Montelukast for chronic asthma in 6- to 14-year-old children: a randomized,
double-blind trial. Pediatric Montelukast Study Group.
JAMA. 1998 Apr 15; 279(15): 1181-1186.
There is compelling evidence in the adult literature on the role of
leucotriene inhibitors in the management of chronic asthma. Zafirlukast (
Accolate) was the first of its kind but only had approval for > 12 years.
Singulair ( Montelukast) is approved over 6 yrs.
It makes sense to use it in chronic pediatric asthma to reduce steroid use
and improve beta agonist responsiveness. I would use it on any child who
has moderate to severe BA needing steroid inhalers for antiinflammatory
purposes. My first option for antiinflammatory action would be cromolyn or
nedocromil inhaler. As you alluded to, even in doses < 400 mcg/day steroid
inhalers have been shown to have systemic effects, especially on growth in
Kids who would particluarly benefit from PO Montelukast would be those
having particular difficulty with inhaler coordination despite use of
spacers or those with nocturnal asthma.
I cannot foresee us initiating this in the ED because we are not following
up these kids for their long term management. However, I am seeing more and
more kids on LTD4 inhibitors coming in with exacerbations, that are
followed by our pulmonologists. Two points to remember are:
1. They are metabolized by the CYP450 system in the liver, hence have
potential drug interactions with azole antifungals, anticonvulsants like
PHT or CMZ, warfarin, cisapride etc
2. There are reports of systemic eosinophilic reactions (fever, rash,
worsened bronchospasm, cardiomyopathy) with Accolate.
Overall their safety profile is excellent.May be the "golden" drugs of the
future in childhood asthma.
Hope this helps. Not sure if this is what you were looking for.
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