Does a Chronic Obstructive Pulmonary Disease (COPD) patient benefit from Singular (montelukast)?

Montelukast (Singulair) is NOT Recommended for COPD Treatment

Montelukast should not be used in COPD patients as it is not included in evidence-based treatment guidelines and lacks sufficient evidence for efficacy in this population. The GOLD 2017 guidelines, which represent the authoritative standard for COPD management, make no mention of leukotriene receptor antagonists like montelukast in their comprehensive treatment algorithms 1.

Why Montelukast is Not Recommended

Absence from Evidence-Based Guidelines

• The GOLD 2017 guidelines explicitly state that leukotriene modifiers have not been adequately tested in COPD 1
• No major COPD treatment guideline recommends montelukast as part of standard therapy 1
• The American College of Chest Physicians and Canadian Thoracic Society 2015 guidelines do not include leukotriene receptor antagonists in their treatment recommendations 1

What IS Recommended Instead

The evidence-based treatment hierarchy for COPD focuses on:

First-line therapy:

• Long-acting bronchodilators (LABAs and LAMAs) are the cornerstone of COPD treatment 1
• For Group B patients: single long-acting bronchodilator initially 1
• For Group D patients: LABA/LAMA combination is preferred over other options 1

Add-on therapy for persistent exacerbations:

• Inhaled corticosteroids (ICS) combined with LABAs for patients with history of exacerbations despite appropriate long-acting bronchodilator treatment 1
• PDE4 inhibitors (roflumilast) for patients with FEV1 <50% predicted, chronic bronchitis, and continued exacerbations despite LABA/LAMA/ICS 1
• Macrolides in former smokers with persistent exacerbations 1

Limited and Conflicting Research Evidence

While one small retrospective study of 20 patients suggested potential benefits of montelukast in moderate to severe COPD 2, this evidence has critical limitations:

• Retrospective design with no randomization or blinding 2
• Very small sample size (n=20) that cannot support clinical recommendations 2
• No inclusion in subsequent guidelines despite publication in 2004, suggesting the findings were not validated or deemed clinically significant by guideline committees 1

Clinical Bottom Line

Use evidence-based COPD therapies instead of montelukast:

1. Start with long-acting bronchodilators (LABA or LAMA) for symptomatic patients 1
2. Escalate to LABA/LAMA combination for persistent breathlessness or Group D patients 1
3. Add ICS to LABA only for patients with recurrent exacerbations despite optimal bronchodilator therapy 1
4. Consider roflumilast or macrolides for patients with continued exacerbations on triple therapy 1

Montelukast may have a role in asthma and allergic rhinitis 3, but there is insufficient evidence to support its use in COPD management, and it should not divert resources or attention from proven therapies that reduce morbidity, mortality, and improve quality of life in COPD patients 1.