Montelukast for Anaphylaxis Prevention
No, montelukast should not be used to prevent anaphylaxis or throat tightening associated with anaphylactic reactions. There is no evidence supporting its use for this indication, and current anaphylaxis guidelines do not recommend it 1.
Why Montelukast Does Not Prevent Anaphylaxis
Mechanism and Approved Uses
- Montelukast is a leukotriene receptor antagonist that blocks inflammatory mediators historically known as "slow-reacting substance of anaphylaxis," but this does not translate to preventing actual anaphylactic reactions 2.
- The drug is approved only as maintenance therapy for asthma and allergic rhinitis, not for preventing or treating anaphylaxis 3, 2.
Lack of Evidence for Anaphylaxis Prevention
- The 2020 Joint Task Force Practice Parameter on Anaphylaxis found no clear evidence that leukotriene antagonists prevent anaphylaxis in any clinical scenario 1.
- Very low-certainty evidence shows that neither antihistamines nor glucocorticoids (let alone leukotriene antagonists) provide clear benefit in preventing biphasic anaphylaxis after initial treatment 1.
- Premedication strategies with various agents, including antihistamines and glucocorticoids, have not been proven effective for preventing anaphylaxis in most high-risk situations 1.
Limited Exception: Rush Immunotherapy Only
- Montelukast has shown benefit in reducing local reactions (injection site swelling) during rush allergen immunotherapy, but this is distinctly different from preventing systemic anaphylaxis 4.
- This specific use is for reducing delayed local swelling at injection sites, not for preventing throat tightening or systemic anaphylactic symptoms 4.
What Actually Works for Anaphylaxis Prevention
Primary Strategy
- Strict allergen avoidance remains the cornerstone of anaphylaxis prevention 1.
- Patients must carry self-injectable epinephrine at all times, as this is the only proven acute treatment 1.
When Avoidance Is Impossible
- For unavoidable exposures (certain chemotherapy protocols), premedication strategies may have limited benefit, but montelukast is not part of these protocols 1.
- Switching to alternative agents (e.g., different radiocontrast media) is more effective than premedication 1.
Important Safety Concerns
- Montelukast carries neuropsychiatric risks including depression, anxiety, suicidal ideation, and behavioral changes, though evidence is conflicting 1, 5, 3.
- The European Respiratory Society recommends it should not be first-line therapy and requires screening for psychiatric conditions before initiation 3.
- Patients must be instructed that montelukast is not for acute attacks of any kind 3.
Clinical Bottom Line
For throat tightening during anaphylaxis: Epinephrine is the only appropriate treatment—administered immediately via intramuscular injection 1. Montelukast has no role in preventing or treating this life-threatening symptom and should never be relied upon for anaphylaxis management.