From the Guidelines
Montelukast is generally more effective than cromolyn sodium for preventing exercise-induced bronchospasm in a 12-year-old with uncontrolled asthma already using albuterol. For this patient, montelukast (Singulair) should be taken at a dose of 5 mg once daily in the evening, as recommended by the guidelines 1. This oral medication works by blocking leukotriene receptors, which are important mediators in the inflammatory cascade of asthma and specifically in exercise-induced symptoms.
Key Points to Consider
- Montelukast has the advantage of providing 24-hour protection with a single daily dose, making it convenient for children.
- In contrast, cromolyn sodium requires multiple daily administrations via inhaler before exercise, which can be challenging for adherence in children.
- Additionally, montelukast addresses the underlying inflammation contributing to the child's uncontrolled asthma status, potentially improving overall asthma control beyond just exercise situations.
- Since this child's asthma is currently uncontrolled on albuterol alone, adding a controller medication like montelukast is appropriate rather than just using another as-needed medication like cromolyn, as supported by the guidelines 1.
- However, it's essential to monitor for potential side effects of montelukast, including mood changes or behavioral issues, which occur rarely but should be discussed with parents.
Clinical Decision Making
The decision to use montelukast over cromolyn sodium is based on the most recent and highest quality evidence available, prioritizing the patient's morbidity, mortality, and quality of life outcomes. The guidelines from the Journal of Allergy and Clinical Immunology 1 and the American Family Physician 1 support the use of montelukast as a preferred treatment option for preventing exercise-induced bronchospasm in patients with uncontrolled asthma. Furthermore, the Mayo Clinic Proceedings 1 emphasize the importance of stepping up medication for patients with uncontrolled asthma and considering the risks and benefits of different treatment options.
Treatment Approach
Given the patient's age and uncontrolled asthma status, montelukast is the recommended treatment option. The patient should be closely monitored for potential side effects and adherence to the treatment regimen. Regular follow-up appointments should be scheduled to assess the effectiveness of the treatment and make any necessary adjustments to the patient's asthma management plan.
From the FDA Drug Label
Cromolyn sodium attenuates bronchospasm caused by exercise Montelukast: No direct information is provided in the label regarding exercise-induced bronchospasm prevention.
The most effective option for preventing exercise-induced bronchospasm in a 12-year-old with uncontrolled asthma on albuterol is cromolyn sodium 2.
From the Research
Comparison of Montelukast and Cromolyn Sodium for Exercise-Induced Bronchospasm
- Montelukast is a leukotriene antagonist that has been shown to be effective in preventing exercise-induced bronchospasm (EIB) in some patients 3, 4.
- Cromolyn sodium is an anti-inflammatory medication that has been used to prevent EIB, and its efficacy is comparable to that of other medications such as theophylline and alpha-adrenergic blockers 5.
- A study comparing pretreatment with albuterol versus montelukast for EIB in children found that albuterol was more effective than montelukast in preventing EIB 6.
- Another study found that cromolyn sodium was effective in preventing EIB in more than 70% of patients, and its efficacy was comparable to that of other medications 5.
- However, a study comparing salmeterol and sodium cromoglycate found that salmeterol was superior to sodium cromoglycate in preventing EIB 7.
Efficacy of Montelukast and Cromolyn Sodium
- Montelukast has been shown to provide effective protection against EIB in some patients, but its efficacy may vary depending on the individual 3, 4.
- Cromolyn sodium has been shown to be effective in preventing EIB in more than 70% of patients, but its efficacy may also vary depending on the individual 5.
- The choice between montelukast and cromolyn sodium may depend on individual patient factors, such as the severity of EIB and the presence of other medical conditions.
Use in Children
- Montelukast has been shown to be effective in preventing EIB in children, but its efficacy may be lower than that of albuterol 6.
- Cromolyn sodium has been used to prevent EIB in children, but its efficacy and safety in this population may vary depending on the individual 5.
- Further studies are needed to determine the optimal treatment for EIB in children, including the use of montelukast and cromolyn sodium.