Which anti-inflammatory drug should we use in asthma?

Asthma is a chronic and heterogeneous inflammatory disorder of the airways defined by its clinical, physiological and pathological characteristics. Accordingly to currently available guidelines inhaled glucocorticosteroids (ICS) represent the most effective anti-inflammatory medication for the treatment of persistent asthma, and this class of drugs is recommended as the first-line controller therapy both in children and adults. Leukotriene modifiers (LTRAs) are usually used as a second line of add-on therapy, although they may be regarded as the first-line therapy in exercise induced bronchoconstriction, in patients with comorbid allergic rhinitis and in children with asthma and frequent viral infections. A recently published pragmatic (real-life) study showed that LTRAs provide an alternative treatment for asthma, which, at least for the evaluated endpoints, may be as effective as ICS in our every-day practice. To assess how the recent data may affect our every-day practice and current guidelines for clinical management of asthma, it needs to be clearly understood what pragmatic trials add to our knowledge. In our opinion, it is premature to change current guidelines. However, pragmatic and observational studies are clearly needed as they provide additional information to randomized controlled trials. The main goal of all those efforts is to improve asthma control and decrease the burden of the disease for patients and societies. It may be that the future approach will introduce several new strategies based on system biology studies for the treatment of asthma guided in a personalized medicine approach.