma symptoms Secondary endpoints included morning and evening peak expiratory flow rates (AM PEFR, PM PEFR), rescue β-agonist requirements, nocturnal awakening due to asthma, and other asthma-related outcomes.

The best treatment for asthma with frequent daytime and nocturnal symptoms is not explicitly stated in the provided drug labels. However, based on the available information, montelukast (SINGULAIR) can be considered as a treatment option for asthma, as it has been shown to improve symptoms and reduce the need for rescue medication in patients with mild to moderate asthma 2, 2.

• Key benefits of montelukast include:
  • Improvement in daytime asthma symptoms
  • Reduction in nocturnal awakenings due to asthma
  • Decrease in rescue β-agonist use
  • Improvement in FEV1 and peak expiratory flow rates However, it is essential to note that the provided drug labels do not directly address the question of the best treatment for asthma with frequent daytime and nocturnal symptoms, and the decision on the best treatment should be made on a case-by-case basis, considering the individual patient's needs and medical history.

From the Research

Treatment Options for Asthma

• The most effective treatment for asthma with frequent daytime and nocturnal symptoms is a combination of an inhaled corticosteroid and a long-acting beta2-agonist, such as fluticasone propionate and salmeterol 3, 4, 5, 6.
• This combination has been shown to provide greater improvement in asthma control, lung function, and quality of life compared to monotherapy with either an inhaled corticosteroid or a leukotriene antagonist 3, 4, 5, 6.
• The combination of fluticasone propionate and salmeterol has also been shown to be more effective than the addition of montelukast to inhaled corticosteroid therapy 5, 6.

Comparison of Treatment Options

• A study comparing the efficacy of fluticasone propionate/salmeterol combination with montelukast found that the combination product provided significantly greater improvements in lung function, symptom control, and quality of life 3.
• Another study found that the combination of salmeterol and fluticasone propionate was more effective than monotherapy with either salmeterol or fluticasone propionate, and was also more effective than the addition of montelukast to fluticasone propionate 4.
• A study comparing the efficacy of fluticasone propionate/salmeterol combination with fluticasone propionate plus oral montelukast found that the combination product provided better overall asthma control, with significantly greater improvements in lung function and symptom control 5.
• A multinational study found that the salmeterol/fluticasone combination was more effective than fluticasone plus oral montelukast in asthma, with significantly greater improvements in lung function and asthma control 6.

Safety and Tolerability

• The combination of fluticasone propionate and salmeterol has been shown to be well tolerated, with a similar adverse event profile to monotherapy with either component 3, 4, 5, 6.
• The most frequent adverse events associated with salmeterol/fluticasone propionate are headache, throat irritation, hoarseness, and candidiasis 4.