Correspondence

Asthma in Pregnancy

N Engl J Med 2009; 361:535-536July 30, 2009

Article

To the Editor:

In their review article on asthma in pregnancy (April 30 issue),1 Schatz and Dombrowski state that leukotriene-receptor antagonists may be considered as an alternative to inhaled corticosteroids in pregnancy. However, current guidelines by the British Thoracic Society2 advocate against starting these agents during pregnancy. Given the limited safety data available on leukotriene-receptor antagonists and the literature regarding the safety of inhaled corticosteroids during pregnancy,3,4 use of the corticosteroids would seem a better approach in cases of mild asthma.

Stuart Schembri, M.D.
Perth Royal Infirmary, Perth PH1 1NX, United Kingdom
sschembri@nhs.net

4 References

1. 1

   Schatz M, Dombrowski M. Asthma in pregnancy. N Engl J Med 2009;360:1862-1869
   Full Text | Web of Science | Medline

2. 2

   British Thoracic Society Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Thorax 2008;63:Suppl 4:iv1-iv121
   CrossRef | Web of Science | Medline

3. 3

   Schatz M, Zeiger RS, Harden K, Hoffman CC, Chilingar L, Petitti D. The safety of asthma and allergy medications during pregnancy. J Allergy Clin Immunol 1997;100:301-306
   CrossRef | Web of Science | Medline

4. 4

   Dombrowski M, Thom E, McNellis D. Maternal-Fetal Medicine Units (MFMU) studies of inhaled corticosteroids during pregnancy. J Allergy Clin Immunol 1999;103:S356-S359
   CrossRef | Web of Science | Medline

Author/Editor Response

We agree that inhaled corticosteroids are the preferred controller therapy for all levels of persistent asthma during pregnancy, as noted in Table 2 and Table 5 of our article. However, because of reassuring data from studies in animals (Food and Drug Administration Pregnancy Category B) and at least some reassuring published data about humans,1 we and the most recent pregnancy-specific guidelines of the National Asthma Education and Prevention Program2 have not considered leukotriene-receptor antagonists to be contraindicated during pregnancy. As “alternative controller medications” for step 2 of asthma therapy, they provide alternatives in circumstances in which inhaled corticosteroids have not been effective, have not been tolerated, or are declined by the patient for other reasons. We also state in Table 5 of our article that another circumstance in which leukotriene-receptor antagonists may be considered for use during pregnancy is when they have been providing good control of asthma before pregnancy.

Michael Schatz, M.D., M.S.
Kaiser Permanente Medical Center, San Diego, CA 92111
michael.x.schatz@kp.org

Mitchell P. Dombrowski, M.D.
St. John Hospital, Detroit, MI 48236

2 References

1. 1

   Bakhireva LN, Jones KL, Schatz M, et al. Safety of leukotriene receptor antagonists during pregnancy. J Allergy Clin Immunol 2007;119:618-625
   CrossRef | Web of Science | Medline

2. 2

   National Asthma Education and Prevention Program Asthma and Pregnancy Working Group. NAEPP Expert Panel report: managing asthma during pregnancy: recommendations for pharmacologic treatment -- 2004 update. J Allergy Clin Immunol 2005;115:34-46[Erratum, J Allergy Clin Immunol 2005;115:477.]
   CrossRef | Web of Science | Medline