3.3.2 Leukotriene receptor antagonists (LTRAs)

Patients in whom leukotriene receptor antagonists (LTRAs) may be particularly effective are those with aspirin sensitivity, a large exercise induced component to the symptoms, highly atopic eczema, and rhinitis.

Montelukast

• Tablets 10mg (£1.42)
• Chewable tablets sugar free 4mg, 5mg (£1.02 = 4mg, £1.08 = 5mg)
• Granules sachets sugar free 4mg (£6.23)

Indications and dose:

• Prophylaxis of asthma:
  
  • Child 6 months–5 years: 4 mg once daily, dose to be taken in the evening.
  • Child 6–14 years: 5 mg once daily, dose to be taken in the evening.
  • Adults and adolescents 15 years of age and above: 10 mg once daily, dose to be taken in the evening.

Notes

1. Montelukast is not indicated for treatment of an acute deterioration of asthma and should not be used to relieve an attack of acute severe asthma. Montelukast does not necessarily allow a reduction in the existing corticosteroid treatment.
2. Montelukast may be considered if exercise induced asthma is a specific problem in a patient who is otherwise well controlled.
3. Treatment should be trialled – if no benefit seen after 4 weeks, montelukast should be discontinued and alternative treatment options discussed with the patient.
4. Refer to paediatric and adult asthma guidance for further information on the use of montelukast in the management of asthmatic patients.
5. MHRA Drug Safety Update (September 2019): reminder of the risk of neuropsychiatric reactions
   1. be alert for neuropsychiatric reactions in patients taking montelukast; events have been reported in adults, adolescents, and children
   2. advise patients and their caregivers to read carefully the list of neuropsychiatric reactions in the patient information leaflet and seek medical advice immediately should they occur
   3. evaluate carefully the risks and benefits of continuing treatment if neuropsychiatric reactions occur
   4. be aware of newly recognised neuropsychiatric reactions of speech impairment (stuttering) and obsessive–compulsive symptoms.

3.3.3 Phosphodiesterase type-4 inhibitors

Roflumilast

• Tablets 250 micrograms, 500 micrograms

Notes

1. NICE TA461: Roflumilast (Daxas), as an add-on to bronchodilator therapy, is recommended as an option for treating severe chronic obstructive pulmonary disease in adults with chronic bronchitis (July 2017), only if:
   1. the disease is severe, defined as a forced expiratory volume in 1 second (FEV1) after a bronchodilator of less than 50% of predicted normal, and
   2. the person has had 2 or more exacerbations in the previous 12 months despite triple inhaled therapy with a long-acting muscarinic antagonist, a long-acting beta-2 agonist and an inhaled corticosteroid.
   3. Treatment with roflumilast should be started by a specialist in respiratory medicine.