xRead - Nasal Obstruction (September 2024) Full Articles

20426984, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.22741 by Stanford University, Wiley Online Library on [01/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

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Orlandi et al.

179 patients, 2 RCTs compared montelukast, a cysLT recep tor 1 (CYSLTR1) antagonist, to placebo; 16491650 2 com pared montelukast to INCS; 16511652 and 1 compared mon telukast and INCS to INCS alone following a course of oral corticosteroids. 1653 Wentzel et al. 1647 were able to combine 2 of the RCTs into a meta-analysis. This study found that anti-LT therapy showed improvement in symptoms over placebo, but no difference compared to INCS. They con cluded that, although anti-LT therapy showed limited ben efit as an adjunctive therapy to INCS, additional study was needed to determine the most beneficial strategy for their use. The Smith and Sautter review 1648 confined itself to English-language studies that addressed the efficacy of montelukast in CRSwNP. They identified 5 such stud ies. Three were RCTs, 164916521653 1 nonrandomized, non controlled study 1654 and a basic science study. 1655 Overall, they found moderate evidence of efficacy as an adjunctive treatment, used in conjunction with corticosteroids. Inter estingly, they noted that the ex vivo basic science study showed montelukast combined with zileuton, a selec tive 5-lipoxygenase enzyme inhibitor, better prevented mast cell activation in CRSwNP tissue than did mon telukast alone, 1655 suggesting that blocking the production of cysLTs may be more powerful than blocking a single cysLT receptor. One double-blinded placebo-controlled study has exam ined zileuton as an add-on therapy to inhaled and/or oral corticosteroids in patients with AERD 1656 anddemon strated that 6 weeks of zileuton (600 mg QID) not only improved pulmonary function but also resulted in improvement in olfaction, rhinorrhea, and nasal obstruc tion. The authors reported no adverse drug-related events in the 40 patients studied. Two more recent randomized, postoperative open-label studies (level 1b/2) of patients with CRSwNP 1657 or AERD 1658 showed that the addition of montelukast to INCS did not significantly improve any outcomes post-operatively, when compared to INCS alone, as did a retrospective review of postoperative CRSwNP patients. 1659 In summary, 2 reviews and several open-label studies have demonstrated the limited benefit of anti-LT ther apy for the treatment of CRSwNP. The risks of LT mod ifying therapy vary with the specific drug chosen. Mon telukast has a relatively limited adverse reaction profile, but zileuton has been associated with reversible hepatic injury. 1660

Anti-Leukotriene Therapy for CRSwNP Aggregate Grade of Evidence: A (Level 1: 2 studies; level 2: 3 studies; level 4: 1 study; Table X-27). Benefit: Improvement in symptoms, comparable to INCS alone. May have limited benefit as an adjunct to INCS. Harm: Limited risks. Montelukast has been asso ciated with rare neuropsychiatric events in post marketing reports. Zileuton is occasionally associ ated with elevated liver enzymes, requiring moni toring during therapy. See Table II-1. Cost: Moderate. Benefits-Harm Assessment: Balance of benefit and harm. Value Judgments: Montelukast may be beneficial in patients who are intolerant or unresponsive to INCS. Policy Level: Option. Intervention: Montelukast is an option for CRSwNP patients either instead of or in addition to INCS. X.D.9 Management of CRSwNP: Probiotics Because of limited data, CRSsNP and CRSwNP are com bined in Section IX.D.8 . X.D.10 Management of CRSwNP: Decongestants Because of limited data, CRSsNP and CRSwNP are com bined in Section IX.D.9 . Mucolytics Because of limited data, CRSsNP and CRSwNP are com bined in Section IX.D.10 . X.D.12 Management of CRSwNP: Herbal Medication Because of limited data, CRSsNP and CRSwNP are com bined in Section IX.D.11 . X.D.11 Management of CRSwNP: