Loss of response to treatment with leukotriene receptor antagonists but not inhaled corticosteroids in patients over 50 years of age

Background: There are limited published data describing the relative efficacy of available treatment options in younger versus older patients with persistent asthma. Objective: To compare the efficacy of fluticasone propionate (FP) and zafirlukast (Z) in younger ( 12 to 49 years of age) versus older (50 years and older) patients with asthma. Methods: A retrospective analysis of five randomized, double-blind, double-dummy studies 4 to 12 weeks in duration of 1,742 patients <50 years of age and 243 patients aged 50 years or older. Interventions were inhaled fluticasone propionate (FP) 88 mug, oral Z 20 mg, or placebo twice daily. Results: Treatment with FP resulted in significantly greater improvements than Z in all efficacy measurements (except for nighttime awakenings) regardless of age. In older patients, treatment with FP significantly increased pulmonary function compared with Z: FEV1 (FP= +0.19 L placebo = -0.34 L; Z -0.06 L); AM peak expiratory flow rate [PEFR] (FP = +25 L/minute; placebo -18 L/minute; Z = +4 L/minute); Pm PEFR (FP = +24 L/minute; placebo = -24 L/minute; Z = +5 L/minute; P less than or equal to 0.023, for all comparisons). Compared with Z, treatment with FP in older patients also resulted in significantly greater increases in the percentage of symptom-free days (25% vs 13%) and rescue-free days (35% vs 17%); and significantly greater reductions in albuterol use (-1.6 vs -0.3 puffs/day) and the percentage of patients with exacerbations (2.7% vs 14.3%; P less than or equal to 0.031). Conclusions: Regardless of age, treatment with FP in patients with asthma significantly improved pulmonary function and overall asthma control. In contrast, treatment with Z in older patients with asthma resulted in small improvements in asthma symptoms, whereas lung function improved minimally or not at all, and exacerbations increased. These data suggest that FP effectively controls inflammation in older patients, whereas Z may mask inflammation and may not provide the level of bronchodilatory or anti-inflammatory activity needed for effective asthma control in older patients.