yours is a Canadian jour nal for Canadian physicians, we believe a fair- er description and review of our prod- uct in the Canadian context is required.
—Dr Ernest Pregent Director, Medical Services Merck Frosst Canada & Co Pointe-Claire–Dorval, Que
References
1. Prescrire. Evidence-based drug reviews.
Montelukast. No current use for asthma [Prescrire]. Can Fam Physician 2000;46:85- 91 (Eng), 92-9 (Fr).
2. Boulet L-P, Becker A, Bérubé D, Beveridge R, Ernst P, on behalf of the Canadian Asthma Consensus Group. Summary of rec- ommendations from the Canadian Asthma Consensus Report, 1999. Can Med Assoc J 1999;161(11 Suppl):S1-S12.
Response
Thank you for your letter.
It is true that articles published in La revue Prescrireare mainly written for health professionals working in France. Versions published in Canadian Family Physician are not rewritten in the light of Canadian indi- cations, a point we should have under- lined. According to the Physicians’ Desk Reference,1 the indication is limited to
“prophylaxis and chronic treatment of asthma in adults and pediatric patients 6 years of age and older,” with no men- tion of failure of short-acting β2 stimu- lants or of exercise-onset asthma.1 The Canadian recommendations to which you refer are probably those published in late November 1999,2 which could not have been included in our article published in January 2000.
In addition, the summar y of the rec- ommendations of the Canadian Asthma Consensus Group states that they met in May 1998. The literature search on which the article in La revue Prescrirewas based was terminated in early 1999, as stated at the head of the references section.
Regarding leukotriene antagonists, the report states that “their potential for modifying the natural evolution of
the disease has yet to be confirmed.
[T]heir use as monotherapy cannot be promoted in most circumstances.”2 The consensus conference proposed that adjunctive leukotriene antago- nists be considered as an alternative to increasing the dose of inhaled glu- cocor ticoids, with only level 2 evi- dence. They fur ther proposed that patients who remain symptomatic despite moderate-dose inhaled gluco- corticoids should receive theophylline to control asthma similarly to high- dose inhaled glucocorticoids (level 2 evidence).2 A sound comparison of montelukast and theophylline is thus fully warranted, even on the basis of the Canadian recommendations.
We think a sound comparison with short-acting β2-stimulants for prevention of exercise-onset asthma is also fully jus- tified, as is a comparison with oral β2- stimulants, which can be useful when first-line treatments fail. The fact that these drugs are rarely used in Canada has nothing to do with their efficacy, and patients finding themselves in unusual circumstances also have a right to strictly assessed treatments.
The fact that the risk of the Churg- Strauss syndrome cannot be ruled out with other asthma treatments does not affect the persistent doubt regarding montelukast, as stated in the Physicians’
Desk Reference, for example.1
We recognize that the English trans- lation of the French subtitle “No cur- rent use for asthma” was clumsy. The rest of the translation and particularly the opinion “judgment reserved,” how- ever, closely reflects the nuances in our conclusion.
— Dr Bruno Toussaint Editor-in-chief La revue Prescrire Paris, France References
1. Singulair. In: Physicians’ Desk Reference.
Monyvale, France: Medical Economics Company Inc; 2000. p. 1882-6.
2. Boulet L-P, Becker A, Bérubé D, Beveridge R, Ernst P, on behalf of the Canadian Asthma Consensus Group. Summary of recommen- dations from the Canadian Asthma
Consensus Report, 1999. Can Med Assoc J 1999;161(11 Suppl):S1-S12.
Conflicting
message in the title
T
his letter concerns the article1 on montelukast in the January issue.In this review article, the authors men- tion the role of leukotriene receptor antagonists (LTRAs) in asthma man- agement in relation to a number of international guidelines. There was no mention of the role of LTRAs in asth- ma management in Canada. I believe this might be related to the time line between the publication of the most recent Canadian guidelines in November 19992and the publication of this review.1 Therefore, the role of LTRAs based on Canadian recommen- dations requires further clarification.
I was puzzled by the message con- veyed in the title of the ar ticle1
“Montelukast. No current use for asth- ma,” and the rating “judgment reserved”
assigned by the editors of Prescrire.
Based on the Prescrire rating system, a rating of judgment reserved indicates that “The editors postpone their judg- ment until better data and a more thor- ough evaluation of the dr ug are available.” Given this definition, the title should be modified accordingly because it explicitly passes judgment, and it does not reflect Canadian recommendations on the use of LTRAs. Current Canadian guidelines2on asthma management sug- gest the use of LTRAs:
1. Leukotriene receptor antagonists may be considered as an alternative to increased doses of inhaled gluco- corticosteroids (ICS) and therefore should be used as a potential add- on therapy to moderate or higher doses of ICS to achieve control of persistent asthma symptoms.
2. There is insuf ficient evidence to recommend LTRAs for regular therapy in place of ICS; however, for patients who choose not to use ICS, LTRAs should be the primary treatment of choice.
VOL 46: JUNE • JUIN 2000❖Canadian Family Physician•Le Médecin de famille canadien 1263
Letters
❖Correspondance
1264 Canadian Family Physician•Le Médecin de famille canadien❖VOL 46: JUNE • JUIN 2000
A recent report3 not included in the Prescrire article1 indicates that 4 weeks of treatment with montelukast decreases air way eosinophilic inflammation in addition to improving clinical end points in adult patients with chron- ic asthma. For further reading on LTRAs in asthma man- agement, readers are referred to a recent review article.4 Finally, while there have been reports of a connection between LTRA use and Churg-Strauss syndrome, a cause- and-effect relationship has not been established. In fact, Churg-Strauss syndrome has been reported with use of other medications for treating chronic asthma.5
—Anthony D. D’Urzo, MD, MSC, CCFP
Toronto, Ont
References
1. Prescrire. Evidence-based drug reviews. Montelukast. No current use for asthma [Prescrire]. Can Fam Physician 2000;46:85-91 (Eng), 92-9 (Fr).
2. Boulet L-P, Becker A, Bérubé D, Beveridge R, Ernst P, on behalf of the Canadian Asthma Consensus Group. Summary of recommenda- tions from the Canadian Asthma Consensus Report, 1999. Can Med Assoc J1999;161(11 Suppl):S1-S12.
3. Pizzichini E, Leff JA, Reis TF, Hendeles L, Baulet LD, Wei LX, et al.
Montelukast reduces airway eosinophilic inflammation in asthma: a randomized, controlled trial. Eur Respir J 1999;14:12-8.
4. D’Urzo AD, Chapman KR. Leukotriene receptor antagonists: role in asthma management. Can Fam Physician 2000;46:872-9.
5. Whechsler ME, Fin D, Gunawardena D, Westlake R, Barker A, Haranath SP, et al. Churg-Strauss syndrome in patients receiving montelukast as treatment for asthma. Chest 2000;117:708-13.
Response
These letters regarding the article on montelukast reveal some of the difficulties we experience in publishing materi- al from Prescrire. The editor at La revue Prescrire has clari- fied some of the issues, but others are related to the nature of the column and its incorporation into Canadian Family Physician.
Prescrire ar ticles are written by a ver y professional research team who rigorously search for all studies, both published and unpublished, on each medication. I con- firmed this personally when I visited the Prescrire office in Paris, France, in January of this year. Their interpretation of the evidence tends to be conser vative—if no major advances are demonstrated, they say so. We believe read- ers can interpret their findings like any other review.
There are some problems, however, in reproducing Prescrire ar ticles in a Canadian journal. Until now, we have tried to modify them to fit our setting by removing dir ect r efer ences to Fr ench medicine and adding Canadian indications and prices, although we have not changed the main text. Inevitably, some of the statements still reflect the European orientation of the original arti- cle and cr eate some dissonance for our r eaders.
Occasionally there are problems with translation, as illus- trated by the conclusion for montelukast. In addition, the delay from the original literature search to publication of the English version might not take into account more recent literature. To counter this, we have requested updates from Prescrire when there has been a delay. To inform readers, we clearly indicate when the original review took place.
In response to these letters and other comments, and at the suggestion of Prescrire editor Dr Bruno Toussaint, we plan to modify our reprinting of the drug reviews. We will now reprint the original versions from La revue Prescrire (French) and Prescrire International (English), and the date of each publication will continue to be clearly identi- fied. A separate box will indicate Canadian indications, availability, and prices.
We hope this change will clarify the process and allow readers of Canadian Family Physician to benefit from the rigorous work by Prescrire. We believe their independent reviews of medications are useful to our readers despite their transatlantic, transcultural journey.
—Tony Reid, MD, CCFP, FCFP
Scientific Editor, Canadian Family Physician
