What is the dosage and administration of Monteleukast (Singulair) for asthma and seasonal allergic rhinitis?

Montelukast Dosing and Administration

Asthma Dosing

For asthma, montelukast should be taken once daily in the evening, with age-based dosing: 10 mg for patients ≥15 years, 5 mg chewable tablet for ages 6-14 years, 4 mg chewable tablet or oral granules for ages 2-5 years, and 4 mg oral granules for ages 6-23 months. 1

Age-Specific Dosing for Asthma

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

Important Administration Details

• Montelukast should be taken continuously for chronic asthma management, even when asymptomatic 1
• Can be administered with or without food 1
• Not for acute asthma attacks - patients must always have rescue inhaler available 1
• Do not discontinue or reduce other asthma medications without physician guidance 1

Exercise-Induced Bronchoconstriction (EIB)

For prevention of exercise-induced bronchoconstriction in patients ≥15 years, take a single 10 mg dose at least 2 hours before exercise, with no additional doses within 24 hours of the previous dose. 1

Critical EIB Considerations

• Patients already taking daily montelukast for chronic asthma or allergic rhinitis should NOT take an additional dose for EIB prevention 1
• Daily chronic administration has not been established to prevent acute EIB episodes 1
• Always maintain rescue β-agonist availability 1

Allergic Rhinitis Dosing

For allergic rhinitis, montelukast dosing is age-based and can be taken once daily at any time of day: 10 mg for patients ≥15 years, 5 mg for ages 6-14 years, 4 mg for ages 2-5 years (seasonal) or 6 months-5 years (perennial). 1

Seasonal Allergic Rhinitis (≥2 years)

• Adults and adolescents ≥15 years: 10 mg tablet once daily 1
• Children 6-14 years: 5 mg chewable tablet once daily 1
• Children 2-5 years: 4 mg chewable tablet or oral granules once daily 1
• Time of administration may be individualized (morning or evening) 1

Perennial Allergic Rhinitis (≥6 months)

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

Combined Asthma and Allergic Rhinitis

Patients with both asthma and allergic rhinitis should take only ONE dose daily in the evening - do not double dose. 1

• The single evening dose addresses both conditions simultaneously 1
• This is particularly valuable as montelukast can manage upper and lower airway disease together 2, 3

Oral Granules Administration

Oral granules must be administered within 15 minutes of opening the packet and cannot be stored for future use after mixing. 1

Administration Options for 4 mg Oral Granules

• Directly in the mouth 1
• Dissolved in 5 mL of cold or room temperature baby formula or breast milk 1
• Mixed with a spoonful of cold or room temperature soft foods: Only applesauce, mashed carrots, rice, or ice cream should be used based on stability studies 1

Critical Granules Precautions

• Do not open packet until ready to use 1
• After opening, entire dose must be given within 15 minutes 1
• Discard any unused portion - never store mixed granules 1
• Do not dissolve in liquids other than baby formula or breast milk (though liquids may be taken after administration) 1

Clinical Context and Efficacy

Comparative Effectiveness

• Intranasal corticosteroids are more effective than montelukast for allergic rhinitis and should be first-line therapy 2, 3
• Montelukast has similar efficacy to oral antihistamines but is less effective than intranasal corticosteroids 2, 3
• Combination of montelukast plus antihistamine is superior to either agent alone 2, 3

Special Patient Populations

• Montelukast is particularly valuable for patients with both asthma and allergic rhinitis, as it treats both conditions with a single medication 2, 3, 4, 5
• Consider for patients who are "steroid-phobic" or cannot tolerate intranasal corticosteroids 2, 3
• Onset of action occurs by the second day of treatment 2, 3
• Does not suppress skin testing, advantageous when allergy testing is needed 2, 3

Safety Profile

• Generally well-tolerated with adverse effects similar to placebo 1, 5
• Safe for use in children as young as 6 months for perennial allergic rhinitis 3, 1
• Recent FDA warnings regarding neuropsychiatric adverse effects require caution - reserve use for selected patients 6