Question

A 10-year-old boy presented to a new pulmonary physician for evaluation. His mother stated that his primary condition was asthma. He had developed respiratory symptoms at 2 months of age, had been seen by many specialists, and had been on multiple medications since that time. The pregnancy was uneventful. When he was 2 months old, he developed a recurrent cough. He was started on albuterol and then, at 6 years of age, switched to levalbuterol hydrochloride. At various times he has also been treated with cromolyn sodium, fluticasone proprionate and salmeterol, and montelukast as well as with a short course of prednisolone for exacerbations. His last course of oral steroids was 9 months ago. The hallmark of his illness was that a cold would always trigger his asthma. He had approximately one emergency department visit per year, but he had never been hospitalized. His asthma symptoms would typically worsen with the weather changes in the spring and fall; the cold winter months were often particularly difficult. In addition to his asthma, his medical history was remarkable for several events of otitis media, seasonal mold allergies, occasional headaches, and croup. One or more of the events occurred about three times a year, lasting approximately 3 days for each episode. His current medications include 1 inhalation of com- bination fluticasone proprionate and salmeterol in the 250/50 strength twice daily and 2 to 4 inhalations of levalbuterol as needed. This visit was scheduled in the hopes of decreasing this child’s episodes of illness, assessing the current medication regimen, and discussing new treatment opportunities.

1. What is the mechanism of action of montelukast, and should it be a part of this child’s daily medication regimen?

Answer 1

Mechanism of action of Montelukast:

• Montelukast is a type of leukotriene receptor inhibitor.
• It blocks the receptor of leukotriene D4.
• This leads to reduced inflammation and relaxes smooth muscle.

This medication should be added to this patient because:

• This patient is receiving a high dose of flulticasone (total 500 ug)
• In spite of this high dose, the patient is still having a seasonal variation.
• At least one visit to the emergency department a year.
• The patient has seasonal allergies.
• Montelukast will be consumed in tablet form. As a result, it will take care of the inflammation in the lungs and the systemic allergies as well.