Montelukast Indications
Montelukast is FDA-approved for three primary indications: prophylaxis and chronic treatment of asthma in patients ≥12 months old, prevention of exercise-induced bronchoconstriction in patients ≥15 years old, and relief of allergic rhinitis symptoms (seasonal allergic rhinitis in patients ≥2 years and perennial allergic rhinitis in patients ≥6 months). 1
Asthma Management
- Montelukast serves as chronic preventative therapy for asthma, not for acute symptom relief during asthma attacks 1
- The drug works systemically as a leukotriene receptor antagonist, blocking inflammatory mediators that cause airway smooth muscle contraction, increased vascular permeability, and chemotaxis 2
- Montelukast can be used as monotherapy as an alternative to low-dose inhaled corticosteroids or added to inhaled corticosteroids for enhanced anti-inflammatory effects 3
- The medication demonstrates particular effectiveness in specific asthma phenotypes: exercise-induced asthma, asthma associated with allergic rhinitis, asthma in obese patients, asthma in smokers, aspirin-induced asthma, and viral-induced wheezing 3
Allergic Rhinitis Treatment
- For allergic rhinitis, montelukast is less effective than intranasal corticosteroids and should not be first-line therapy 4
- Montelukast demonstrates similar efficacy to oral antihistamines (particularly loratadine) for controlling rhinitis symptoms 4, 5
- The drug improves all four cardinal nasal symptoms: congestion, rhinorrhea, sneezing, and nasal itching, plus ocular symptoms 6, 7
- Montelukast is FDA-approved for seasonal allergic rhinitis in children as young as 2 years and perennial allergic rhinitis in children as young as 6 months 1, 8
Optimal Clinical Scenarios for Montelukast
Combined Upper and Lower Airway Disease
- Montelukast should be strongly considered as first-line therapy when patients have both asthma and allergic rhinitis, as it addresses both conditions simultaneously 4, 8, 5
- Approximately 40% of allergic rhinitis patients have coexisting asthma, making montelukast particularly valuable in this population 4, 8
Steroid-Averse Patients
- Montelukast provides an effective non-steroidal alternative for families unwilling to use intranasal or inhaled corticosteroids 4, 8, 5
- This is particularly relevant in pediatric populations where parents are "steroid-phobic" 4, 8
Combination Therapy Strategy
- The combination of montelukast with a second-generation antihistamine is superior to either therapy alone for allergic rhinitis 4, 5
- This combination may provide an alternative for patients unresponsive to or non-compliant with intranasal corticosteroids 4
Exercise-Induced Bronchoconstriction
- Montelukast prevents exercise-induced bronchoconstriction in patients ≥15 years old when taken at least 2 hours before exercise 1
- Patients already taking daily montelukast for chronic asthma or allergic rhinitis should not take an additional dose before exercise 1
- No additional dose should be taken within 24 hours of a previous dose 1
Key Clinical Pearls
Dosing and Administration
- Take montelukast once daily in the evening for asthma patients 1
- For allergic rhinitis, take once daily at the same time each day 1
- The medication can be taken with or without food 1
- Onset of action typically occurs by the second day of daily treatment 8
Advantages Over Other Therapies
- Montelukast does not significantly suppress skin tests, allowing allergy testing without medication discontinuation 4, 8, 5
- The safety profile is excellent with minimal side effects, comparable to placebo in pediatric populations 8
Critical Limitations
- Do not use montelukast for acute asthma attacks—patients must always carry inhaled rescue medication 1
- Intranasal corticosteroids remain superior to montelukast for initial treatment of allergic rhinitis in patients without contraindications or special circumstances 4, 8, 5
- Some patients prefer oral agents despite lesser efficacy compared to intranasal corticosteroids 4, 5