Adding Montelukast to Combination Therapy
Yes, you can add montelukast to a patient already using Seretide (fluticasone/salmeterol) and ipratropium/salbutamol, as this represents a guideline-supported step-up strategy for inadequately controlled asthma or COPD. 1
Clinical Context and Rationale
The patient is currently on:
- Seretide (fluticasone + salmeterol): provides inhaled corticosteroid (ICS) + long-acting beta-agonist (LABA) for maintenance control 1
- Ipratropium + salbutamol: provides short-acting muscarinic antagonist (SAMA) + short-acting beta-agonist (SABA) for rescue therapy 1
This combination suggests either moderate-to-severe persistent asthma or COPD with inadequate symptom control, warranting additional controller therapy. 1
Guideline-Based Algorithm for Adding Montelukast
For Asthma Patients
Step 3-4 Asthma Management:
- When patients on low-to-medium dose ICS + LABA (like Seretide) continue experiencing symptoms, adding a leukotriene receptor antagonist is an alternative step-up option 1
- Montelukast can be added to medium-dose ICS + LABA combinations as adjunctive therapy 1
- The typical approach: Medium-dose ICS + LABA + leukotriene receptor antagonist represents a valid Step 4 alternative strategy 1
Mechanism Justification:
- Leukotrienes are pro-inflammatory mediators poorly suppressed by corticosteroids, making leukotriene receptor antagonists a rational add-on with complementary anti-inflammatory effects 2
- Montelukast provides both modest anti-inflammatory and bronchodilating activity through a different pathway than ICS or beta-agonists 1
For COPD Patients
While the evidence is primarily asthma-focused, montelukast can be considered in COPD patients with:
- Overlapping asthma-COPD features
- Persistent symptoms despite optimal bronchodilator therapy
- History suggesting allergic or eosinophilic component 3
Practical Implementation
Dosing:
- Montelukast 10 mg once daily (preferably in the evening) 1, 4
- Continue existing Seretide and ipratropium/salbutamol regimens 1
No drug interactions exist between montelukast and the patient's current medications 4
Timeline for Assessment:
- Montelukast begins producing clinical benefits within 1-2 days of starting therapy 4
- Reassess control after 4-6 weeks to determine if additional step-up is needed 5
Critical Safety Considerations
FDA Black Box Warning:
- Monitor for mood changes, depression, and suicidal thoughts when starting montelukast 4
- Patients should be counseled about potential neuropsychiatric effects before initiation 4
Common Pitfall to Avoid:
- The frequent use of ipratropium/salbutamol (more than 2 days per week for symptom relief) indicates inadequate asthma control and confirms the appropriateness of adding montelukast 1
- If symptoms persist after adding montelukast, consider increasing ICS dose or adding other controllers rather than increasing rescue medication frequency 1
Evidence Comparison
Montelukast vs. Increasing ICS Dose:
- Adding montelukast to low-dose ICS provides an alternative to simply increasing the ICS dose 1
- Both strategies are acceptable, though combination ICS/LABA (already being used) is generally preferred over either option alone 6
Montelukast Added to ICS/LABA:
- Research shows that while fluticasone/salmeterol combination provides superior lung function improvements compared to fluticasone + montelukast, both approaches protect most patients from asthma attacks over a 1-year period 7
- The combination of ICS/LABA + montelukast represents a rational triple-controller strategy for difficult-to-control asthma 7, 2
When NOT to Add Montelukast
Reassess the diagnosis if:
- Patient is using rescue therapy (ipratropium/salbutamol) more than 4-6 times daily despite optimal controller therapy 1
- Consider hospital admission and oral corticosteroids instead 1
For acute exacerbations: