Analysis of behavior-related adverse experiences in clinical trials of montelukast

Montelukast in paediatric asthma and allergic rhinitis: a systematic review and meta-analysis

BACKGROUND

We aim to assess the impact of montelukast on paediatric patients with asthma/allergic rhinitis, measured using patient-reported outcome measures, compared with other treatments or placebo.

METHODS

Protocol registration CRD42020216098 (www.crd.york.ac.uk/PROSPERO). MEDLINE and Embase databases were used to conduct the search. Two authors independently selected studies and extracted data, and a third reviewer resolved discrepancies. Meta-analyses were constructed to estimate the standardised mean difference (SMD) using a random-effects model.

RESULTS

Out of 3937 articles identified, 49 studies met the inclusion criteria, mostly randomised clinical trials (sample sizes: 21-689 patients). The SMD of change pooled estimators for the global, mental and physical domains of health-related quality of life were not statistically significant. For daytime and night-time symptoms scores, the SMD (95% CI) was in favour of inhaled corticosteroids (-0.12, -0.20- -0.05 and -0.23, -0.41- -0.06, respectively). The pooled estimator for global asthma symptoms was better for montelukast when compared with placebo (0.90, 0.44-1.36).

CONCLUSIONS

The synthesis of the available evidence suggests that, in children and adolescents, montelukast was effective in controlling asthma symptoms when compared with placebo, but inhaled corticosteroids were superior in controlling symptoms, especially at night-time. These findings of our systematic review concur with current guidelines for asthma treatment.

The Risk of Neuropsychiatric Adverse Events With Use of Leukotriene Receptor Antagonists in Patients With Asthma: Analysis of Korea's National Health Insurance Sharing Service Database

BACKGROUND

Montelukast, a selective leukotriene receptor antagonist, is a commonly prescribed allergy medication but its potential association with neuropsychiatric adverse events is concerning.

OBJECTIVE

To analyze Korea's National Health Insurance System claims records to identify the risk of neuropsychiatric adverse events in patients with asthma treated with montelukast.

METHODS

This retrospective population-based study analyzed the National Health Insurance claims records of the entire Korean population between 2008 and 2015. We compared the risk of neuropsychiatric adverse events among patients with asthma using inhaled corticosteroids and/or long-acting β2-agonists with montelukast or pranlukast and those not using leukotriene receptor antagonists (control group).

RESULTS

There was no increased risk of the composite outcome of all measured neuropsychiatric adverse events in patients with asthma who were prescribed montelukast or pranlukast compared with those who were not. However, montelukast use was associated with an increased risk of hallucinations (inverse probability treatment weighting hazard ratio, 1.45; 95% CI, 1.07-1.96) and attention problems (inverse probability treatment weighting hazard ratio, 1.24; 95% CI, 1.01-1.52). Significant negative hazards for disorientation, anxiety, stress reactions, and somatic symptoms were observed in the montelukast group. When grouped by sex, the risk of hallucinations and attention problems was higher in men prescribed montelukast compared with the controls.

CONCLUSIONS

We did not observe an increase in all neuropsychiatric adverse events in the leukotriene receptor antagonist-treated group; however, an increased risk of hallucinations and attention problems was observed in those taking montelukast, regardless of the medication administration period.

Neuropsychiatric events associated with montelukast in patients with asthma: a systematic review

BACKGROUND

The United States Food and Drug Administration issued a black box warning on the mental health adverse effects of montelukast in 2020. Age-related effects on the risk of developing specific neuropsychiatric events in montelukast users remain largely unknown.

OBJECTIVE

To describe the risk of neuropsychiatric events associated with montelukast in adults and children with asthma.

METHODS

A systematic search of all studies investigating neuropsychiatric events in montelukast users was performed in PubMed, the Cochrane Library and Embase from inception to 7 September 2022. Animal studies and conference abstracts were excluded.

RESULTS

59 studies (21 pharmacovigilance studies, four reviews from 172 randomised controlled trials, 20 observational studies, 10 case reports and four case series) evaluating neuropsychiatric events in patients with asthma on montelukast were reviewed. No significant association was shown between montelukast and suicide-related events in six of the observational studies. No association was found for depression as defined by the International Classification of Diseases 10th revision codes in three observational studies and a review of randomised clinical trials. However, findings from four studies using antidepressant prescriptions as the outcome identified significant associations. Consistent with nine pharmacovigilance studies, two large-scale observational studies revealed possible associations of montelukast with anxiety and sleeping disorders in adult patients with asthma, respectively. However, the results were not replicated in two observational studies on children.

CONCLUSION

Montelukast is not associated with suicide- and depression-related events in asthma patients. Older adults may be particularly susceptible to anxiety and sleeping disorders.

Highlights of the treatment of allergic rhinitis according to Chinese guidelines

PURPOSE OF REVIEW

This review aimed to introduce the pharmacotherapy of allergic rhinitis according to the 2022 updated Chinese guidelines.

RECENT FINDINGS

Despite recent advances in basic and clinical research worldwide, pharmacotherapy remains a mainstream in allergic rhinitis treatment. Usually, the first-line drugs, involving intranasal corticosteroids, second-generation oral and intranasal H1-antihistamines, or leukotriene receptor antagonists, can achieve acceptable outcomes in the treatment of allergic rhinitis. The second-line drugs, such as oral corticosteroids, intranasal decongestants and intranasal anticholinergics, can assist in controlling severe symptoms, like nasal congestion/blockage and watery rhinorrhea. For those with moderate-to-severe allergic rhinitis, evidence-based stepwise strategies are suitable, in which the types and dosages of drugs are de-escalated or upgraded according to their therapeutic efficacy. Meanwhile, omalizumab, a novel biological agent, has burgeoned to satisfy the need of patients.

SUMMARY

This review highlights the staples in Chinese guidelines about the pharmacotherapy for allergic rhinitis to better understand the guidelines and promote the clinical practice.

Evaluating the Association of Montelukast Use on Neuropsychiatry-Related Healthcare Utilization and Depression in COVID-19-Hospitalized Veterans: A Nationwide VA Observational Cohort Study

BACKGROUND

Montelukast's new boxed warning for neuropsychiatric events questions its use in the setting of coronavirus disease 2019 (COVID-19) due to increased risk for new-onset psychiatric diagnoses.

OBJECTIVE

We aim to evaluate the impact of using montelukast in patients hospitalized with COVID-19 on neuropsychiatry-related healthcare utilization and depression.

METHODS

This retrospective nationwide observational cohort study using the Veterans Health Administration database included patients from January 1, 2020, through July 1, 2021. The treatment cohorts consisted of patients with and without montelukast use prior to COVID-19 hospitalization and matched using propensity score (PS) to two control cohorts: patients with COVID-19-related hospitalization without prior montelukast use and patients with prior montelukast use who were hospitalized for reasons other than COVID-19. The primary outcome of psychiatric hospitalizations at 90 days and 180 days and mental health visits at 180 days were compared using Poisson or negative binomial regression. Secondary outcomes of new-onset depression and new use of antidepressants were analyzed using multivariable logistic regression.

RESULTS

After PS matching, a total of 415 patients were included in COVID-19 with and without montelukast matched cohort and 409 patients in montelukast with and without COVID-19-related hospitalization matched cohorts. For the primary outcomes, inpatient psychiatric hospitalization at 90 days [incidence rate ratio (IRR) 95% CI 1.79 (1.36-2.36)] and 180 days [IRR 95% CI 1.79 (1.32-2.25)] and mental health visits at 180 days [IRR 95% CI 1.72 (1.45-2.03)] were significantly higher in the montelukast with COVID-19 hospitalization group compared with those hospitalized without COVID-19. No difference in primary outcomes were noted in patients hospitalized with COVID-19 with and without use of montelukast. No significant difference was found in the secondary outcomes between either comparator group.

CONCLUSIONS

Patients with prior montelukast use who were hospitalized with COVID-19 appeared to have increased rate of neuropsychiatry-related healthcare utilization.

Psychiatric Adverse Effects of Montelukast-A Nationwide Cohort Study

BACKGROUND

Recent observational studies suggest that the leukotriene receptor antagonist montelukast may have neuropsychiatric adverse effects; however, results are conflicting.

OBJECTIVE

To assess whether montelukast exposure in adults with asthma is associated with onset of neuropsychiatric adverse events using data from the Danish nationwide health registers.

METHODS

Individuals 18 years old or older with either 1 or more prescription redemption of inhaled corticosteroids or with at least 1 hospital contact with asthma as the main diagnosis between January 1, 2011, and December 31, 2018, were included. Montelukast exposure was assessed as a time-dependent variable. The 2 outcomes of interest were use of neuropsychiatric medicine including antidepressants, antipsychotics, anxiolytics, lithium, and medication used for attention-deficit/hyperactivity disorder (outcome 1), and hospital contacts with a neuropsychiatric diagnosis (outcome 2), within 90 days of exposure to montelukast.

RESULTS

Initiation of montelukast was significantly associated with outcome 1: use of neuropsychiatric medicine (hazard ratio [95% confidence interval]) 1.14 [1.08-1.20]; P < .0001). In the assessment of outcome 2: hospital contacts with a neuropsychiatric diagnosis, a significant risk associated with montelukast initiation was found only in the youngest age groups (hazard ratio [95% confidence interval] 1.28 [1.12-1.47], P < .001 and 1.16 [1.02-1.31]; P < .05, for age group 18-29 y and 30-44 y, respectively). Age-stratified analyses showed that the risk of both outcomes increased with decreasing age, with the highest risk seen in patients aged 18 to 29 years.

CONCLUSIONS

Among younger individuals, montelukast use was significantly associated with an increased risk of neuropsychiatric events such as use of neuropsychiatric medicine and hospital treatment. Clinicians should increase awareness of such adverse effects when prescribing montelukast.

Leukotriene Receptor Antagonists and Risk of Neuropsychiatric Entities: A Meta-Analysis of Observational Studies

BACKGROUND

Leukotriene receptor antagonists (LTRAs) are commonly prescribed to patients with allergic diseases. Several case reports and pharmacovigilance studies have indicated that LTRAs might increase the risk of neuropsychiatric (NP) entities. However, the results are mixed in observational studies. Thus, the association between LTRAs and NP entities remains controversial.

OBJECTIVE

To quantitatively evaluate the NP risk with LTRAs based on current observational studies to provide a reference for clinical practice.

METHODS

We systematically reviewed the literature in Medline, Embase, Web of Science, Cochrane Library, Scopus, and PsycINFO. A meta-analysis of observational studies that investigated the association between LTRA use and the risk of NP entities was performed. Odds ratios (OR) with 95% confidence intervals (CI) were used to measure the effect; heterogeneity was evaluated using I-squared (I²) statistics. Subgroup and sensitivity analyses were conducted to assess bias.

RESULTS

Eleven articles were included in the primary analysis. No significant association was found between LTRA use and NP entities (OR: 1.08, 95% CI: 0.93-1.24, I² = 93.7%). In patients with allergic rhinitis (AR), a mildly increased NP risk was found (OR: 1.099, 95% CI: 1.004-1.202). The association between LTRA use and NP entities was not significant in patients with asthma (OR: 1.06, 95% CI: 0.90-1.26). LTRAs increased the risk of NP entities in a single study using data from an asthma clinic (OR: 9.00, 95% CI: 1.20-69.50), but not in studies from databases (OR: 1.07, 95% CI: 0.93-1.23).

CONCLUSION

At the population level, LTRAs and NP entities were unrelated. However, the association may exist in particular groups (eg, patients with AR or NP history). Subject-specific studies are required to further examine the relationship between LTRAs and NP entities and identify the underlying mechanisms.

Adverse drug reactions affecting treatment adherence in first-line treatment of asthma: An observational study

BACKGROUND

Asthma is the most common chronic lung disease among children. International guidelines recommend inhaled corticosteroids (ICS) as the first-line daily controller therapy for children with asthma and leukotriene receptor antagonists (LTRA) as the second alternative therapy. Adherence to treatment is the most significant component to optimize the benefits of therapy in asthma.

OBJECTIVE

This study aims to investigate the frequency of drug discontinuation due to adverse drug reactions (ADRs) that affect adherence to treatment in children with asthma or asthma and allergic rhinitis using LTRA or ICS as monotherapy.

METHODS

The subjects aged 4-18 years with asthma or asthma and allergic rhinitis and using montelukast or ICS as monotherapy were included in the study. They were evaluated in terms of ADRs affecting adherence to treatment in the first and third months of treatment.

RESULTS

A total of 468 cases, 356 of whom received montelukast monotherapy and 112 of whom received ICS treatment, with a mean age of 9.10 ± 3.08 (4-17) years, were included in the study. Males constituted 65.6% of the total cases (n = 307). In the first month of follow-up of the cases, it was observed that 4.8% (n = 17) of the patients in the montelukast group could not continue the treatment due to ADR. It was determined that the drug discontinuation rate in the montelukast group in the first month was significantly higher than in the ICS group (P = 0.016), and the risk of drug discontinuation due to ADR in the montelukast group was 1.333 (95% CI, 1.26-1.40) times higher.

CONCLUSIONS

As a result, it was observed that the drug was discontinued due to ADR at a higher rate in children with asthma who received montelukast monotherapy compared to those who received ICS monotherapy.

Diagnosis and management of asthma in infants and preschoolers

Asthma is one of the most common chronic disease affecting children, and it often starts in infancy and preschool years. In previous birth cohorts, frequent wheezing in early life was associated with the development of asthma in later childhood and reduced lung function persisting into adulthood. Preschool wheezing is considered an umbrella term for distinctive diseases with different clinical features (phenotypes), each of which may be related to different underlying pathophysiologic mechanisms (endotypes). The classification of phenotypes of early wheezing is needed to identify children at high risk for developing asthma later who might benefit from early intervention. However, diagnosis of asthma in infants and preschoolers is particularly difficult because objective lung function tests cannot be performed and definitive biomarkers are lacking. Moreover, management of early asthma is challenging because of its different phenotypic presentations. Many prediction models and asthma guidelines have been developed to provide useful information for physicians to assess young children with recurrent wheezing and manage them appropriately. Many recent studies have investigated the application of personalized medicine for early asthma by identifying specific phenotypes and biomarkers. Further researches, including genetic and molecular studies, are needed to establish a clear definition of asthma and develop more targeted therapeutic approaches in this age group.

Adverse Drug Reactions (ADRs) of Montelukast in Children

Montelukast is a leukotriene receptor antagonist (LTRA) commonly prescribed for asthma, allergic rhinitis and sleep-related breathing disorders. Recently, some studies have reported several adverse events, such as neuropsychiatric disorders and sleep disturbances, among children.

OBJECTIVE

To obtain more insight into the safety profile of montelukast for children with asthma, allergic rhinitis and sleep-related breathing disorders.

METHOD AND RESULTS

We retrospectively studied all adverse drug reactions to montelukast among 385 children 6 months or older in six tertiary centers over a two-year period. A total of 89.6% were asthmatic, 50% had allergic rhinitis and 13.6% had sleep-related breathing disorders; Singulair was the most common type of montelukast used (67.9%). This study reported a high prevalence of adverse drug reactions among 123 patients (31.9%), predominantly in those aged 4-9 years (52.8%), followed by adolescents (24.4%) and toddlers (22.8%). Two (ADRs) were reported in 9.8% of the children, while three or more were reported in 5.5%. Sleep disturbance was the most common (ADRs), affecting 15.1% of participants (overlap was common; 5.5% of children experienced sleep difficulties, 4.4% experienced sleep interruption and decreased sleep, and 1.82% experienced nightmares), followed by agitation (10.4%), pain (9.4%) and hyperactivity (6.8%). No serious (ADRs) were reported. Eleven percent of families faced difficulties in purchasing montelukast, and only 57% of families had insurance. Misconceptions were common (9.8% reported it to be a steroid, while 30.6% believed it to be a bronchodilator). Although 81% of the families believed it was an effective and preventive medication, 5.3% stopped the drug due to concern about side effects, especially agitation (3%) and nightmares (0.6%).

CONCLUSION

These data demonstrate that montelukast is effective, but the associated adverse neuropsychiatric drug reactions are more prevalent than those reported in the literature. In particular, sleep disturbance, agitation, pain and hyperactivity were observed. Pediatricians should be aware of such (ADRs). Misconceptions about montelukast are still common, and parental counseling and urgent epidemiological studies are needed to quantify the risk for management plans.

Montelukast and Nightmares: Further Characterisation Using Data from VigiBase

INTRODUCTION

Montelukast is a medicine indicated for use in asthma. Psychiatric disorders including nightmares have not been described in clinical trials but during recent years have been included in the product information as having been reported post-marketing, without further description of the events. Previous descriptions in the scientific literature were based on limited numbers of reports or lacked detailed case information.

OBJECTIVE

The study aim was to further characterise post-marketing adverse drug reactions for nightmares, suspected to be induced by montelukast, to facilitate safer use of the medicine by providing additional information to patients and healthcare professionals.

METHODS

We clinically reviewed reports of nightmares with montelukast present in VigiBase, World Health Organization's global database of suspected adverse reactions to medicinal products, developed and maintained by the Uppsala Monitoring Centre, until 3 May, 2020.

RESULTS

There were 1118 reports of nightmares with montelukast in VigiBase, which provided valuable descriptions of the nightmares as well as information about the impact on the daily lives, with many cases describing a severe impact of the nightmares. About half of the reports were classified as serious. Two thirds concerned children, with the largest age group represented being children aged 5-10 years. In most cases, the nightmares disappeared upon discontinuation of the drug but for some patients it took a long time until the nightmares ceased.

CONCLUSIONS

The nature and potential severity of this adverse drug reaction, as described in these reports, present important knowledge for patients and healthcare providers that could help reduce drug-induced harm. This study highlights the value of post-marketing reports for further characterisation of known adverse drug reactions. The benefit-risk balance should be continuously monitored while patients are taking montelukast.

Analysis of Neuropsychiatric Diagnoses After Montelukast Initiation

IMPORTANCE

The evidence base for the association between montelukast and adverse neuropsychiatric outcomes is mixed and inconclusive. Several methodological limitations have been identified in the evidence base on the safety of montelukast in observational studies.

OBJECTIVE

To investigate the association between new montelukast exposure and 1-year incident neuropsychiatric diagnoses with improved precision and control for baseline confounders.

DESIGN, SETTING, AND PARTICIPANTS

This propensity score-matched cohort study was conducted using electronic health records from 2015 to 2019 in the TriNetX Analytics Network patient repository of more than 51 million patients from 56 health care organizations, mainly in the US. Included patients were those aged 15 to 64 years at index prescription for montelukast or for control prescription who had a history of asthma or allergic rhinitis. After propensity score matching for various baseline confounders, including comorbidities and dispensed prescription medicines, we included 154 946 patients, of whom 77 473 individuals were exposed to montelukast. Patients were followed up for 12 months. Data were analyzed from June through November 2021.

EXPOSURES

New dispensed prescription for leukotriene receptor antagonist montelukast or control medication.

MAIN OUTCOMES AND MEASURES

Incident neuropsychiatric diagnoses at 12 months identified using International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes.

RESULTS

There were 72 490 patients with asthma (44 726 [61.7%] women; mean [SD] age at index prescription, 35 [15] years) and 82 456 patients with allergic rhinitis (54 172 [65.7%] women; mean [SD] age at index prescription, 40 [14] years). In patients exposed to montelukast, the odds ratio [OR] for any incident neuropsychiatric outcome was 1.11 (95% CI, 1.04-1.19) in patients with asthma and 1.07 (95% CI, 1.01-1.14) in patients with allergic rhinitis compared with patients who were unexposed. The highest OR was for anxiety disorders (OR, 1.21; 95% CI, 1.05-1.20) among patients with asthma exposed to montelukast and insomnia (OR, 1.15; 95% CI, 1.05-1.27) among patients with allergic rhinitis exposed to montelukast.

CONCLUSIONS AND RELEVANCE

This study found that patients with asthma or allergic rhinitis had increased odds of adverse neuropsychiatric outcomes after montelukast initiation. These findings suggest that clinicians should consider monitoring potential adverse mental health symptoms during montelukast treatment, particularly in individuals with a history of mental health or sleep problems.

Neuropsychiatric Adverse Events of Montelukast: An Analysis of Real-World Datasets and drug-gene Interaction Network

Montelukast is a selective leukotriene receptor antagonist that is widely used to treat bronchial asthma and nasal allergy. To clarify the association between montelukast and neuropsychiatric adverse events (AEs), we evaluated case reports recorded between January 2004 and December 2018 in the Food and Drug Administration Adverse Event Reporting System (FAERS). Furthermore, we elucidated the potential toxicological mechanisms of montelukast-associated neuropsychiatric AEs through functional enrichment analysis of human genes interacting with montelukast. The reporting odds ratios of suicidal ideation and depression in the system organ class of psychiatric disorders were 21.5 (95% confidence interval (CI): 20.3–22.9) and 8.2 (95% CI: 7.8–8.7), respectively. We explored 1,144 human genes that directly or indirectly interact with montelukast. The molecular complex detection (MCODE) plug-in of Cytoscape detected 14 clusters. Functional analysis indicated that several genes were significantly enriched in the biological processes of “neuroactive ligand–receptor interaction.” “Mood disorders” and “major depressive disorder” were significant disease terms related to montelukast. Our retrospective analysis based on the FAERS demonstrated a significant association between montelukast and neuropsychiatric AEs. Functional enrichment analysis of montelukast-associated genes related to neuropsychiatric symptoms warrant further research on the underlying pharmacological mechanisms.

Levocetirizine and montelukast in the COVID-19 treatment paradigm

Levocetirizine, a third-generation antihistamine, and montelukast, a leukotriene receptor antagonist, exhibit remarkable synergistic anti-inflammatory activity across a spectrum of signaling proteins, cell adhesion molecules, and leukocytes. By targeting cellular protein activity, they are uniquely positioned to treat the symptoms of COVID-19. Clinical data to date with an associated six-month follow-up, suggests the combination therapy may prevent the progression of the disease from mild to moderate to severe, as well as prevent/treat many of the aspects of ‘Long COVID,’ thereby cost effectively reducing both morbidity and mortality. To investigate patient outcomes, 53 consecutive COVID-19 test (+) cases (ages 3–90) from a well-established, single-center practice in Boston, Massachusetts, between March – November 2020, were treated with levocetirizine and montelukast in addition to then existing protocols [2]. The data set was retrospectively reviewed. Thirty-four cases were considered mild (64%), 17 moderate (32%), and 2 (4%) severe. Several patients presented with significant comorbidities (obesity: n = 22, 41%; diabetes: n = 10, 19%; hypertension: n = 24, 45%). Among the cohort there were no exclusions, no intubations, and no deaths. The pilot study in Massachusetts encompassed the first COVID-19 wave which peaked on April 23, 2020 as well as the ascending portion of the second wave in the fall. During this period the average weekly COVID-19 case mortality rate (confirmed deaths/confirmed cases) varied considerably between 1 and 7.5% [37]. FDA has approved a multicenter, randomized, placebo-controlled, Phase 2 clinical trial design, replete with electronic diaries and laboratory metrics to explore scientific questions not addressed herein.

Investigation of the relationship between chronic montelukast treatment, asthma and depression-like behavior in mice

In 2008, the Food and Drug Administration of the US issued a warning about the neuropsychiatric side effects of montelukast. Previous clinical studies on montelukast have reported conflicting results and, to the best of our knowledge, no experimental studies concerning these side effects had been conducted. In the current study, the effect of montelukast on depression-like behavior in an ovalbumin (OVA)-induced mouse model was investigated. A total of 3 OVA challenges were applied at 2 week intervals for the persistence of asthma. Depression-like behavior was assessed using forced swim tests following each challenge and locomotor activities were evaluated using open field tests. At the end of the current study, plasma montelukast concentrations were measured and the development of asthma and effect of montelukast treatment were histopathologically examined. Inflammation scores that were increased in the OVA mice following all challenges were indicated to be reduced by montelukast treatment. The immobility time of mice increased beginning with the first challenge and this was also reduced by montelukast treatment. Montelukast administration to the control mice did not alter immobility times. Moreover, motor activity of the OVA and montelukast-treated mice were not altered. The results indicated there was no association between chronic montelukast treatment and depression. Furthermore, the chronic administration of montelukast to non-asthmatic mice did not increase immobility. However, depressive behavior increased at all time points in the OVA mice. These results indicated that chronic montelukast treatment is not associated with depression-like behavior and confirmed the association between asthma and depression. Further studies are required to provide an improved understanding of the neuropsychiatric side effects of montelukast.

Risk of Psychiatric Adverse Events Among Montelukast Users

BACKGROUND

There have been conflicting results from observational studies regarding the risk of psychiatric adverse events (PAEs) with montelukast use.

OBJECTIVE

To determine whether there are associations of depressive disorders, self-harm, and suicide with use of montelukast compared with inhaled corticosteroid (ICS) use.

METHODS

Using data from the Sentinel Distributed Database from January 1, 2000, to September 30, 2015, patients (n = 457,377) exposed to montelukast or ICS, aged 6 years and older with a diagnosis of asthma, were matched 1:1 on propensity scores. Hazard ratios (HRs) and 95% CIs were estimated for each study outcome overall and by age, sex, psychiatric history, and pre-/post-2008 labeling updates using Cox proportional hazards regression models.

RESULTS

Exposure to montelukast was associated with a lower risk of treated outpatient depressive disorder (HR, 0.91; 95% CI, 0.89-0.93). No increased risks of inpatient depressive disorder (HR, 1.06; 95% CI, 0.90-1.24), self-harm (HR, 0.92; 95% CI, 0.69-1.21), or self-harm using a modified algorithm (HR, 0.81; 95% CI, 0.63-1.05) were observed with montelukast use compared with ICS use. Most PAEs occurred in the roughly one-third of patients having a past psychiatric history.

CONCLUSIONS

When compared with use of ICS, we did not find associations between montelukast use and hospitalizations for depression or self-harm events. Our findings should be interpreted considering the study's limitations. Psychiatric comorbidity was common, and most PAEs occurred in patients with a past psychiatric history.

Probiotics, prebiotics, and synbiotics for the treatment of asthma: Protocol for a systematic review

BACKGROUND

Asthma is a common chronic disease with heavy burden. The number of asthma patients may continue to grow in the next 10 years. Existing conventional treatments have problems in which a small number of patients do not respond, often accompanied by side effects, or are too expensive. Probiotics, prebiotics, and synbiotics have been widely used in allergic and inflammatory diseases including asthma. However, their effectiveness and safety are still obscure and deserve further investigation.

OBJECTIVE

To assess the effect and safety of probiotics, prebiotics, and synbiotics in treating asthma.

METHODS

We will summarize and meta-analyze randomized controlled trials (RCTs) of probiotics, prebiotics, and synbiotics for the treatment of asthma. RCTs comparing probiotics, prebiotics, and synbiotics with blank control, placebo, or conventional therapies will be included. RCTs comparing probiotics, prebiotics, and synbiotics plus conventional therapies with conventional therapies alone will also be included. The following electronic databases will be searched: PubMed, Cochrane Library, EMBASE, China National Knowledge Infrastructure Database, Chinese Biomedical Literature Database, VIP Chinese Science and Technology Periodical Database, and Wanfang Data. The methodological quality of RCTs will be assessed using the Cochrane risk assessment tool. All trials included will be analyzed according to the criteria of the Cochrane Handbook. Review Manager 5.3, R-3.5.1 software will be used for publication bias analysis. Grading of recommendations assessment, development, and evaluation pro GDT web solution will be used for evidence evaluation.

RESULTS

This review will evaluate the effects of probiotics, prebiotics, and synbiotics on symptoms, lung function, asthma exacerbations, quality of life, and safety in patients with asthma.

CONCLUSIONS

This review will provide clear evidence to assess the effectiveness and safety of probiotics, prebiotics, and synbiotics for asthma.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/V7DM9.

Allergy and the Pediatric Otolaryngologist

Food allergy and allergic rhinitis are childhood diseases with special relevance to the pediatric otolaryngologist. Much of the diagnosis of food allergy can be made on history alone; strict avoidance is the mainstay treatment. Skin prick testing and serum-specific IgE testing play a stronger role in allergic rhinitis diagnosis. If pharmacotherapy fails, allergen immunotherapy is an option. Currently, there is intense investigation on diagnostic tests, novel treatments, and prevention strategies that could dramatically affect the way these diseases are identified and managed. This article summarizes the epidemiology, pathophysiology, diagnosis, and management of food allergy and allergic rhinitis.

Montelukast and Neuropsychiatric Events in Children with Asthma: A Nested Case-Control Study

OBJECTIVE

To examine the association between montelukast prescription and neuropsychiatric events in children with asthma.

STUDY DESIGN

A matched, nested case-control design was used to identify cases and controls from a cohort of children aged 5-18 years with physician-diagnosed asthma from 2004 to 2015, in Ontario, Canada, prescribed an asthma maintenance medication. Cases were children with a hospitalization or emergency department visit for a neuropsychiatric event. Cases were matched to up to 4 controls on birth year, year of asthma diagnosis, and sex. The exposures were dispensed prescriptions for montelukast (yes/no) and number of dispensed montelukast prescriptions in the year before the index date. Conditional logistic regression was used to measure the unadjusted OR and aOR and 95% CIs for montelukast prescription and neuropsychiatric events. Covariates in the adjusted model included sociodemographic factors and measures of asthma severity.

RESULTS

In total, 898 cases with a neuropsychiatric event and 3497 matched controls were included. Children who experienced a new-onset neuropsychiatric event had nearly 2 times the odds of having been prescribed montelukast, compared with controls (OR 1.91, 95% CI 1.15-3.18; P = .01). Most cases presented for anxiety (48.6%) and/or sleep disturbance (26.1%).

CONCLUSIONS

Children with asthma who experienced a new-onset neuropsychiatric event had nearly twice the odds of having been prescribed montelukast in the year before their event. Clinicians should be aware of the association between montelukast and neuropsychiatric events in children with asthma, to inform prescribing practices and clinical follow-up.

Neuropsychiatric Events Associated with Leukotriene-Modifying Agents: A Systematic Review

INTRODUCTION

Leukotriene-modifying agents (LTMAs) including montelukast, zafirlukast, and zileuton are approved by the US Food and Drug Administration (FDA) for the treatment of asthma and allergic rhinitis. Various neuropsychiatric events (NEs) have been reported; however, the evidence of the association is conflicting. This systematic review investigates the association between NEs and LTMAs by assessing the relevant published literature.

METHODS

PubMed, EMBASE, MEDLINE, and Cochrane Library were searched using keywords. Studies designed to investigate the association were eligible for inclusion without restriction to any study design or language. The primary outcome was defined as suicidal conditions, while secondary outcomes included all other NEs.

RESULTS

Thirty-three studies were included for a narrative review. Four observational studies did not find a significant association, while ten pharmacovigilance studies using different global databases detected the signals. Notably, some studies suggest that the FDA warning issued in 2008 might have influenced the reporting rate of NEs as a result of increased awareness.

LIMITATIONS

The risk of NEs was not quantified, because of the lack of randomized controlled trials and observational studies investigating the association.

CONCLUSION

Many pharmacovigilance studies have been conducted to determine the association between NEs and LTMAs, but there is limited evidence from observational studies. High-quality epidemiological studies should be conducted to evaluate the association and quantify the risk, not only in children, but also in adults.

Benefits and Risks of Long-Term Asthma Management in Children: Where Are We Heading?

International guidelines provide recommendations for a stepwise approach to the management of asthma in children 0-4 years old, 5-11 years old, and adolescents who are treated as adults. Therapy is aimed at two domains of control: current impairment and future risk. The long-term controller medications, inhaled corticosteroids (ICSs), ICSs in combination with long-acting β₂ agonists, leukotriene receptor antagonists, and immunomodulators, exhibit different efficacies for these domains. The risk:benefit ratios of the available medications need to be carefully assessed. This review briefly presents the benefits and the potential risks of available asthma medications in children to assist the practitioner in the optimal use of asthma medications. Specifically, the systemic activity of the ICSs and how to minimize their effects on growth and adrenal activity are reviewed as well as other potential adverse effects. Dosing strategies such as intermittent therapy are also assessed.

Using the affective bias test to predict drug-induced negative affect: implications for drug safety

Background and Purpose

Predicting the risk of drug‐induced adverse psychiatric effects is important but currently not possible in non‐human species. We investigated whether the affective bias test (ABT) could provide a preclinical method with translational and predictive validity.

Experimental Approach

The ABT is a bowl‐digging task, which quantifies biases associated with learning and memory. Rats encounter independent learning experiences, on separate days, under either acute manipulations (e.g. pro‐depressant vs. control) or different absolute reward values (e.g. high vs. low). A bias is observed during a preference test when an animal's choices reflect their prior experience. We investigated the effects of putative pro‐depressant drug treatments following acute or chronic administration on the formation of an affective bias or reward‐induced positive bias respectively.

Key Results

The immunomodulators LPS (10 μg·kg⁻¹), corticosterone (10 and 30 mg·kg⁻¹) and IFN‐α (100 U·kg⁻¹) induced a negative affective bias following acute treatment. Tetrabenazine (1 mg·kg⁻¹) also induced a negative bias, but no effects were observed with varenicline, carbamazepine or montelukast. Chronic treatment with IFN‐α (100 U·kg⁻¹) and retinoic acid (10 mg·kg⁻¹) impaired the formation of a reward‐induced positive bias but did not alter sucrose preference test (SPT).

Conclusions and Implications

The ABT has the potential to provide a novel approach to predict pro‐depressant risk in a non‐human species. Negative biases induced by acute treatment in the standard version of the task may also predict longer‐term effects on reward processing as shown by the deficit in reward‐induced positive bias following chronic treatment, an effect distinct from anhedonia in the SPT.

Linked Articles

This article is part of a themed section on Pharmacology of Cognition: a Panacea for Neuropsychiatric Disease? To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.19/issuetoc

Neuropsychiatric adverse drug reactions in children initiated on montelukast in real-life practice

Although montelukast is generally well tolerated, postmarketing studies have reported serious neuropsychiatric adverse drug reactions (ADRs) leading to a United States Food and Drug Administration black box warning. The objective of this study was to determine the incidence of neuropsychiatric ADRs leading to discontinuation of montelukast in asthmatic children.We conducted a retrospective cohort study in children aged 1-17 years initiated on montelukast. In a nested cohort study, children initiated on montelukast as monotherapy or adjunct therapy to inhaled corticosteroids (ICS) were matched to those initiated on ICS monotherapy. A non-leading parental interview served to ascertain the occurrence of any ADRs with any asthma medication, and circumstances related to, and evolution of, the event.Out of the 106 participants who initiated montelukast, most were male (58%), Caucasian (62%) with a median (interquartile range) age of 5 (3-8) years. The incidence (95% CI) of drug cessation due to neuropsychiatric ADRs was 16 (10-26)%, mostly occurring within 2 weeks. Most frequent ADRs were irritability, aggressiveness and sleep disturbances. The relative risk of neuropsychiatric ADRs associated with montelukast versus ICS was 12 (2-90).In the real-life setting, asthmatic children initiated on montelukast experienced a notable risk of neuropsychiatric ADRs leading to drug cessation, that is significantly higher than that associated with ICS.

Adverse events are rare after single-dose montelukast exposures in children

STUDY OBJECTIVE

Montelukast sodium is a leukotriene-receptor antagonist approved as a controller medication for chronic asthma and allergic rhinitis in children and adults. We sought to characterize adverse events associated with single montelukast exposures in children ages 5-17 years and to determine whether adverse events were dose related for all-dose and for ultra-high-dose (≥50 mg) exposures.

METHODS

This is a retrospective analysis of data from the National Poison Data System for exposures that included montelukast in individuals aged 5-17 years for calendar years 2000-2016. Filters were applied to identify exposure events in which montelukast was the primary exposure and for which the exact or lowest-possible ingested dose was recorded. Characteristics of adverse events were examined using descriptive statistics and multivariable logistic models were used to examine whether associations of montelukast and adverse events were dose related.

RESULTS

During the 17-year study period, there were 17,069 montelukast exposures available for analyses. Patients were median [interquartile range] age 7 (5, 9) years, and 10,907 (64%) male gender. Abdominal pain was the most common adverse event (0.23%). There were 618 ultra-high-dose exposures (≥50 mg). These patients had median age 6 (5, 8) years, and 347 (56%) male gender. Abdominal pain was the most common adverse event (1.46%). Increasing ingested dose was associated with abdominal pain (adjusted odds ratio, 1.01, 95% confidence interval 1.01, 1.02) after adjustment for age and gender. No serious or life-threatening events were reported.

CONCLUSIONS

Single-dose exposures of montelukast up to 445 mg are rarely associated with any adverse events and are not associated with serious or life-threatening adverse events in children aged 5-17 years.

Lipid Mediators of Allergic Disease: Pathways, Treatments, and Emerging Therapeutic Targets

Bioactive lipids are critical regulators of inflammation. Over the last 75 years, these diverse compounds have emerged as clinically-relevant mediators of allergic disease pathophysiology. Animal and human studies have demonstrated the importance of lipid mediators in the development of asthma, allergic rhinitis, urticaria, anaphylaxis, atopic dermatitis, and food allergy. Lipids are critical participants in cell signaling events which influence key physiologic (bronchoconstriction) and immune phenomena (degranulation, chemotaxis, sensitization). Lipid-mediated cellular mechanisms including: (1) formation of structural support platforms (lipid rafts) for receptor signaling complexes, (2) activation of a diverse family of G-protein coupled receptors, and (3) mediating intracellular signaling cascades by acting as second messengers. Here, we review four classes of bioactive lipids (platelet activating factor, the leukotrienes, the prostanoids, and the sphingolipids) with special emphasis on lipid synthesis pathways and signaling, atopic disease pathology, and the ongoing development of atopy treatments targeting lipid mediator pathways.

Montelukast in the treatment of perennial allergic rhinitis in paediatric Japanese patients; an open-label clinical trial

Background: This study was conducted to evaluate the safety and tolerability, and population pharmacokinetics (PPK) of montelukast as well as efficacy in the treatment of perennial allergic rhinitis (PAR) in paediatric Japanese patients aged between 1 and 15 years. Methods: In this multi-centre, open-label trial, 87 paediatric Japanese patients with PAR received montelukast 4 mg oral granules (OG) for 4 weeks (1-5-year-olds, N = 15), 4 mg OG for 12 weeks (1-5-year-olds, N = 36), 5 mg chewable tablets (CT) for 12 weeks (6-9-year-olds, N = 18), or 5 mg CT for12 weeks (10-15-year-olds, N = 18). Clinical exams and laboratory assessments were conducted at study visits, and adverse events (AE) were monitored throughout the study up to 14 days after the last visit. Population pharmacokinetic approach was used to estimate AUC0-∞, Cmax, Tmax and apparent elimination half-life in each age group. Efficacy was assessed based on global evaluations by the subject's caregiver. Results: There were no serious AEs and one discontinuation due to an AE. The most common AEs in any of the treatment groups were nasopharyngitis, pharyngitis, and acute sinusitis. Montelukast exposure (AUC0-∞) was similar in the 1-5-year-old group and the 6-9-year-old group, but 19% lower in the 10-15-year-old group. Among all patients, the total proportion of patients whose global evaluation was "very much better" was 5.7% (week 2), 11.5% (week 4), and 16.9% (week 12) reflecting improvement in symptoms over time. Conclusion: Montelukast was generally well tolerated in Japanese children with PAR. AUC0-∞was similar in 1-5 and 6-9-year-olds, while a lower exposure was observed in the 10-15-year-old group likely due to differences in bodyweight. The exposure in Japanese paediatric patients was generally consistent with that in non-Japanese paediatric and adult patients. As assessed by the patients' caregivers, montelukast also demonstrated symptomatic improvement based on global evaluations of PAR.

Asthma Review for Pharmacists Providing Asthma Education

Asthma is the most common pediatric illness affecting more than 6 million children in the United States. Children with asthma have more frequent office visits and hospitalizations compared with adults. Despite advances in therapies, asthma still has a significant effect on the health care system. Regardless of the setting, pharmacists are uniquely equipped with an intimate knowledge of medications. With this knowledge, they can provide education to patients at various points throughout the health care system, from hospitalization to office visits to point of pick up at the pharmacy. The goal of this article is to equip the pharmacist with the necessary knowledge to provide education to these patients in a variety of practice settings, including community pharmacies, ambulatory care settings, and during transitions in care.

Effects of academic exam stress on nasal leukotriene B4 and vascular endothelial growth factor in asthma and health

OBJECTIVE

To examine the effect of final exam stress on the concentrations of leukotriene B4 (LTB4) and vascular endothelial growth factor (VEGF) in the upper airways among healthy and asthmatic individuals.

METHOD

Nasal samples were collected from 12 individuals with asthma and 23 healthy controls early and late in a final exam period, and during a low-stress period in the semester. We determined LTB4 and VEGF concentrations using Enzyme-Linked Immunoassays.

RESULTS

Mixed effects analysis of variance models showed that asthmatic participants with allergies in contrast to healthy individuals experienced a decrease in nasal LTB4 during the final exam period as compared to mid-semester (low stress period). There were no significant changes in nasal VEGF across the observation period. Changes in nasal LTB4 and VEGF were not associated with salivary cortisol, exhaled nitric oxide, or spirometric lung function.

CONCLUSIONS

Our results suggest that nasal LTB4 concentrations change in periods of psychological stress for asthmatic individuals with allergies.

Antileukotrienes in upper airway inflammatory diseases

Leukotrienes (LTs) are a family of inflammatory mediators including LTA4, LTB4, LTC4, LTD4, and LTE4. By competitive binding to the cysteinyl LT1 (CysLT1) receptor, LT receptor antagonist drugs, such as montelukast, zafirlukast, and pranlukast, block the effects of CysLTs, improving the symptoms of some chronic respiratory diseases, particularly bronchial asthma and allergic rhinitis. We reviewed the efficacy of antileukotrienes in upper airway inflammatory diseases. An update on the use of antileukotrienes in upper airway diseases in children and adults is presented with a detailed literature survey. Data on LTs, antileukotrienes, and antileukotrienes in chronic rhinosinusitis and nasal polyps, asthma, and allergic rhinitis are presented. Antileukotriene drugs are classified into two groups: CysLT receptor antagonists (zafirlukast, pranlukast, and montelukast) and LT synthesis inhibitors (5-lipoxygenase inhibitors such as zileuton, ZD2138, Bay X 1005, and MK-0591). CysLTs have important proinflammatory and profibrotic effects that contribute to the extensive hyperplastic rhinosinusitis and nasal polyposis (NP) that characterise these disorders. Patients who receive zafirlukast or zileuton tend to show objective improvements in, or at least stabilisation of, NP. Montelukast treatment may lead to clinical subjective improvement in NP. Montelukast treatment after sinus surgery can lead to a significant reduction in eosinophilic cationic protein levels in serum, with a beneficial effect on nasal and pulmonary symptoms and less impact in NP. Combined inhaled corticosteroids and long-acting β-agonists treatments are most effective for preventing exacerbations among paediatric asthma patients. Treatments with medium- or high-dose inhaled corticosteroids, combined inhaled corticosteroids and LT receptor antagonists, and low-dose inhaled corticosteroids have been reported to be equally effective. Antileukotrienes have also been reported to be effective for allergic rhinitis.

Side Effects of Leukotriene Receptor Antagonists in Asthmatic Children

Background:

Leukotriene receptor antagonists (LTRAs) are drugs which have been widely used more than ten years. As the use of LTRAs increases, our knowledge with respect to their side effects increases as well.

Objectives:

The objective of our study was to evaluat the observed side effects of LTRAs used in patients with astma.

Patients and Methods:

1024 patients treated only with LTRAs owing to asthma or early wheezing were included in the study for a five-year period. The observed side effects of LTRAs in these patients were retrospectively investigated. The side effects were divided into two parts as psychiatric and non-psychiatric.

Results:

Among the 1024 cases included in the study, 67.5% of the patients out of 41 with side effects were male, 32.5% were female and the average age was 6.5 years. The rate of patients with asthma was 63.41% and 36.58% of the patients had early wheezing. It was determined that sex, age and diagnosis (early wheezing or asthma) of the patients were ineffective in the emergence of side effects. The average period for the emergence of side effects was the first month. It was observed that hyperactivity was the most frequently observed psychiatric side effect and that abdominal pain was the non-psychiatric side effect.

Conclusions:

The side effects of LTRAs were common in children. Therefore, patients must be informed at the beginning of the treatment and they must be evaluated at certain intervals.

Pediatric Sleep Pharmacology: A Primer

"What will you give my child to help him sleep?" is a common question parents ask and some health care providers abhor hearing. Entire families may suffer when one member does not sleep well. Poor sleep may complicate the management of other comorbid conditions. Health care providers may have received only limited education on sleep disorders and are frequently forced to choose between treatment options that are poorly studied in children. Fortunately, when addressed correctly, many children with chronic sleep disorders may improve their sleep and daytime behavior in a relatively short time. This review provides a framework to help understand the causes of poor sleep in children and the potential pharmacologic options.

Clinical practice guideline: Allergic rhinitis

OBJECTIVE

Allergic rhinitis (AR) is one of the most common diseases affecting adults. It is the most common chronic disease in children in the United States today and the fifth most common chronic disease in the United States overall. AR is estimated to affect nearly 1 in every 6 Americans and generates $2 to $5 billion in direct health expenditures annually. It can impair quality of life and, through loss of work and school attendance, is responsible for as much as $2 to $4 billion in lost productivity annually. Not surprisingly, myriad diagnostic tests and treatments are used in managing this disorder, yet there is considerable variation in their use. This clinical practice guideline was undertaken to optimize the care of patients with AR by addressing quality improvement opportunities through an evaluation of the available evidence and an assessment of the harm-benefit balance of various diagnostic and management options.

PURPOSE

The primary purpose of this guideline is to address quality improvement opportunities for all clinicians, in any setting, who are likely to manage patients with AR as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The guideline is intended to be applicable for both pediatric and adult patients with AR. Children under the age of 2 years were excluded from the clinical practice guideline because rhinitis in this population may be different than in older patients and is not informed by the same evidence base. The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing AR. The recommendations outlined in the guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients.

ACTION STATEMENTS

The development group made a strong recommendation that clinicians recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. (3) Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. (4) Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls. The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR. The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls (ie, removal of pets; the use of air filtration systems, bed covers, and acaricides [chemical agents formulated to kill dust mites]) in patients with AR who have identified allergens that correlate with clinical symptoms. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. (4) Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. (5) Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. The development group provided no recommendation regarding the use of herbal therapy for patients with AR.

The HEDIS Medication Management for People with Asthma Measure is Not Related to Improved Asthma Outcomes

BACKGROUND

A new Healthcare Effectiveness Data and Information Set (HEDIS) asthma quality-of-care measure designed to quantify patient adherence to asthma controller medication has been implemented. The relationship between this measure and asthma outcomes is unknown.

OBJECTIVE

To examine the relationship between the HEDIS Medication Management for people with Asthma (MMA) measure and asthma outcomes.

METHODS

Administrative data identified 30,040 patients who met HEDIS criteria for persistent asthma during 2012. These patients were classified as compliant or noncompliant with the MMA measure at the 75% and 50% threshold, respectively. The association between MMA compliance in 2012 and asthma outcomes in 2013 was determined.

RESULTS

Patients who were 75% or 50% MMA compliant in 2012 showed no clinically meaningful difference in asthma-related hospitalizations, emergency department visits, or rescue inhaler dispensing in 2013 compared with those who were noncompliant. Stepwise comparison of patients who were 75% or more, 50% to 74%, and less than 50% MMA compliant showed no meaningful difference in asthma outcomes between groups.

CONCLUSIONS

Compliance with the HEDIS MMA measure is not related to improvement in the asthma outcomes assessed (rescue inhaler dispensing, asthma-coded hospitalizations, or asthma-coded emergency department visits).

Asthma and self-harm: a population-based cohort study in Taiwan

OBJECTIVE

Few studies have investigated the relationship between asthma and suicidality-related outcomes in the world. We sought to investigate the association between asthma and risk of non-fatal self-harm in a large national sample.

METHODS

Cases aged 10years and over were identified from Taiwan's National Health Insurance Research Database with a new primary diagnosis of asthma (ICD-9:493) between 2000 and 2008. Case status required the presence of any inpatient diagnosis of asthma and/or at least two recorded diagnoses and 1year duration of asthma in outpatient services. These 27,781 cases were compared to 138,905 sex- and age-matched controls and both groups were followed until end of 2008 for instances of self-harm, defined as ICD-9 codes E950-E959 (self-harm causes) and E980-E989 (undetermined causes). Competing risk adjusted Cox regression analyses were applied, adjusting for sex, age, residence (urban/rural), insurance premium, episode of psychiatric disease, montelukast, Charlson comorbidity index and mortality.

RESULTS

Of the 166,686 subjects, 445 carried out self-harm during a mean (SD) follow-up period of 5.84 (2.35) years. Asthma (hazard ratio=1.70, 95% CI: 1.35-2.14), age, residence, episode of psychiatric disease and Charlson comorbidity index were independent risks on self-harm in the fully adjusted model.

CONCLUSIONS

Asthma was associated with increased risk of self-harm in this population, independent of a number of potential confounding factors including montelukast use. This reinforces the need to consider mental health in routine asthma care, and to consider asthma as a potentially important stressor in people with comorbid mental disorder.

Pediatric allergic rhinitis

Allergic rhinitis is a common pediatric problem with significant comorbidities and potential complications. This article is an overview of the epidemiology, pathophysiology, and current therapeutic strategies. Allergic rhinitis management in a specific child is age dependent and influenced by the severity and frequency of the symptoms and the presence of any concurrent conditions. Current strategies permit symptomatic control and improved quality of life for most patients.

Delayed Onset of Neuropsychiatric Effects Associated with Montelukast

Montelukast (a leukotriene receptor antagonist) is a commonly prescribed medication used in the management of asthma in both children and adults. It has been associated with a possible increased risk of various neuropsychiatric events in post-marketing analyses of clinical trial data and surveillance studies. When establishing a link between a medication and side effects, it is usual to establish and enquire whether there is a chronological relationship between the commencement of the medication and the onset of the symptoms. We report a case where a number of unusual neuropsychiatric events were reported several years after commencement of montelukast in a young boy who may have a genetic predisposition and a likely psychological trigger. There was complete resolution of these symptoms upon the withdrawal of montelukast.

Effectiveness of montelukast in pediatric patients with allergic rhinitis

Allergic rhinitis (AR) is one of the most common chronic diseases of childhood and carries significant morbidity as well as physical and psychosocial consequences. Therapy aims to alleviate clinical symptoms, prevent complications and improve psychosocial consequences. Leukotrienes which are amongst the main mediators in pathogenesis of AR have chemotactic properties and lead to increased vascular permeability. Thus, leukotriene antagonism may be an effective therapeutic option in treatment of allergic diseases, specifically AR. Montelukast which is a leukotriene receptor type I inhibitor has variable efficacy in children with AR and the guidelines recommend its use in children with seasonal AR aged six years and above. Although its efficacy is inferior to anti-histamines and intranasal corticosteroids, combination treatment may warrant clinical efficacy. Therefore, montelukast may be considered to be a well-tolerated therapeutic option for children with AR with minor side effects though long term results need to be assessed. In conclusion, larger scale research enrolling pediatric cases with seasonal and persistent AR are required before concise recommendations about montelukast use in pediatric AR can be made.

Sleeptalking! Sleepwalking! Side effects of montelukast

A 16-year-old Caucasian female presented to the pulmonary clinic for a followup on her asthma. Due to the worsening of allergy-related symptoms, therapy with montelukast 10 mg daily was started and resulted in good relief of the patient's symptoms. In the nights following initiating therapy with montelukast, the patient's mother reported daily parasomnias in the form of sleeptalking and sleepwalking. Montelukast was discontinued, and that resulted in absence of the parasomnias. In a second attempt montelukast was reinstituted to control the patient's symptoms. Parasomnias were immediately reported after resuming therapy. Montelukast was then discontinued indefinitely. Our patient has never had any history of parasomnias, and since the discontinuation of montelukast, parasomnias were never reported again. Parasomnias in the form of sleeptalking or sleepwalking were not previously reported as adverse effects of montelukast. Alternative modalities to treat allergy-related symptoms in patients, who develop parasomnias while receiving montelukast, should be explored.

Antidepressant medication dispensing among montelukast initiators

OBJECTIVE

This study investigates the potential association between montelukast use and psychiatric adverse events by monitoring changes in antidepressant medication dispensing rates before and after initiating montelukast.

METHODS

The primary study group of montelukast initiators was identified using the Wolters Kluwer's SOURCE Lx® pharmacy claims database (WK). This group included 232,159 patients ≤45 years old who had at least two montelukast prescriptions from 2003 to 2007. Comparison groups comprised of 264,704 fluticasone initiators and 89,635 long-acting β-agonist corticosteroid (LABA/ICS) initiators were also identified. Antidepressant medication dispensing rates in these three groups were determined using WK, and changes in rates before and after the first asthma controller medication prescription date were evaluated using interrupted time-series analysis (ITS). ITS was performed separately for four age categories, with a focus on youth (12-17 years) and young adult (18-24 years).

RESULTS

For patients 18-24 years old, antidepressant medication dispensing rates increased significantly after initiating montelukast [1.93% (1.55-2.32%, p < 0.001)] but also after initiating fluticasone and LABA/ICS [1.72% (1.30-2.15%, p < 0.001) and 2.76% (2.35-3.17%, p < 0.001)]. Similar patterns were observed across the three medication groups for other age categories but these differences were not all significant.

CONCLUSIONS

Small increases in antidepressant medication dispensing rates occurred after initiating montelukast. However, similar increases were observed in the fluticasone and LABA/ICS comparison groups. The results of this study cannot support a specific association between initiation of montelukast treatment and an increase in psychiatric adverse effects.

Montelukast in asthma: a review of its efficacy and place in therapy

Many studies have been published in the last 10 years on the efficacy and safety of montelukast in asthma since this drug entered the market. Experimental studies, in vitro and in vivo, and clinical studies on large numbers of patients with asthma of different severity have clearly demonstrated that montelukast is able to modify the pathophysiological mechanisms of the disease, and to improve to some extent the clinical and functional manifestations of asthma. Studies of montelukast as monotherapy or in combination with other drugs, mainly inhaled corticosteroids (ICS), versus different comparator drugs have contributed to the positioning of montelukast in the different levels of asthma treatment, according to the Global Initiative for Asthma Guidelines. Montelukast may be used as monotherapy as an alternative to low-dose ICS (particularly in a step-down strategy) or in addition to ICS for improving clinical manifestations by an increase in anti-inflammatory effects and a sparing of corticosteroids. The heterogeneity of asthma has received a large amount of attention in the last few years in order to better tailor treatment according to the different clinical and biological phenotypes of asthma. Montelukast has proven to be particularly effective in exercise-induced asthma and in asthma associated with allergic rhinitis. Other phenotypes where montelukast is effective include asthma in obese patients, asthma in smokers, aspirin-induced asthma and viral-induced wheezing episodes. The safety profile of montelukast is very good, and the suspicions of increased risk of Churg-Strauss syndrome or suicide have not been confirmed.

That ICS should be first line therapy for asthma--con

Asthma is a heterogeneous disease and it is therefore unrealistic to expect that inhaled corticosteroids (ICS) would be appropriate first line preventer therapy for all children with asthma. There is good theoretical and clinical trial evidence demonstrating that leukotriene receptor antagonists (LTRAs) are more effective than ICS for viral induced wheezing and equivalent to ICS for mild persistent asthma in children. LTRAS do not have the systemic adverse effects of ICS, are generally well tolerated and their once daily oral administration enhances adherence. LTRAs should therefore be first line preventer therapy for children with frequent intermittent or mild persistent asthma while ICS should be reserved as first line treatment for children with moderate to severe persistent asthma. Given the skew in paediatric asthma severity towards the milder end, this effectively means that LTRAs should be tried first in 2 of every 3 children with asthma requiring preventer treatment.

Relationship between leukotriene-modifying agent prescriptions dispensed and rate of suicide deaths by county in the US

BACKGROUND

The US Food and Drug Administration has issued warnings about a potential link between leukotriene receptor-modifying agents (LTMA) and suicide. These warnings are based on case reports and there is controversy about the association. While spontaneous reporting of suicide-related events attributed to LTMA has risen dramatically, these data may be biased by the warnings. The objective of this study was to explore the relationship between LTMA and suicide deaths using event data preceding the Food and Drug Administration warnings.

METHODS

We conducted a mixed-effects Poisson regression analysis of the association between LTMA prescriptions dispensed and suicide deaths at the county level. Counts of suicide deaths in each US county, stratified by race, age group, gender, and year were obtained from the National Center for Health Statistics for the period January 1, 1999 to December 31, 2006. Counts of LTMA prescriptions dispensed in each US county were obtained from IMS Health Incorporated. The model estimated the overall suicide rate conditional on LTMA use, adjusted for age, gender, race, year, and antidepressant utilization. We also assessed the intracounty and intercounty associations.

RESULTS

There were 249,872 suicides in the US between 1999 and 2006, and the annual suicide rate ranged from 11.17 to 11.92 per 100,000 population. There were 118.63, 11.68, and 0.12 million prescriptions dispensed for montelukast, zafirlukast, and zileuton, respectively, between 1999 and 2006. The mean rate of LTMA prescriptions dispensed by county was 42.91 (95% confidence interval [CI] 42.78-43.04), 4.82 (95% CI 4.81-4.84), and 0.05 (95% CI 0.05-0.05) per 1000 for montelukast, zafirlukast, and zileuton, respectively. We found a negative within-county association between the rate of total LTMA prescriptions dispensed and the suicide rate by county (P = 0.0296). This association was primarily driven by montelukast.

CONCLUSION

Our results, while subject to certain limitations, provide preliminary evidence that the association between LTMA and suicide could be different (ie, reduced risk) than that which might be anticipated based on previous warnings. Patient-level research is needed to understand more clearly the association between LTMA and suicide.

[Montelukast in the treatment of mild to moderate persistent asthma]

INTRODUCTION

Anti-inflammatory preventive treatment is recommended in cases of persistent asthma. Besides inhaled corticosteroids (ICS), which represent the mainstay of treatment, other therapeutic options are available, of which only antileukotrienes are approved for all age groups.

BACKGROUND

Given as a substitute of low-dose ICS, montelukast prevents exacerbations as efficiently and for a longer period than long-acting β2-agonists. Montelukast is as efficient as doubling the dose of ICS on asthma symptoms in cases of inadequate control with low-dose ICS. Combined with ICS, it can lead to better control of asthma and potentially to ICS sparing.

CONCLUSIONS

Given the efficacy, tolerance and long-term treatment compliance of montelukast in mild persistent asthma in adults and children, montelukast, given as a substitute or combined with ICS, could contribute to enhanced control of asthma, especially in children.

Asthma in sickle cell disease: implications for treatment

Objective. To review issues related to asthma in sickle cell disease and management strategies. Data Source. A systematic review of pertinent original research publications, reviews, and editorials was undertaken using MEDLlNE, the Cochrane Library databases, and CINAHL from 1947 to November 2010. Search terms were [asthma] and [sickle cell disease]. Additional publications considered relevant to the sickle cell disease population of patients were identified; search terms included [sickle cell disease] combined with [acetaminophen], [pain medications], [vitamin D], [beta agonists], [exhaled nitric oxide], and [corticosteroids]. Results. The reported prevalence of asthma in children with sickle cell disease varies from 2% to approximately 50%. Having asthma increases the risk for developing acute chest syndrome , death, or painful episodes compared to having sickle cell disease without asthma. Asthma and sickle cell may be linked by impaired nitric oxide regulation, excessive production of leukotrienes, insufficient levels of Vitamin D, and exposure to acetaminophen in early life. Treatment of sickle cell patients includes using commonly prescribed asthma medications; specific considerations are suggested to ensure safety in the sickle cell population. Conclusion. Prospective controlled trials of drug treatment for asthma in patients who have both sickle cell disease and asthma are urgently needed.

Common behavioral problems among children with asthma: is there a role of asthma treatment?

BACKGROUND

An increased prevalence of behavioral problems has been described among children with asthma.

OBJECTIVE

To investigate those associations between common behavioral problems and asthma, with an emphasis on the roles of medications used for asthma.

METHOD

We studied 409 children who had been followed-up in pediatric allergy clinics and 157 age-matched healthy controls. A diagnostic and statistical manual disorder-referenced symptom inventory was used to assess "attention deficit-hyperactivity disorder" (ADHD), "attention deficit" (AD), "hyperactivity and impulsivity" (HI), and "oppositional defiant disorder" (ODD) behavioral problems.

RESULTS

The study group consisted of 409 patients (male: 251, female: 158), with a mean age of 9.0 ± 2.67 years, and the control group consisted of 157 children (male: 75, female: 82), with a mean age of 9.0 ± 2.86 years. Prevalences of AD, hyperactivity, ADHD, and ODD were not significantly different between the study and control groups. Among those patients receiving leukotriene antagonist (LA) drugs adjunctive to inhaled corticosteroids (ICS), duration of treatment was correlated with total scores calculated for hyperactivity (P = .035, r = 0.432), AD (P = .044, r = 0.414), ADHD (P = .042, r = 0.418), and ODD (P = .032, r = 0.439). Among patients with asthma, children with ODD had a significantly longer duration of LA+ICS use (P = .024) compared with those with no ODD. Patients with hyperactivity had a longer duration of ICS+LA use compared with those with no hyperactivity (P = .009). Patients with asthma receiving LA+ICS treatment had a higher risk for oppositional behavior (4.282 times compared with the control group [P = .042, confidence interval (CI): 1.542-15.949]) and 8.3 times compared with patients with asthma not using any drug (P = .021, CI: 1.419-48.543).

CONCLUSION

Rather than asthma itself, adjunctive use of ICS+LA therapy appears to be related with symptoms of common behavioral problems, including hyperactivity, AD, ADHD, and ODD and to increase the risk of ODD.