title: Stepping down from inhaled corticosteroids with leukotriene inhibitors in asthma: a systematic review and meta-analysis.
abstract: BACKGROUND
  The risks of using leukotriene receptor antagonists (LTRA) as part of a strategy for stepping down inhaled corticosteroid (ICS) are not well known.
  
  
  OBJECTIVE
  To estimate the risk of asthma exacerbation in individuals with stable asthma who start LTRA when stopping ICS or reducing ICS dose.
  
  
  METHODS
  We identified articles from a systematic review of English and non-English articles by using a number of data bases. We included randomized controlled trials with a stable asthma run-in period of 4 weeks or more and a follow-up period of at least 3 months. We included studies of individuals with stable asthma who stopped ICS and substituted LTRA (versus continuing ICS) and who reduced ICS while starting LTRA (versus placebo).
  
  
  RESULTS
  The search strategy identified 1132 potential articles, of which 52 were reviewed at the full-text level, and four met criteria for inclusion. The single article that met the inclusion criteria for substitution of LTRA for ICS as a step-down strategy found a statistically increased risk of treatment failure of 30.3% for substituting LTRA compared with 20.2% for continuing ICS. The three articles that met the inclusion criteria for comparing LTRA versus placebo in patients with stable asthma who reduce ICS found a modestly decreased risk ratio that favored LTRA of 0.57 (95% confidence interval, 0.36-0.90; I(2) = 0%) in studies that only included individuals >15 years old.
  
  
  CONCLUSIONS
  Only one study addressed the risk of substitution of LTRA for ICS in stable asthma, which limited any strong conclusions about this step-down strategy.
authors.affiliation: Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona, USA.
authors.forename: Matthew A
authors.initials: MA
authors.lastname: Rank
authors.forename: Michael R
authors.initials: MR
authors.lastname: Gionfriddo
authors.forename: Thanai
authors.initials: T
authors.lastname: Pongdee
authors.forename: Gerald W
authors.initials: GW
authors.lastname: Volcheck
authors.forename: James T
authors.initials: JT
authors.lastname: Li
authors.forename: Christina R
authors.initials: CR
authors.lastname: Hagan
authors.forename: Patricia J
authors.initials: PJ
authors.lastname: Erwin
authors.forename: John B
authors.initials: JB
authors.lastname: Hagan
mesh_terms: D000280:Administration, Inhalation; D018927:Anti-Asthmatic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D001249:Asthma / Q000188:drug therapy*; D057915:Drug Substitution; D005938:Glucocorticoids / Q000008:administration & dosage*; D006801:Humans; D020024:Leukotriene Antagonists / Q000008:administration & dosage* / Q000009:adverse effects; D016017:Odds Ratio; D016896:Treatment Outcome
chemical_list: D018927:Anti-Asthmatic Agents; D005938:Glucocorticoids; D020024:Leukotriene Antagonists