Leukotriene modifiers include LTRAs and leukotriene inhibitors, which both act as anti-inflammatory medications. LTRAs block leukotriene receptors, whereas leukotriene inhibitors block the production of 5-lipoxygenase. The two LTRAs licensed in the United States are montelukast (Singulair) and zafirlukast (Accolate). LTRAs may be used as monotherapy for mild persistent asthma, but are considered second-line agents based on the EPR-3 10 and GINA guidelines. 30 For mild to moderate asthma, the risk of exacerbation is approximately 50% less in patients prescribed an inhaled corticosteroid compared with those prescribed an LTRA. 15 A 2014 Cochrane review found an LABA plus inhaled corticosteroid to be modestly superior to an LTRA plus inhaled corticosteroid in adults with inadequately controlled asthma. 26 LTRAs are best used to improve pulmonary function in patients with aspirin-sensitive asthma 31 and to decrease symptoms in exercise-induced bronchospasm. 32 , 33 They should also be considered in patients with mild persistent asthma who prefer not to use inhaled corticosteroids. Although LTRAs generally have few adverse effects, physicians should be aware of rare case reports of eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome), psychiatric symptoms, hypertriglyceridemia, angioedema, urticaria, and glomerulonephritis. 34
Patients requiring oral corticosteroids should be weaned slowly from systemic corticosteroid use after transferring to Advair Diskus. Prednisone reduction can be accomplished by reducing the daily prednisone dose by mg on a weekly basis during therapy with Advair Diskus. Lung function (mean forced expiratory volume in 1 second [FEV 1 ] or morning peak expiratory flow [AM PEF]), beta-agonist use, and asthma symptoms should be carefully monitored during withdrawal of oral corticosteroids. In addition, patients should be observed for signs and symptoms of adrenal insufficiency, such as fatigue, lassitude, weakness, nausea and vomiting, and hypotension.