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Montelukast (Monograph)

Brand name: Singulair
Drug class: Leukotriene Modifiers
VA class: RE109
Chemical name: [R-(E)]-1-[[[1-[3-[2-(7-chloro-2-quinolinyl)ethenyl]phenyl]-3-[2-(7-chloro-2-quinolinyl)ethenyl]phenyl]-3-[2-(1-hydroxy-1-methylethyl)phenyl]propyl]thio]methyl cyclopropane acetic acid sodium
Molecular formula: C35H35ClNNaO3S
CAS number: 151767-02-1

Medically reviewed by Drugs.com on Dec 11, 2023. Written by ASHP.

Warning

  • Serious neuropsychiatric effects, including suicidal thoughts or behavior, reported in patients receiving montelukast.128 129 (See Neuropsychiatric Effects under Cautions.)

  • Discuss benefits and risks of treatment with patients and caregivers; monitor patients receiving montelukast for neuropsychiatric symptoms.128 129

  • Discontinue montelukast if neuropsychiatric symptoms occur and contact a clinician immediately.128 129

  • Benefits of montelukast treatment may not outweigh the risks of neuropsychiatric symptoms, especially for respiratory disease symptoms that may be mild and adequately treated with alternative therapies.128 129 Reserve use of the drug for patients with allergic rhinitis who have an inadequate response or intolerance to alternative therapies.128 129 In patients with asthma or exercise-induced bronchospasm, consider the benefits and risks of treatment before prescribing montelukast.128 129

Introduction

Antiasthmatic agent; leukotriene modifier.1 2 3 4 5 6 7 8 9 10 11 12 13 14 30 31 44 45 53 54 71 105 Pharmacologically but not structurally related to zafirlukast.2 71

Uses for Montelukast

Asthma

Prevention and long-term symptomatic management of asthma.1 31 40 43 45 51 53 54 55 56 57 58 59 60 69 70 105 109 110 119 Efficacy for this indication demonstrated when the drug was administered in the evening.1 31 45

Because of the risk of neuropsychiatric effects, consider the benefits and risks of montelukast treatment before prescribing the drug for patients with asthma.128 129 (See Neuropsychiatric Effects under Cautions.)

In patients with mild persistent asthma, low-dose orally inhaled corticosteroids considered first-line agents for long-term control.21 44 45 47 70 80 86 92 105 110 119 Alternative agents, including certain leukotriene modifiers (i.e., montelukast, zafirlukast), may be used44 70 80 86 87 88 91 98 99 105 110 119 but are less effective than inhaled corticosteroids and are not preferred as initial therapy.110 119 121

In patients with moderate persistent asthma, low-dose inhaled corticosteroids with a long-acting inhaled β2-agonist bronchodilator (e.g., salmeterol, formoterol) or monotherapy with medium-dose inhaled corticosteroids preferred.110 119 However, the National Asthma Education and Prevention Program (NAEPP) recommends that beneficial effects of long-acting inhaled β2-agonists be weighed carefully against increased risk of severe asthma exacerbations and asthma-related deaths associated with daily use of such agents.119

Alternative agents, including certain leukotriene modifiers (i.e., montelukast, zafirlukast), can be added to a low dosage of inhaled corticosteroid for treatment of moderate persistent asthma, but these options are less effective.110 119 Considerations favoring combination with orally inhaled corticosteroids include intolerance to long-acting β2-adrenergic agonists, marked preference for oral therapy, and demonstration of superior responsiveness to these leukotriene modifiers.119

In adults and children ≥5 years of age with severe persistent asthma, NAEPP and the Global Initiative for Asthma (GINA) state that maintenance therapy with inhaled corticosteroids at medium to high dosages and adjunctive therapy with a long-acting inhaled β2-agonist is preferred.110 119 Alternatives to a long-acting inhaled β2-agonist in such patients receiving medium-dose inhaled corticosteroids include certain leukotriene modifiers (i.e., montelukast, zafirlukast), but these agents are generally not preferred.110 119

In infants and children ≤4 years of age, NAEPP states that an inhaled corticosteroid at medium or high dosages and adjunctive therapy with either a long-acting inhaled β2-agonist or montelukast is the only preferred treatment.119

Maintenance therapy with montelukast may be considered in patients who are unable or unwilling to comply with therapy using inhaled corticosteroids (e.g., young children).119

Not recommended for relief of acute bronchospasm; however, may continue therapy during acute asthma exacerbations.1 53 (See Acute Asthma under Cautions.)

Exercise-induced Bronchospasm

Prevention of exercise-induced bronchospasm.1 48 49 50 52

Because of the risk of neuropsychiatric effects, consider the benefits and risks of montelukast treatment before prescribing the drug for patients with exercise-induced bronchospasm.128 129 (See Neuropsychiatric Effects under Cautions.)

Leukotriene modifiers not included as first-line agents or as alternative agents to orally inhaled β2-adrenergic agonists in current guidelines;22 70 92 110 119 addition of montelukast may provide additional measure of control in patients currently maintained on long-term controller therapy.88 98 99

Manufacturer states that patients who experience exacerbations of asthma after exercise should have a short-acting orally inhaled β2-adrenergic agonist available for rescue.1 98 Not established that daily administration of montelukast for chronic treatment of asthma prevents acute episodes of exercise-induced bronchospasm.1

Allergic Rhinitis

Symptomatic management of seasonal or perennial allergic rhinitis.1 87 93 111 Efficacy for this indication demonstrated when the drug was administered in the morning or evening.1

Because the benefits of montelukast treatment may not outweigh the risks of neuropsychiatric effects in patients with allergic rhinitis, reserve use of the drug for such patients who have an inadequate response or intolerance to alternative therapies.128 129 (See Neuropsychiatric Effects under Cautions.)

Urticaria

Has been used successfully in patients with chronic idiopathic urticaria† [off-label]; beneficial when added to existing therapy.83

Montelukast Dosage and Administration

Administration

Oral Administration

Administer at regular intervals (once daily) without regard to meals.1 31 45

Administer in the evening in patients with asthma with or without coexisting allergic rhinitis.1 31 45

May individualize time of administration in patients with allergic rhinitis; administer at the same time each day.1 125

Administer ≥2 hours before exercise in patients with exercise-induced bronchospasm; do not take an additional dose within 24 hours of previous dose.1 125

Oral Granules

Generally used in children 12 months to 5 years of age.1 Do not open packet until ready to use; administer full dose within 15 minutes of opening packet and without regard to meals.1 125

Administer directly in the mouth alone or mix with a teaspoonful (5 mL) of cold or room temperature baby formula, breast milk, or soft food (i.e., applesauce, carrots, rice, ice cream).1 Granules are not intended to be dissolved in liquid other than baby formula or breast milk prior to administration; however, liquids can be taken after administration of the granules.1 125 (See Stability.)

Do not store granules mixed with food for future use; discard any unused portion.1 125

Dosage

Available as montelukast sodium; dosage expressed in terms of montelukast.1

Pediatric Patients

Asthma With or Without Allergic Rhinitis
Oral

Children 12–23 months: 4 mg once daily as oral granules.1

Children 2–5 years of age: 4 mg once daily as chewable tablets or oral granules.1 109

Children 6–14 years of age: 5 mg once daily as chewable tablets.1

Adolescents ≥15 years of age: 10 mg once daily as film-coated tablets.1 45

Additional dosage not needed for treatment of allergic rhinitis in patients already receiving chronic therapy for asthma.1

Exercise-induced Bronchospasm
Prevention
Oral

Children 6–14 years of age: 5 mg as a chewable tablet administered at least 2 hours before exercise.128

Adolescents ≥15 years of age: 10 mg as a film-coated tablet administered at least 2 hours before exercise.1 48 49 50 52 77 78

Not indicated in those already taking the drug for another indication.128

Seasonal Allergic Rhinitis With or Without Asthma
Oral

Children 2–5 years of age: 4 mg once daily as chewable tablets or oral granules.1

Children 6–14 years of age: 5 mg once daily as chewable tablets.1

Adolescents ≥15 years of age: 10 mg once daily as film-coated tablets.1

Perennial Allergic Rhinitis With or Without Asthma
Oral

Infants 6–23 months of age: 4 mg once daily as oral granules.1

Children 2–5 years of age: 4 mg once daily as chewable tablets or oral granules.1

Children 6–14 years of age: 5 mg once daily as chewable tablets.1

Adolescents ≥15 years of age: 10 mg once daily as film-coated tablets.1

Adults

Asthma With or Without Allergic Rhinitis
Oral

10 mg once daily as film-coated tablets.1

Additional dosage not needed for treatment of allergic rhinitis in patients already receiving chronic therapy for asthma.1

Exercise-induced Bronchospasm
Prevention
Oral

10 mg as a film-coated tablet administered at least 2 hours before exercise.1 48 49 50 52 77 78

Not indicated in those already taking the drug for another indication.128

Seasonal Allergic Rhinitis With or Without Asthma
Oral

10 mg once daily as film-coated tablets.1

Perennial Allergic Rhinitis With or Without Asthma
Oral

10 mg once daily as film-coated tablets.1

Urticaria† [off-label]
Oral

5–20 mg daily.83

Special Populations

Hepatic Impairment

No dosage adjustment required in patients with mild to moderate hepatic impairment.1 Not evaluated in patients with severe hepatic impairment or hepatitis.1

Renal Impairment

No dosage adjustment required.1

Geriatric Patients

No dosage adjustment required.1

Detailed Montelukast dosage information

Cautions for Montelukast

Contraindications

Warnings/Precautions

Warnings

Neuropsychiatric Effects

Serious neuropsychiatric effects reported with montelukast during postmarketing experience.120 125 126 127 128 129 Such reports were highly variable and included agitation, aggressive behavior or hostility, anxiousness, depression, disorientation, disturbance in attention, dream abnormalities, dysphemia (stuttering), hallucinations, insomnia, irritability, memory impairment, obsessive-compulsive symptoms, restlessness, somnambulism, suicidal thoughts and behavior (including completed suicide), tic, and tremor in adults, adolescents, and pediatric patients with or without a previous history of psychiatric disorders.128 129 Neuropsychiatric effects occurred mostly during treatment, and resolved after the drug was discontinued; some of these effects developed or continued following discontinuance of the drug.128 129 A total of 82 cases of completed suicide associated with montelukast use identified; many of these cases reported development of concomitant neuropsychiatric symptoms prior to the event.129 Most reports did not contain sufficient information to determine the exact relationship between montelukast and these neuropsychiatric events.129 Following extensive review of postmarketing reports and analysis of available clinical data, FDA convened a panel of outside experts to reevaluate benefits and risks of montelukast and concluded that there was a need to strengthen existing warnings in the labeling for the drug, including restrictions for use in patients with allergic rhinitis.129 (See Allergic Rhinitis under Uses.)

Be alert to the potential for neuropsychiatric effects in patients receiving the drug.128 129 Prior to initiation of therapy, ask patients about history of psychiatric illness.129 Consider the risks and benefits of montelukast when deciding to prescribe therapy with the drug.128 129 Instruct patients to discontinue the drug and contact their clinician immediately if behavior or mood changes occur.128 129 If neuropsychiatric effects occur during treatment, provide patient monitoring and supportive care until symptoms resolve.128 Carefully evaluate the risks and benefits of reinitiating montelukast therapy in patients who develop such symptoms.128 129 (See Advice to Patients.)

Sensitivity Reactions

Hypersensitivity Reactions

Hypersensitivity reactions, including anaphylaxis, angioedema, pruritus, urticaria, and, rarely, hepatic eosinophilic infiltration, reported.1

Eosinophilia and Churg-Strauss Syndrome

Systemic eosinophilia, sometimes presenting with clinical features of vasculitis consistent with Churg-Strauss syndrome, reported rarely in patients receiving leukotriene modifiers;1 33 39 61 62 63 64 65 66 67 72 85 96 in almost all cases, these events were associated with reduction (tapered dosage) or withdrawal of oral or high-dose inhaled corticosteroid therapy.1 33 39 61 62 63 64 65 66 67 72 96

Be alert to the development of eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, and/or neuropathy;1 31 39 72 96 causal relationship not established.1 31 33 39 61 62 63 64 65 66 67 72 96 Advise patients to report symptoms (i.e., feeling of pins and needles, numbness of extremities, flu-like symptoms, rash, sinusitis) immediately to their clinician.125

Other Warnings and Precautions

Acute Asthma

Do not use for the relief of acute bronchospasm (including status asthmaticus); montelukast can be continued during acute exacerbations of asthma, but it will not provide immediate symptomatic relief.1

Concomitant Corticosteroid Therapy

Do not abruptly substitute montelukast for oral or inhaled corticosteroids.1 Orally inhaled corticosteroid requirements may be reduced during montelukast therapy; undertake only gradual (e.g., at 2-week intervals) reduction of corticosteroid dosage.1 40 98 99

Exercise-induced Bronchospasm

Do not use as monotherapy for prevention of exercise-induced bronchospasm; patients who experience exacerbations of asthma after exercise should continue their usual regimen of inhaled β2-adrenergic agonist for prophylaxis and have a short-acting orally inhaled β2-adrenergic agonist available for rescue.1

Aspirin Sensitivity

Patients in whom asthma is precipitated by aspirin or other NSAIAs should continue to avoid aspirin and NSAIAs.1 81 Montelukast can improve airway function in asthmatic patients with aspirin sensitivity; however, the drug has not been shown to truncate the bronchoconstrictor response to aspirin or other NSAIAs.1

Phenylketonuria

Montelukast chewable tablets contain aspartame (NutraSweet), which is metabolized in the GI tract to provide 0.674 mg of phenylalanine per 4-mg chewable tablet or 0.842 mg of phenylalanine per 5-mg chewable tablet.1 125

Specific Populations

Pregnancy

Category B.1

Pregnancy registry at 1 800-986-8999. ACOG generally recommends use of leukotriene receptor antagonists (i.e., montelukast, zafirlukast) as alternatives to a long-acting β2-agonist in pregnant women with moderate persistent asthma who are inadequately controlled with low to medium dosages of an inhaled corticosteroid.107 (See Asthma under Uses.)

Lactation

Distributed into milk in rats; not known whether distributed into human milk.1 Use with caution.1

Pediatric Use

Safety and efficacy for treatment of asthma in infants <12 months of age not established.1 31 Safety and efficacy for prevention of exercise-induced bronchospasm in children <6 years of age not established.128 Safety demonstrated in infants and children 12 months to 5 years of age with asthma; efficacy extrapolated from demonstrated efficacy in children ≥6 years of age based on similar pharmacokinetic data (systemic exposure), the similarity of the disease course, pathophysiology, and effects of the drug among these populations.1 85 Efficacy also supported by exploratory efficacy assessments from pediatric safety studies.1 109

Safety and efficacy in infants <6 months of age with perennial allergic rhinitis not established.1 Safety and efficacy in infants <2 years of age with seasonal allergic rhinitis not established.1 Efficacy in children 2–14 years of age or 6 months to 14 years of age with seasonal or perennial allergic rhinitis, respectively, extrapolated from demonstrated efficacy in adolescents ≥15 years of age and the similarity of the disease course, pathophysiology, and effects of the drug among these populations.1 Safety in pediatric patients 2–14 years of age with allergic rhinitis supported by data from studies in children from this age group with asthma.1 Safety in infants 6–23 months of age with perennial allergic rhinitis supported by data from studies in infants with asthma and by pharmacokinetic data comparing systemic exposure in such pediatric patients with that in adults.1

No effect of long-term therapy (56 weeks) on growth rate in pediatric patients (6–8 years of age) with mild asthma.1 112

Geriatric Use

No substantial differences in safety and efficacy relative to younger adults; however, increased sensitivity in some older patients cannot be ruled out.1

Hepatic Impairment

Exposure to montelukast may be increased.1 (See Special Populations under Pharmacokinetics and see Special Populations under Dosage and Administration.)

Common Adverse Effects

Headache, influenza, abdominal pain, cough.1 125

Drug Interactions

Metabolized by CYP3A4 and CYP2C9.1 12

Does not inhibit CYP3A4, 2C9, 1A2, 2A6, 2C19, or 2D6.1 Inhibits CYP2C8 in vitro; 1 does not inhibit CYP2C8 in vivo.1 113

Drugs Affecting Hepatic Microsomal Enzymes

CYP3A4 or CYP2C9 inducers: Potential pharmacokinetic interaction (decreased plasma concentrations of montelukast).1

CYP3A4 or CYP2C9 inhibitors: Potential pharmacokinetic interaction (increased plasma concentrations of montelukast).1

Specific Drugs

Drug

Interaction

Comments

Benzodiazepines

No increase in adverse effects noted1

Contraceptives, oral (fixed combination of ethinyl estradiol-norethindrone)

No alteration in contraceptive pharmacokinetics1 104

Corticosteroids (prednisone, prednisolone)

No clinically important effects on corticosteroid pharmacokinetics1

Decongestants

No increase in adverse effects noted1

Digoxin

No alteration in digoxin pharmacokinetics1 74

NSAIAs

No increase in adverse effects noted1

Paclitaxel

No effect anticipated on paclitaxel metabolism1 113

Phenobarbital

Decreased AUC of montelukast1 102

Montelukast dosage adjustment not recommended;1 monitor for alterations in clinical response and/or adverse effects1

Repaglinide

No effect anticipated on repaglinide metabolism1 113

Rifampin

Potential for decreased montelukast concentrations1

Monitor for alterations in clinical response and/or adverse effects1

Rosiglitazone

No effect anticipated on rosiglitazone pharmacokinetics1 113

Sedative-hypnotics

No increase in adverse effects noted1

Terfenadine (no longer commercially available in US)

No alteration in terfenadine pharmacokinetics; no effect on QTc interval1 103

Theophylline

No clinically important effects on theophylline pharmacokinetics at usual montelukast dosage1 76

Decreased plasma concentrations, AUC, and half-life of theophylline at higher than recommended montelukast dosages76

Thyroid hormones

No increase in adverse effects noted1

Warfarin

No clinically important effects on warfarin pharmacokinetics; no alteration in PT or INR1 73
Montelukast drug interactions (more detail)

Montelukast Pharmacokinetics

Absorption

Bioavailability

Rapidly absorbed from the GI tract; peak plasma concentrations attained within 3–4, 2–2.5, or 2 hours following oral administration in the fasted state of a single 10-mg film-coated tablet (in adults), 5-mg chewable tablet (in adults), or 4-mg chewable tablet (in children 2–5 years of age), respectively.1 13 14 37 53

Oral bioavailability of the 10-mg tablet in adults is 58–66%; bioavailability of the 5-mg chewable tablet in fasting adults is 73%.1

Plasma concentration profile following oral administration of montelukast 10 mg in adolescents ≥15 years of age is similar to that in young adults.1

Plasma concentration profile following oral administration of 4- or 5-mg chewable tablet in children 2–5 or 6–14 years of age, respectively, is similar to the profile in adults receiving 10-mg film-coated tablet.1 37 101

Systemic exposure and variability of plasma concentrations with 4-mg granule formulation in infants 6–11 months of age are greater than the exposure and variability with the 10-mg film-coated tablet in adults.1 Systemic exposure with 4-mg granule formulation in infants 12–23 months of age is less variable than that with the same formulation in younger children but is still greater than that with the 10-mg film-coated tablet in adults.1

4-mg oral granule formulation and 4-mg chewable tablet are bioequivalent (fasting adults).1

Bioequivalence of the 10-mg film-coated tablet versus two 5-mg chewable tablets not evaluated.1

Onset

Improvement in asthma symptoms and/or lung function test results and decreased use of β-agonist bronchodilators are evident after the first dose.1 31 45

Duration

Therapeutic effects persist for at least 24 hours.1 31 45

Food

10-mg tablets: Food does not affect absorption.1

5-mg chewable tablet: Food decreases extent of absorption.1 Bioavailability is 63% when administered with a standard meal in the morning.1

4-mg oral granule formulation: High-fat meal decreases rate of absorption and peak plasma concentration; no effect on AUC.1 Applesauce does not appear to have a clinically important effect on the pharmacokinetics of montelukast granules.1

Special Populations

In patients with mild to moderate hepatic impairment, AUC increased 41%.1

Distribution

Extent

Not fully characterized.98 99

Crosses the placenta in animals (rats, rabbits); not known whether montelukast crosses the placenta in humans.1

Distributed into milk in rats; not known whether distributed into human milk.1

Plasma Protein Binding

99%.1

Elimination

Metabolism

Extensively metabolized in the GI tract and/or liver.1 12 20 Several pathways have been identified, including acyl glucuronidation and oxidation catalyzed by CYP3A4 and CYP2C9.1 12 20

Elimination Route

Excreted principally in feces (about 86%) via bile as unchanged drug and metabolites.1 12 20

Half-life

Children 6–14 years of age: 3.4–4.2 hours.37

Adults 19–48 years of age: 2.7–5.5 hours.1 13 14 37 51

Special Populations

In patients with mild to moderate hepatic impairment, elimination half-life prolonged (7.4 hours).1 13 51 Pharmacokinetics not evaluated in patients with severe hepatic impairment or hepatitis.1

In geriatric adults 65–73 years of age, elimination half-life prolonged (6.6 hours).1 13 51

Stability

Storage

Oral

Granules

25°C (may be exposed to 15–30°C).1 125 Protect from moisture and light.1 125

Do not store opened packets or granules mixed with food, baby formula, or breast milk for future use.1 125 Administer contents within 15 minutes of opening packet.1 125

Tablets, Chewable or Film-coated

25°C (may be exposed to 15–30°C).1 125 Protect from moisture and light.1 125

Compatibility

Oral

Granules

Granules may be mixed with cold or room temperature soft food; based on stability studies, only applesauce, carrots, rice, or ice cream should be used.1 125

Actions

Advice to Patients

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Montelukast Sodium

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Granules

4 mg (of montelukast) per packet

Singulair

Merck

Tablets, chewable

4 mg (of montelukast)

Singulair

Merck

5 mg (of montelukast)

Singulair

Merck

Tablets, film-coated

10 mg (of montelukast)

Singulair

Merck

AHFS DI Essentials™. © Copyright 2024, Selected Revisions December 21, 2020. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

† Off-label: Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

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