Should we use montelukast (Singulair) for viral upper respiratory tract infections?

Montelukast Should Not Be Used for Viral Upper Respiratory Tract Infections

Montelukast is not recommended for the treatment of viral upper respiratory tract infections as it has not been shown to reduce the incidence or severity of these infections. 1

Evidence Against Montelukast Use in Viral URTIs

Clinical Trial Evidence

• A randomized, double-blind, placebo-controlled study in 300 healthy children aged 1-5 years showed that 12-week prophylactic treatment with montelukast did not reduce the incidence of URI compared to placebo 1
• The study found no significant difference in URI occurrence between children treated with montelukast (30.4%) versus placebo (30.7%) 1

Guideline Recommendations

• The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS 2020) does not recommend montelukast for viral upper respiratory tract infections 2
• The French guidelines on systemic antibiotic treatment in upper respiratory tract infections do not mention montelukast as a treatment option, emphasizing that most URTIs are viral in origin 2

Appropriate Use of Montelukast

Montelukast is appropriately used for:

1. Allergic Rhinitis:

   • Effective for treating allergic rhinitis, particularly in combination with antihistamines 2
   • Produces statistically significant improvement in nasal symptoms and quality of life scores compared to placebo 2
   • Onset of action occurs by the second day of daily treatment 2

2. Asthma Management:

   • Particularly beneficial when treating patients with combined upper and lower airway allergic diseases 2
   • Recommended for monotherapy in children with mild persistent asthma and coexisting allergic rhinitis 2

3. Specific Allergic Conditions:

   • May prevent reductions in lung function during cold infections in patients with asthma 3
   • May prevent increases in sputum eosinophils caused by common cold infections in asthmatic patients 3

Important Limitations and Considerations

• Montelukast is not effective in controlling allergic symptoms outside the airways (such as conjunctivitis, oral symptoms, eczema, or urticaria) 4
• Montelukast is less effective than intranasal corticosteroids for allergic rhinitis 2
• Neuropsychiatric events have been reported as adverse effects of montelukast, although evidence for this association is contradictory 2, 5
• For viral URTIs, first-line antibiotic therapy is of no value because of the low risk of invasive bacterial infection (Grade C evidence) 2

Treatment Recommendations for Viral URTIs

Instead of montelukast, consider:

1. Supportive Care:

   • Adequate hydration
   • Rest
   • Symptomatic relief measures

2. For Specific Symptoms:

   • Nasal congestion: Short-term use of decongestants (avoiding prolonged use due to risk of rhinitis medicamentosa) 5
   • Rhinorrhea: Ipratropium bromide nasal spray 5
   • Fever/pain: Acetaminophen or NSAIDs as appropriate

3. For Patients with Underlying Allergic Rhinitis:

   • Second-generation antihistamines for sneezing and itching 5
   • Intranasal corticosteroids for congestion 5

Conclusion

Despite some theoretical potential based on its anti-inflammatory properties 6, 7, the evidence does not support using montelukast for viral upper respiratory tract infections. Treatment should focus on symptomatic relief and addressing any underlying conditions like allergic rhinitis or asthma with appropriate therapies.