When to Start Singulair (Montelukast)
For allergic rhinitis, intranasal corticosteroids should be initiated first, and montelukast reserved as a second-line alternative for patients who fail, cannot tolerate, or refuse intranasal steroids. 1, 2
FDA-Approved Indications and Age Requirements
Montelukast is FDA-approved for: 3
- Allergic rhinitis: Seasonal (ages ≥2 years) and perennial (ages ≥6 months)
- Asthma: Prophylaxis and chronic treatment (ages ≥12 months)
- Exercise-induced bronchoconstriction: Prevention (ages ≥15 years)
Treatment Algorithm for Allergic Rhinitis
Initial Treatment Selection
Start with intranasal corticosteroids as first-line therapy for moderate-to-severe allergic rhinitis, NOT montelukast. 1 This is a strong recommendation based on clear evidence that intranasal corticosteroids are more effective than leukotriene receptor antagonists for nasal symptom reduction. 1
When to Consider Montelukast
Initiate montelukast only in these specific scenarios: 2
Patient refuses or cannot tolerate intranasal administration - Some patients do not accept intranasal corticosteroids despite their superior efficacy 1
Inadequate response to intranasal corticosteroids - After appropriate trial of intranasal steroids at adequate doses 2
Concurrent asthma and allergic rhinitis - Montelukast offers the advantage of treating both upper and lower airway disease simultaneously 2, 4
Patient preference for oral medication - Despite lesser efficacy, some patients strongly prefer oral agents 1
Dosing and Administration Timing
Standard Dosing by Age 3
- Ages 15+ years: 10 mg tablet once daily
- Ages 6-14 years: 5 mg chewable tablet once daily
- Ages 2-5 years: 4 mg chewable tablet or oral granules once daily
- Ages 6-23 months: 4 mg oral granules once daily
Timing Considerations 3
- For allergic rhinitis: Take once daily at the same time each day (timing can be individualized, though evening is traditional)
- For asthma: Take once daily in the evening
- For exercise-induced bronchoconstriction: Take at least 2 hours before exercise (do NOT take additional dose if already on daily therapy)
Critical Pitfalls to Avoid
Do not bypass intranasal corticosteroids - The 2017 Joint Task Force provides a strong recommendation against using montelukast as initial therapy when intranasal corticosteroids are appropriate. 1 Five trials clearly demonstrated superior efficacy of intranasal corticosteroids over montelukast. 1
Do not add oral antihistamines to intranasal corticosteroids as initial combination therapy - Evidence shows no advantage of this combination over intranasal corticosteroids alone. 1
Monitor for neuropsychiatric events - Though evidence of causation is conflicting, neuropsychiatric events including mood changes, behavioral changes, and suicidal ideation have been reported with leukotriene antagonists. 2, 5 Counsel patients accordingly.
Recognize onset of action differences - Intranasal corticosteroids take hours to days for full effect (though ciclesonide is faster), while intranasal antihistamines work within minutes. 1 Montelukast shows improvement by the second day of treatment. 2
Special Clinical Scenarios
Patients with Both Asthma and Allergic Rhinitis
For patients with concurrent conditions, montelukast offers dual benefit and may be more appropriate as initial therapy. 2, 4 Take only one dose daily (do not double dose for two conditions). 3
Pregnancy and Renal Impairment
- Pregnancy: Avoid during pregnancy, especially first trimester, due to limited safety data 6
- Renal impairment: No dose adjustment needed for montelukast (unlike levocetirizine which requires adjustment) 6
Real-World Treatment Patterns
Evidence shows most patients with rhinitis self-medicate and use on-demand treatment when symptoms are suboptimally controlled, with poor adherence to guidelines. 1 This behavioral reality should inform shared decision-making about route of administration.