What is the recommended dosage and treatment plan for Monteleukast (Singulair) in patients with asthma or seasonal allergic rhinitis?

Montelukast Dosage and Treatment Plan for Asthma and Seasonal Allergic Rhinitis

For patients with asthma or seasonal allergic rhinitis, montelukast should be taken once daily, with specific dosages based on age: 10 mg for adults and adolescents 15 years and older, 5 mg for children 6-14 years, 4 mg for children 2-5 years, and 4 mg oral granules for children 6-23 months (for perennial allergic rhinitis) or 12-23 months (for asthma). 1

Dosage Recommendations by Age and Condition

Asthma

• Adults and adolescents ≥15 years: One 10-mg tablet once daily in the evening 1
• Children 6-14 years: One 5-mg chewable tablet once daily in the evening 1
• Children 2-5 years: One 4-mg chewable tablet or one packet of 4-mg oral granules once daily in the evening 1
• Children 12-23 months: One packet of 4-mg oral granules once daily in the evening 1

Seasonal Allergic Rhinitis

• Adults and adolescents ≥15 years: One 10-mg tablet once daily 1
• Children 6-14 years: One 5-mg chewable tablet once daily 1
• Children 2-5 years: One 4-mg chewable tablet or one packet of 4-mg oral granules once daily 1
• Not approved for children <2 years with seasonal allergic rhinitis 1

Perennial Allergic Rhinitis

• Adults and adolescents ≥15 years: One 10-mg tablet once daily 1
• Children 6-14 years: One 5-mg chewable tablet once daily 1
• Children 2-5 years: One 4-mg chewable tablet or one packet of 4-mg oral granules once daily 1
• Children 6-23 months: One packet of 4-mg oral granules once daily 1

Administration Guidelines

Timing

• For asthma: Take once daily in the evening 1
• For allergic rhinitis: Take once daily at about the same time each day; timing can be individualized to suit patient needs 1
• For patients with both conditions: Take only one tablet daily in the evening 1

Administration of Oral Granules

• Can be given directly in the mouth or mixed with cold/room temperature soft foods (only applesauce, carrots, rice, or ice cream) 1
• Can be dissolved in 1 teaspoon of cold/room temperature baby formula or breast milk 1
• Must be administered within 15 minutes of opening the packet 1
• Do not store mixed medication for future use 1

Efficacy Considerations

Asthma

• Montelukast is effective for long-term management of asthma but should not be used for immediate relief of an asthma attack 1
• Patients should always have their rescue inhaler available 1
• Montelukast is less effective than inhaled corticosteroids as monotherapy for asthma but may be considered as an alternative for patients unable or unwilling to use inhaled corticosteroids 2

Allergic Rhinitis

• Montelukast is effective in treating both seasonal and perennial allergic rhinitis 3
• Efficacy is similar to second-generation antihistamines but less than intranasal corticosteroids 2
• Combination with an antihistamine may provide additive effects for symptom control 3, 2

Special Considerations

Patients with Both Conditions

• Montelukast is particularly valuable for patients with both allergic rhinitis and asthma as it can manage both conditions simultaneously 2
• In patients with both conditions, a single daily dose is sufficient 1
• Studies show montelukast improves both nasal and asthma symptoms in patients with both conditions 4, 5

Exercise-Induced Bronchoconstriction

• For prevention of exercise-induced bronchoconstriction in patients ≥15 years: Take one 10-mg tablet at least 2 hours before exercise 1
• Do not take an additional dose within 24 hours of a previous dose 1
• Patients already taking daily montelukast for asthma or allergic rhinitis should not take an additional dose for exercise-induced bronchoconstriction 1

Safety and Monitoring

• Montelukast has an excellent safety profile and is approved for children as young as 6 months for perennial allergic rhinitis 3
• Side effects are generally mild and similar to placebo 1
• Monitor for potential behavior and mood-related changes including agitation, depression, and sleep disturbances 1
• If asthma symptoms worsen or if rescue medication use increases, contact a healthcare provider immediately 1
• Patients with aspirin-sensitive asthma should continue to avoid aspirin and NSAIDs while taking montelukast 1

Clinical Pearls and Pitfalls

• Montelukast is not a steroid and does not affect children's growth rate 1
• Intranasal corticosteroids are preferred over montelukast for initial treatment of seasonal allergic rhinitis due to greater efficacy 3, 2
• Do not discontinue other asthma medications unless directed by a healthcare provider 1
• Montelukast should not be used for immediate relief of an asthma attack - always keep rescue medication available 1
• The onset of action for montelukast typically begins on the second day of treatment 2