Can Singular (montelukast) be used for sinus tenderness and rhinitis?

Montelukast (Singulair) for Sinus Tenderness and Rhinitis

Yes, montelukast (Singulair) is effective for treating allergic rhinitis and can help with associated sinus tenderness, particularly in patients who also have asthma or who have not responded adequately to antihistamines or intranasal corticosteroids.

Mechanism and Efficacy

Montelukast works by blocking cysteinyl leukotriene type-1 (CysLT1) receptors, which are found in the human airway and on pro-inflammatory cells. This mechanism helps reduce:

• Nasal congestion
• Rhinorrhea (runny nose)
• Nasal pruritus (itching)
• Sneezing
• Inflammation that can lead to sinus tenderness 1

Clinical studies have demonstrated that montelukast produces statistically significant improvement in nasal symptoms and quality of life scores compared to placebo for both seasonal and perennial allergic rhinitis 1. The onset of action typically occurs by the second day of daily treatment.

Comparative Efficacy

When considering treatment options:

• Montelukast shows similar efficacy to antihistamines (particularly loratadine) 1
• Montelukast is less effective than intranasal corticosteroids 1
• The combination of montelukast with an antihistamine is superior to either therapy alone 1
• For nasal congestion specifically, pseudoephedrine is more effective than montelukast 1

Dosing and Administration

• For adults and adolescents 15 years and older: 10 mg tablet once daily 2
• For children 6-14 years: 5 mg chewable tablet once daily 2
• For children 2-5 years: 4 mg chewable tablet or oral granules once daily 2
• For children 6 months to 2 years with perennial allergic rhinitis: Appropriate dosing based on FDA approval 2

Montelukast can be taken without regard to food timing, and is typically administered in the evening for asthma and either morning or evening for allergic rhinitis 2.

Special Considerations

Patients with Coexisting Asthma and Rhinitis

Montelukast is particularly valuable for patients with both allergic rhinitis and asthma 3:

• Up to 40% of patients with allergic rhinitis have coexisting asthma 1
• Montelukast can benefit both upper and lower airway symptoms simultaneously 1, 3
• In children with mild persistent asthma and coexisting allergic rhinitis, montelukast has been recommended as monotherapy 1

Combination Therapy

For patients with inadequate response to montelukast alone:

• Combination with a second-generation antihistamine may provide added benefit for allergic rhinitis 1
• This combination may also provide better protection against seasonal decrease in lung function 1
• Consider this approach for patients who are unresponsive to or cannot use intranasal corticosteroids 1

Safety Profile

Montelukast has an excellent safety profile:

• Well-tolerated with adverse events similar to placebo in most studies 2
• Common adverse events include headache, fever, upper respiratory infection, and cough 2
• Unlike antihistamines, montelukast does not significantly suppress skin tests 1
• Approved for perennial allergic rhinitis in children as young as 6 months 1

Important Caveats

• Montelukast is not a rescue medication for acute symptoms
• Full benefit may take several days of continuous use
• Neuropsychiatric events have been reported (agitation, depression, insomnia) 2
• Less effective for nasal congestion than pseudoephedrine 1
• If symptoms persist after 2-4 weeks, consider adding or switching to another medication class 3

Algorithm for Treatment Decision

1. First-line therapy for allergic rhinitis is typically intranasal corticosteroids
2. Consider montelukast when:
   • Patient has both allergic rhinitis and asthma
   • Patient has inadequate response to antihistamines
   • Patient cannot or will not use intranasal medications
   • Patient has concerns about steroid use
3. Consider combination therapy (montelukast plus antihistamine) when:
   • Monotherapy with either agent alone provides insufficient relief
   • Patient has significant eye symptoms in addition to nasal symptoms

Montelukast provides a valuable oral treatment option for patients with allergic rhinitis and associated sinus tenderness, with particular benefit for those who also have asthma.