np events are currently not well understood. based upon the available data, it is difficult to identify risk factors for or quantify the risk of np events with montelukast sodium use. because of the risk of np events, the benefits of montelukast sodium may not outweigh the risks in some patients, particularly when the symptoms of disease may be mild and adequately treated with alternative therapies. reserve use of montelukast sodium for patients with allergic rhinitis who have an inadequate response or intolerance to alternative therapies [see indications and usage (1.3)]. in patients with asthma or exercise-induced bronchoconstriction, consider the benefits and risks before prescribing montelukast sodium. discuss the benefits and risks of montelukast sodium use with patients and caregivers when prescribing montelukast sodium. advise patients and/or caregivers to be alert for changes in behavior or for new np symptoms when taking montelukast sodium. if changes in behavior are observed, or if new np symptoms or suicidal thoughts and/or behavior occur, advise patients to discontinue montelukast sodium and contact a healthcare provider immediately. in many cases, symptoms resolved after stopping montelukast sodium therapy; however, in some cases symptoms persisted after discontinuation of montelukast sodium. therefore, continue to monitor and provide supportive care until symptoms resolve. re-evaluate the benefits and risks of restarting treatment with montelukast sodium if such events occur. 5.2 acute asthma montelukast sodium is not indicated for use in the reversal of bronchospasm in acute asthma attacks, including status asthmaticus. patients should be advised to have appropriate rescue medication available. therapy with montelukast sodium can be continued during acute exacerbations of asthma. patients who have exacerbations of asthma after exercise should have available for rescue a short-acting inhaled β-agonist. 5.3 concomitant corticosteroid use while the dose of inhaled corticosteroid may be reduced gradually under medical supervision, montelukast sodium should not be abruptly substituted for inhaled or oral corticosteroids. 5.4 aspirin sencitivity patients with known aspirin sensitivity should continue avoidance of aspirin or non-steroidal anti-inflammatory agents while taking montelukast sodium. although montelukast sodium is effective in improving airway function in asthmatics with documented aspirin sensitivity, it has not been shown to truncate bronchoconstrictor response to aspirin and other non-steroidal anti-inflammatory drugs in aspirin-sensitive asthmatic patients [see clinical studies (14.1)]. 5.5 eosinophilic conditions patients with asthma on therapy with montelukast sodium may present with systemic eosinophilia, sometimes presenting with clinical features of vasculitis consistent with churg-strauss syndrome, a condition which is often treated with systemic corticosteroid therapy. these events have been sometimes associated with the reduction of oral corticosteroid therapy. physicians should be alert to eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, and/or neuropathy presenting in their patients. a causal association between montelukast sodium and these underlying conditions has not been established [see adverse reactions (6.2)]. 5.6 phenylketonuria phenylketonuric patients should be informed that the 4-mg and 5-mg chewable tablets contain phenylalanine (a component of aspartame), 0.672 and 0.84 mg per 4-mg and 5-mg chewable tablet, respectively.

st sodium should be taken at least 2 hours before exercise. the following doses are recommended: for adults and adolescents 15 years of age and older: one 10-mg tablet. for pediatric patients 6 to 14 years of age: one 5-mg chewable tablet. an additional dose of montelukast sodium should not be taken within 24 hours of a previous dose. patients already taking montelukast sodium daily for another indication (including chronic asthma) should not take an additional dose to prevent eib. all patients should have available for rescue a short-acting β-agonist. safety and efficacy in patients younger than 6 years of age have not been established. daily administration of montelukast sodium for the chronic treatment of asthma has not been established to prevent acute episodes of eib. 2.3 allergic rhinitis for allergic rhinitis, montelukast sodium should be taken once daily. efficacy was demonstrated for seasonal allergic rhinitis when montelukast was administered in the morning or the evening without regard to time of food ingestion. the time of administration may be individualized to suit patient needs. the following doses for the treatment of symptoms of seasonal allergic rhinitis are recommended: for adults and adolescents 15 years of age and older: one 10-mg tablet. for pediatric patients 6 to 14 years of age: one 5-mg chewable tablet. for pediatric patients 2 to 5 years of age: one 4-mg chewable tablet. safety and effectiveness in pediatric patients younger than 2 years of age with seasonal allergic rhinitis have not been established. the following doses for the treatment of symptoms of perennial allergic rhinitis are recommended: for adults and adolescents 15 years of age and older: one 10-mg tablet. for pediatric patients 6 to 14 years of age: one 5-mg chewable tablet. for pediatric patients 2 to 5 years of age: one 4-mg chewable tablet. safety and effectiveness in pediatric patients younger than 6 months of age with perennial allergic rhinitis have not been established. patients who miss a dose should take the next dose at their regular time and should not take 2 doses at the same time. 2.4 asthma and allergic rhinitis patients with both asthma and allergic rhinitis should take only one montelukast sodium dose daily in the evening. patients who miss a dose should take the next dose at their regular time and should not take 2 doses at the same time.

se experiences reported with montelukast sodium occurred in greater than or equal to 1% of patients and at an incidence greater than that in patients treated with placebo: table 1: adverse experiences occurring in ≥1% of patients with an incidence greater than that in patients treated with placebo montelukast sodium 10 mg/day placebo (%) (%) (n=1955) (n=1180) body as a whole pain, abdominal 2.9 2.5 asthenia/fatigue 1.8 1.2 fever 1.5 0.9 trauma 1.0 0.8 digestive system disorders dyspepsia 2.1 1.1 pain, dental 1.7 1.0 gastroenteritis, infectious 1.5 0.5 nervous system/psychiatric headache 18.4 18.1 dizziness 1.9 1.4 respiratory system disorders influenza 4.2 3.9 cough 2.7 2.4 congestion, nasal 1.6 1.3 skin/skin appendages disorder rash 1.6 1.2 laboratory adverse experiences* alt increased 2.1 2.0 ast increased 1.6 1.2 pyuria 1.0 0.9 *number of patients tested (montelukast sodium and placebo, respectively): alt and ast, 1935, 1170; pyuria, 1924, 1159. the frequency of less common adverse events was comparable between montelukast sodium and placebo. the safety profile of montelukast sodium, when administered as a single dose for prevention of eib in adult and adolescent patients 15 years of age and older, was consistent with the safety profile previously described for montelukast sodium. cumulatively, 569 patients were treated with montelukast sodium for at least 6 months, 480 for one year, and 49 for two years in clinical trials. with prolonged treatment, the adverse experience profile did not significantly change. pediatric patients 6 to 14 years of age with asthma montelukast sodium has been evaluated for safety in 476 pediatric patients 6 to 14 years of age. cumulatively, 289 pediatric patients were treated with montelukast sodium for at least 6 months, and 241 for one year or longer in clinical trials. the safety profile of montelukast sodium in the 8-week, double-blind, pediatric efficacy trial was generally similar to the adult safety profile. in pediatric patients 6 to 14 years of age receiving montelukast sodium, the following events occurred with a frequency ≥2% and more frequently than in pediatric patients who received placebo: pharyngitis, influenza, fever, sinusitis, nausea, diarrhea, dyspepsia, otitis, viral infection, and laryngitis. the frequency of less common adverse events was comparable between montelukast sodium and placebo. with prolonged treatment, the adverse experience profile did not significantly change. the safety profile of montelukast sodium, when administered as a single dose for prevention of eib in pediatric patients 6 years of age and older, was consistent with the safety profile previously described for montelukast sodium. in studies evaluating growth rate, the safety profile in these pediatric patients was consistent with the safety profile previously described for montelukast sodium. in a 56-week, double-blind study evaluating growth rate in pediatric patients 6 to 8 years of age receiving montelukast sodium, the following events not previously observed with the use of montelukast sodium in this age group occurred with a frequency ≥2% and more frequently than in pediatric patients who received placebo: headache, rhinitis (infective), varicella, gastroenteritis, atopic dermatitis, acute bronchitis, tooth infection, skin infection, and myopia. pediatric patients 2 to 5 years of age with asthma montelukast sodium has been evaluated for safety in 573 pediatric patients 2 to 5 years of age in single- and multiple-dose studies. cumulatively, 426 pediatric patients 2 to 5 years of age were treated with montelukast sodium for at least 3 months, 230 for 6 months or longer, and 63 patients for one year or longer in clinical trials. in pediatric patients 2 to 5 years of age receiving montelukast sodium, the following events occurred with a frequency ≥2% and more frequently than in pediatric patients who received placebo: fever, cough, abdominal pain, diarrhea, headache, rhinorrhea, sinusitis, otitis, influenza, rash, ear pain, gastroenteritis, eczema, urticaria, varicella, pneumonia, dermatitis, and conjunctivitis. adults and adolescents 15 years of age and older with seasonal allergic rhinitis montelukast sodium has been evaluated for safety in 2199 adult and adolescent patients 15 years of age and older in clinical trials. montelukast sodium administered once daily in the morning or in the evening had a safety profile similar to that of placebo. in placebo-controlled clinical trials, the following event was reported with montelukast sodium with a frequency ≥1% and at an incidence greater than placebo: upper respiratory infection, 1.9% of patients receiving montelukast sodium vs. 1.5% of patients receiving placebo. in a 4-week, placebo-controlled clinical study, the safety profile was consistent with that observed in 2-week studies. the incidence of somnolence was similar to that of placebo in all studies. pediatric patients 2 to 14 years of age with seasonal allergic rhinitis montelukast sodium has been evaluated in 280 pediatric patients 2 to 14 years of age in a 2-week, multicenter, double-blind, placebo-controlled, parallel-group safety study. montelukast sodium administered once daily in the evening had a safety profile similar to that of placebo. in this study, the following events occurred with a frequency ≥2% and at an incidence greater than placebo: headache, otitis media, pharyngitis, and upper respiratory infection. adults and adolescents 15 years of age and older with perennial allergic rhinitis montelukast sodium has been evaluated for safety in 3357 adult and adolescent patients 15 years of age and older with perennial allergic rhinitis of whom 1632 received montelukast sodium in two, 6-week, clinical studies. montelukast sodium administered once daily had a safety profile consistent with that observed in patients with seasonal allergic rhinitis and similar to that of placebo. in these two studies, the following events were reported with montelukast sodium with a frequency ≥1% and at an incidence greater than placebo: sinusitis, upper respiratory infection, sinus headache, cough, epistaxis, and increased alt. the incidence of somnolence was similar to that of placebo. pediatric patients 6 months to 14 years of age with perennial allergic rhinitis the safety in patients 2 to 14 years of age with perennial allergic rhinitis is supported by the safety in patients 2 to 14 years of age with seasonal allergic rhinitis. 6.2 postmarketing experience the following adverse reactions have been identified during post-approval use of montelukast sodium. because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. blood and lymphatic system disorders: increased bleeding tendency, thrombocytopenia. immune system disorders: hypersensitivity reactions including anaphylaxis, hepatic eosinophilic infiltration. psychiatric disorders: including, but not limited to, agitation, aggressive behavior or hostility, anxiousness, depression, disorientation, disturbance in attention, dream abnormalities, dysphemia (stuttering), hallucinations, insomnia, irritability, memory impairment, obsessive-compulsive symptoms, restlessness, somnambulism, suicidal thinking and behavior (including suicide), tic, and tremor [see boxed warnings, warnings and precautions (5.1)]. nervous system disorders: drowsiness, paraesthesia/hypoesthesia, seizures. cardiac disorders: palpitations. respiratory, thoracic and mediastinal disorders: epistaxis, pulmonary eosinophilia. gastrointestinal disorders: diarrhea, dyspepsia, nausea, pancreatitis, vomiting. hepatobiliary disorders: cases of cholestatic hepatitis, hepatocellular liver-injury, and mixed-pattern liver injury have been reported in patients treated with montelukast sodium. most of these occurred in combination with other confounding factors, such as use of other medications, or when montelukast sodium was administered to patients who had underlying potential for liver disease such as alcohol use or other forms of hepatitis. skin and subcutaneous tissue disorders: angioedema, bruising, erythema multiforme, erythema nodosum, pruritus, stevens-johnson syndrome/toxic epidermal necrolysis, urticaria. musculoskeletal and connective tissue disorders: arthralgia, myalgia including muscle cramps. renal and urinary disorders: enuresis in children. general disorders and administration site conditions: edema. patients with asthma on therapy with montelukast sodium may present with systemic eosinophilia, sometimes presenting with clinical features of vasculitis consistent with churg-strauss syndrome, a condition which is often treated with systemic corticosteroid therapy. these events have been sometimes associated with the reduction of oral corticosteroid therapy. physicians should be alert to eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, and/or neuropathy presenting in their patients [see warnings and precautions (5.5)].

or moderately controlled asthma in pregnancy increases the maternal risk of perinatal adverse outcomes such as preeclampsia and infant prematurity, low birth weight, and small for gestational age. data human data published data from prospective and retrospective cohort studies have not identified an association with montelukast sodium use during pregnancy and major birth defects. available studies have methodologic limitations, including small sample size, in some cases retrospective data collection, and inconsistent comparator groups. animal data in embryo-fetal development studies, montelukast administered to pregnant rats and rabbits during organogenesis (gestation days 6 to 17 in rats and 6 to 18 in rabbits) did not cause any adverse developmental effects at maternal oral doses up to 400 and 300 mg/kg/day in rats and rabbits, respectively (approximately 100 and 110 times the auc in humans at the mrhdod, respectively). 8.2 lactation risk summary a published clinical lactation study reports the presence of montelukast in human milk. data available on the effects of the drug on infants, either directly [see use in specific populations (8.4)] or through breast milk, do not suggest a significant risk of adverse events from exposure to montelukast sodium. the effects of the drug on milk production are unknown. the developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for montelukast sodium and any potential adverse effects on the breastfed infant from montelukast sodium or from the underlying maternal condition. 8.4 pediatric use safety and efficacy of montelukast sodium have been established in adequate and well-controlled studies in pediatric patients with asthma 6 to 14 years of age. safety and efficacy profiles in this age group are similar to those seen in adults [see adverse reactions (6.1), clinical pharmacology, special populations (12.3), and clinical studies (14.1, 14.2)]. the efficacy of montelukast sodium for the treatment of seasonal allergic rhinitis in pediatric patients 2 to 14 years of age and for the treatment of perennial allergic rhinitis in pediatric patients 2 to 14 years of age is supported by extrapolation from the demonstrated efficacy in patients 15 years of age and older with allergic rhinitis as well as the assumption that the disease course, pathophysiology and the drug’s effect are substantially similar among these populations. the safety of montelukast sodium 4-mg chewable tablets in pediatric patients 2 to 5 years of age with asthma has been demonstrated by adequate and well-controlled data [see adverse reactions (6.1)]. efficacy of montelukast sodium in this age group is extrapolated from the demonstrated efficacy in patients 6 years of age and older with asthma and is based on similar pharmacokinetic data, as well as the assumption that the disease course, pathophysiology and the drug’s effect are substantially similar among these populations. efficacy in this age group is supported by exploratory efficacy assessments from a large, well-controlled safety study conducted in patients 2 to 5 years of age. the safety of montelukast sodium 4-mg and 5-mg chewable tablets in pediatric patients aged 2 to 14 years with allergic rhinitis is supported by data from studies conducted in pediatric patients aged 2 to 14 years with asthma. a safety study in pediatric patients 2 to 14 years of age with seasonal allergic rhinitis demonstrated a similar safety profile [see adverse reactions (6.1)]. the safety and effectiveness in pediatric patients below the age of 12 months with asthma, 6 months with perennial allergic rhinitis, and 6 years with exercise-induced bronchoconstriction have not been established. growth rate in pediatric patients a 56-week, multi-center, double-blind, randomized, active- and placebo-controlled parallel group study was conducted to assess the effect of montelukast sodium on growth rate in 360 patients with mild asthma, aged 6 to 8 years. treatment groups included montelukast sodium 5 mg once daily, placebo, and beclomethasone dipropionate administered as 168 mcg twice daily with a spacer device. for each subject, a growth rate was defined as the slope of a linear regression line fit to the height measurements over 56 weeks. the primary comparison was the difference in growth rates between montelukast sodium and placebo groups. growth rates, expressed as least-squares (ls) mean (95% ci) in cm/year, for the montelukast sodium, placebo, and beclomethasone treatment groups were 5.67 (5.46, 5.88), 5.64 (5.42, 5.86), and 4.86 (4.64, 5.08), respectively. the differences in growth rates, expressed as least-squares (ls) mean (95% ci) in cm/year, for montelukast sodium minus placebo, beclomethasone minus placebo, and montelukast sodium minus beclomethasone treatment groups were 0.03 (-0.26, 0.31), -0.78 (-1.06, -0.49); and 0.81 (0.53, 1.09), respectively. growth rate (expressed as mean change in height over time) for each treatment group is shown in figure 1. figure 1: change in height (cm) from randomization visit by scheduled week (treatment group mean ± standard error* of the mean) [figure1] *the standard errors of the treatment group means in change in height are too small to be visible on the plot 8.5 geriatric use of the total number of subjects in clinical studies of montelukast, 3.5% were 65 years of age and over, and 0.4% were 75 years of age and over. no overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. the pharmacokinetic profile and the oral bioavailability of a single 10-mg oral dose of montelukast are similar in elderly and younger adults. the plasma half-life of montelukast is slightly longer in the elderly. no dosage adjustment in the elderly is required. 8.6 hepatic insufficiency no dosage adjustment is required in patients with mild-to-moderate hepatic insufficiency [see clinical pharmacology (12.3)]. 8.7 renal insufficiency no dosage adjustment is recommended in patients with renal insufficiency [see clinical pharmacology (12.3)].

he cyslt1 receptor (in preference to other pharmacologically important airway receptors, such as the prostanoid, cholinergic, or β-adrenergic receptor). montelukast inhibits physiologic actions of ltd4 at the cyslt1 receptor without any agonist activity. 12.2 pharmacodynamics montelukast causes inhibition of airway cysteinyl leukotriene receptors as demonstrated by the ability to inhibit bronchoconstriction due to inhaled ltd4 in asthmatics. doses as low as 5 mg cause substantial blockage of ltd4-induced bronchoconstriction. in a placebo-controlled, crossover study (n=12), montelukast sodium inhibited early- and late-phase bronchoconstriction due to antigen challenge by 75% and 57%, respectively. the effect of montelukast sodium on eosinophils in the peripheral blood was examined in clinical trials. in patients with asthma aged 2 years and older who received montelukast sodium, a decrease in mean peripheral blood eosinophil counts ranging from 9% to 15% was noted, compared with placebo, over the double-blind treatment periods. in patients with seasonal allergic rhinitis aged 15 years and older who received montelukast sodium, a mean increase of 0.2% in peripheral blood eosinophil counts was noted, compared with a mean increase of 12.5% in placebo-treated patients, over the double-blind treatment periods; this reflects a mean difference of 12.3% in favor of montelukast sodium. the relationship between these observations and the clinical benefits of montelukast noted in the clinical trials is not known [see clinical studies (14)].

tility and fecundity indices at an oral dose of 200 mg/kg (estimated exposure was approximately 70 times the auc for adults at the maximum recommended daily oral dose). no effects on female fertility or fecundity were observed at an oral dose of 100 mg/kg (estimated exposure was approximately 20 times the auc for adults at the maximum recommended daily oral dose). montelukast had no effects on fertility in male rats at oral doses up to 800 mg/kg (estimated exposure was approximately 160 times the auc for adults at the maximum recommended daily oral dose).

percent of predicted forced expiratory volume in 1 second (fev1) of 66% (approximate range, 40 to 90%). the co-primary endpoints in these trials were fev1 and daytime asthma symptoms. in both studies after 12 weeks, a random subset of patients receiving montelukast sodium was switched to placebo for an additional 3 weeks of double-blind treatment to evaluate for possible rebound effects. the results of the u.s. trial on the primary endpoint, morning fev1, expressed as mean percent change from baseline averaged over the 12-week treatment period, are shown in figure 2. compared with placebo, treatment with one montelukast sodium 10-mg tablet daily in the evening resulted in a statistically significant increase in fev1 percent change from baseline (13.0%-change in the group treated with montelukast sodium vs. 4.2%-change in the placebo group, p<0.001); the change from baseline in fev1 for montelukast sodium was 0.32 liters compared with 0.10 liters for placebo, corresponding to a between-group difference of 0.22 liters (p<0.001, 95% ci 0.17 liters, 0.27 liters). the results of the multinational trial on fev1 were similar. figure 2: fev1 mean percent change from baseline (u.s. trial: montelukast sodium n=406; placebo n=270) (anova model) [figure2] the effect of montelukast sodium on other primary and secondary endpoints, represented by the multinational study is shown in table 2. results on these endpoints were similar in the us study. table 2: effect of montelukast sodium on primary and secondary endpoints in a multinational placebo-controlled trial (anova model) montelukast sodium placebo endpoint n baseline mean change from baseline n baseline mean change from baseline daytime asthma symptoms(0 to 6 scale) 372 2.35 -0.49* 245 2.4 -0.26 β-agonist(puffs per day) 371 5.35 -1.65* 241 5.78 -0.42 am pefr(l/min) 372 339.57 25.03* 244 335.24 1.83 pm pefr(l/min) 372 355.23 20.13* 244 354.02 -0.49 nocturnal awakenings(#/week) 285 5.46 -2.03* 195 5.57 -0.78 *p<0.001, compared with placebo both studies evaluated the effect of montelukast sodium on secondary outcomes, including asthma attack (utilization of health-care resources such as an unscheduled visit to a doctor's office, emergency room, or hospital; or treatment with oral, intravenous, or intramuscular corticosteroid), and use of oral corticosteroids for asthma rescue. in the multinational study, significantly fewer patients (15.6% of patients) on montelukast sodium experienced asthma attacks compared with patients on placebo (27.3%,p < 0.001). in the us study,7.8% of patients on montelukast sodium and 10.3% of patients on placebo experienced asthma attacks, but the difference between the two treatment groups was not significant (p = 0.334). in the multinational study, significantly fewer patients (14.8% of patients) on montelukast sodium were prescribed oral corticosteroids for asthma rescue compared with patients on placebo (25.7%, p < 0.001). in the us study, 6.9% of patients on montelukast sodium and 9.9% of patients on placebo were prescribed oral corticosteroids for asthma rescue, but the difference between the two treatment groups was not significant (p = 0.196). onset of action and maintenance of effects in each placebo-controlled trial in adults, the treatment effect of montelukast sodium, measured by daily diary card parameters, including symptom scores, "as-needed" β-agonist use, and pefr measurements, was achieved after the first dose and was maintained throughout the dosing interval (24 hours). no significant change in treatment effect was observed during continuous once-daily evening administration in non-placebo-controlled extension trials for up to one year. withdrawal of montelukast sodium in asthmatic patients after 12 weeks of continuous use did not cause rebound worsening of asthma. pediatric patients 6 to 14 years of age with asthma the efficacy of montelukast sodium in pediatric patients 6 to 14 years of age was demonstrated in one 8-week, double-blind, placebo-controlled trial in 336 patients (201 treated with montelukast sodium and 135 treated with placebo) using an inhaled β-agonist on an "as-needed" basis. the patients had a mean baseline percent predicted fev1 of 72% (approximate range, 45 to 90%) and a mean daily inhaled β-agonist requirement of 3.4 puffs of albuterol. approximately 36% of the patients were on inhaled corticosteroids. the median age was 11 years (range 6 to 15); 35.4% were females and 64.6% were males. the ethnic/racial distribution in this study was 80.1% caucasian, 12.8% black, 4.5% hispanic, and 2.7% other origins. compared with placebo, treatment with one 5-mg montelukast sodium chewable tablets daily resulted in a significant improvement in mean morning fev1 percent change from baseline (8.7% in the group treated with montelukast sodium vs. 4.2% change from baseline in the placebo group, p<0.001). there was a significant decrease in the mean percentage change in daily "as-needed" inhaled β-agonist use (11.7% decrease from baseline in the group treated with montelukast sodium vs. 8.2% increase from baseline in the placebo group, p<0.05). this effect represents a mean decrease from baseline of 0.56 and 0.23 puffs per day for the montelukast and placebo groups, respectively. subgroup analyses indicated that younger pediatric patients aged 6 to 11 had efficacy results comparable to those of the older pediatric patients aged 12 to 14. similar to the adult studies, no significant change in the treatment effect was observed during continuous once-daily administration in one open-label extension trial without a concurrent placebo group for up to 6 months. pediatric patients 2 to 5 years of age with asthma the efficacy of montelukast sodium for the chronic treatment of asthma in pediatric patients 2 to 5 years of age was explored in a 12-week, placebo-controlled safety and tolerability study in 689 patients, 461 of whom were treated with montelukast sodium. the median age was 4 years (range 2 to 6); 41.5% were females and 58.5% were males. the ethnic/racial distribution in this study was 56.5% caucasian, 20.9% hispanic, 14.4% other origins, and 8.3% black. while the primary objective was to determine the safety and tolerability of montelukast sodium in this age group, the study included exploratory efficacy evaluations, including daytime and overnight asthma symptom scores, β-agonist use, oral corticosteroid rescue, and the physician's global evaluation. the findings of these exploratory efficacy evaluations, along with pharmacokinetics and extrapolation of efficacy data from older patients, support the overall conclusion that montelukast sodium is efficacious in the maintenance treatment of asthma in patients 2 to 5 years of age. effects in patients on concomitant inhaled corticosteroids separate trials in adults evaluated the ability of montelukast sodium to add to the clinical effect of inhaled corticosteroids and to allow inhaled corticosteroid tapering when used concomitantly. one randomized, placebo-controlled, parallel-group trial (n=226) enrolled adults with stable asthma with a mean fev1 of approximately 84% of predicted who were previously maintained on various inhaled corticosteroids (delivered by metered-dose aerosol or dry powder inhalers). the median age was 41.5 years (range 16 to 70); 52.2% were females and 47.8% were males. the ethnic/racial distribution in this study was 92.0% caucasian, 3.5% black, 2.2% hispanic, and 2.2% asian. the types of inhaled corticosteroids and their mean baseline requirements included beclomethasone dipropionate (mean dose, 1203 mcg/day), triamcinolone acetonide (mean dose, 2004 mcg/day), flunisolide (mean dose, 1971 mcg/day), fluticasone propionate (mean dose, 1083 mcg/day), or budesonide (mean dose, 1192 mcg/day). some of these inhaled corticosteroids were non-u.s.-approved formulations, and doses expressed may not be ex-actuator. the pre-study inhaled corticosteroid requirements were reduced by approximately 37% during a 5- to 7-week placebo run-in period designed to titrate patients toward their lowest effective inhaled corticosteroid dose. treatment with montelukast sodium resulted in a further 47% reduction in mean inhaled corticosteroid dose compared with a mean reduction of 30% in the placebo group over the 12-week active treatment period (p≤0.05). it is not known whether the results of this study can be generalized to patients with asthma who require higher doses of inhaled corticosteroids or systemic corticosteroids. in another randomized, placebo-controlled, parallel-group trial (n=642) in a similar population of adult patients previously maintained, but not adequately controlled, on inhaled corticosteroids (beclomethasone 336 mcg/day), the addition of montelukast sodium to beclomethasone resulted in statistically significant improvements in fev1 compared with those patients who were continued on beclomethasone alone or those patients who were withdrawn from beclomethasone and treated with montelukast or placebo alone over the last 10 weeks of the 16-week, blinded treatment period. patients who were randomized to treatment arms containing beclomethasone had statistically significantly better asthma control than those patients randomized to montelukast sodium alone or placebo alone as indicated by fev1, daytime asthma symptoms, pefr, nocturnal awakenings due to asthma, and "as-needed" β- agonist requirements. in adult patients with asthma with documented aspirin sensitivity, nearly all of whom were receiving concomitant inhaled and/or oral corticosteroids, a 4-week, randomized, parallel-group trial (n=80) demonstrated that montelukast sodium, compared with placebo, resulted in significant improvement in parameters of asthma control. the magnitude of effect of montelukast sodium in aspirin-sensitive patients was similar to the effect observed in the general population of asthma patients studied. the effect of montelukast sodium on the bronchoconstrictor response to aspirin or other non-steroidal anti-inflammatory drugs in aspirin-sensitive asthmatic patients has not been evaluated [see warnings and precautions (5.4)]. 14.2 exercise-induced bronchoconstriction (eib) exercise-induced bronchoconstriction (adults, adolescents, and pediatric patients 6 years of age and older) the efficacy of montelukast sodium, 10 mg, when given as a single dose 2 hours before exercise for the prevention of eib was investigated in three (u.s. and multinational), randomized, double-blind, placebo-controlled crossover studies that included a total of 160 adult and adolescent patients 15 years of age and older with eib. exercise challenge testing was conducted at 2 hours, 8.5 or 12 hours, and 24 hours following administration of a single dose of study drug (montelukast sodium 10 mg or placebo). the primary endpoint was the mean maximum percent fall in fev1 following the 2 hours post-dose exercise challenge in all three studies (study a, study b, and study c). in study a, a single dose of montelukast sodium 10 mg demonstrated a statistically significant protective benefit against eib when taken 2 hours prior to exercise. some patients were protected from eib at 8.5 and 24 hours after administration; however, some patients were not. the results for the mean maximum percent fall at each timepoint in study a are shown in table 3 and are representative of the results from the other two studies. table 3: mean maximum percent fall in fev1 following exercise challenge in study a (n=47) anova model time of exercise challenge following medication administration mean maximum percent fall in fev1 * treatment difference % for montelukast sodium versus placebo (95% ci)* montelukast sodium placebo 2 hours 13 22 -9(-12,-5) 8.5 hours 12 17 -5(-9,-2) 24 hours 10 14 -4(-7,-1) * least squares-mean the efficacy of montelukast sodium 5-mg chewable tablets, when given as a single dose 2 hours before exercise for the prevention of eib, was investigated in one multinational, randomized, double-blind, placebo-controlled crossover study that included a total of 64 pediatric patients 6 to 14 years of age with eib. exercise challenge testing was conducted at 2 hours and 24 hours following administration of a single dose of study drug (montelukast sodium 5 mg or placebo). the primary endpoint was the mean maximum percent fall in fev1 following the 2 hours post-dose exercise challenge. a single dose of montelukast sodium 5 mg demonstrated a statistically significant protective benefit against eib when taken 2 hours prior to exercise (table 4). similar results were shown at 24 hours post-dose (a secondary endpoint). some patients were protected from eib at 24 hours after administration; however, some patients were not. no timepoints were assessed between 2 and 24 hours post-dose. table 4: mean maximum percent fall in fev1 following exercise challenge in pediatric patients (n=64) anova model time ofexercisechallengefollowingmedicationadministration mean maximumpercentfall in fev1* treatmentdifference % formontelukast sodium versusplacebo(95%ci)* montelukast sodium placebo 2 hours 15 20 -5(-9,-1) 24 hours 13 17 -4(-7,-1) *least squares-mean the efficacy of montelukast sodium for prevention of eib in patients below 6 years of age has not been established. daily administration of montelukast sodium for the chronic treatment of asthma has not been established to prevent acute episodes of eib. in a 12-week, randomized, double-blind, parallel group study of 110 adult and adolescent asthmatics 15 years of age and older, with a mean baseline fev1 percent of predicted of 83% and with documented exercise-induced exacerbation of asthma, treatment with montelukast sodium, 10 mg, once daily in the evening, resulted in a statistically significant reduction in mean maximal percent fall in fev1 and mean time to recovery to within 5% of the pre-exercise fev1. exercise challenge was conducted at the end of the dosing interval (i.e., 20 to 24 hours after the preceding dose). this effect was maintained throughout the 12-week treatment period indicating that tolerance did not occur. montelukast sodium did not, however, prevent clinically significant deterioration in maximal percent fall in fev1 after exercise (i.e., ≥20% decrease from pre-exercise baseline) in 52% of patients studied. in a separate crossover study in adults, a similar effect was observed after two once-daily 10-mg doses of montelukast sodium. in pediatric patients 6 to 14 years of age, using the 5-mg chewable tablet, a 2-day crossover study demonstrated effects similar to those observed in adults when exercise challenge was conducted at the end of the dosing interval (i.e., 20 to 24 hours after the preceding dose). 14.3 allergic rhinitis (seasonal and perennial) seasonal allergic rhinitis the efficacy of montelukast sodium tablets for the treatment of seasonal allergic rhinitis was investigated in 5 similarly designed, randomized, double-blind, parallel-group, placebo- and active-controlled (loratadine) trials conducted in north america. the 5 trials enrolled a total of 5029 patients, of whom 1799 were treated with montelukast sodium tablets. patients were 15 to 82 years of age with a history of seasonal allergic rhinitis, a positive skin test to at least one relevant seasonal allergen, and active symptoms of seasonal allergic rhinitis at study entry. the period of randomized treatment was 2 weeks in 4 trials and 4 weeks in one trial. the primary outcome variable was mean change from baseline in daytime nasal symptoms score (the average of individual scores of nasal congestion, rhinorrhea, nasal itching, sneezing) as assessed by patients on a 0 to 3 categorical scale. four of the five trials showed a significant reduction in daytime nasal symptoms scores with montelukast sodium 10-mg tablets compared with placebo. the results of one trial are shown below. the median age in this trial was 35.0 years (range 15 to 81); 65.4% were females and 34.6% were males. the ethnic/racial distribution in this study was 83.1% caucasian, 6.4% other origins, 5.8% black, and 4.8% hispanic. the mean changes from baseline in daytime nasal symptoms score in the treatment groups that received montelukast sodium tablets, loratadine, and placebo are shown in table 5. the remaining three trials that demonstrated efficacy showed similar results. table 5: effects of montelukast sodium on daytime nasal symptoms score* in a placebo- and active-controlled trial in patients with seasonal allergic rhinitis (ancova model) treatment group (n) baseline mean score mean change from baseline difference between treatment and placebo (95% ci) least-squares mean montelukast sodium 10 mg (344) 2.09 -0.39 -0.13† (-0.21,-0.06) placebo (351) 2.10 -0.26 n.a. active control‡ (loratadine 10 mg) (599) 2.06 -0.46 -0.24 † (-0.31,-0.17) * average of individual scores of nasal congestion, rhinorrhea, nasal itching, sneezing as assessed by patients on a 0 to 3 categorical scale. † statistically different from placebo (p≤0.001). ‡ the study was not designed for statistical comparison between montelukast sodium and the active control (loratadine). perennial allergic rhinitis the efficacy of montelukast sodium tablets for the treatment of perennial allergic rhinitis was investigated in 2 randomized, double-blind, placebo-controlled studies conducted in north america and europe. the two studies enrolled a total of 3357 patients, of whom 1632 received montelukast sodium 10-mg tablets. patients 15 to 82 years of age with perennial allergic rhinitis as confirmed by history and a positive skin test to at least one relevant perennial allergen (dust mites, animal dander, and/or mold spores), who had active symptoms at the time of study entry, were enrolled. in the study in which efficacy was demonstrated, the median age was 35 years (range 15 to 81); 64.1% were females and 35.9% were males. the ethnic/racial distribution in this study was 83.2% caucasian, 8.1% black, 5.4% hispanic, 2.3% asian, and 1.0% other origins. montelukast sodium 10-mg tablets once daily was shown to significantly reduce symptoms of perennial allergic rhinitis over a 6-week treatment period (table 6); in this study the primary outcome variable was mean change from baseline in daytime nasal symptoms score (the average of individual scores of nasal congestion, rhinorrhea, and sneezing). table 6: effects of montelukast sodium on daytime nasal symptoms score* in a placebo-controlled trial in patients with perennial allergic rhinitis (ancova model) treatment group (n) baseline mean score mean change from baseline difference between treatment and placebo (95% ci) least-squares mean montelukast sodium 10 mg (1000) 2.09 -0.42 -0.08† (-0.12, -0.04) placebo (980) 2.10 -0.35 n.a. * average of individual scores of nasal congestion, rhinorrhea, sneezing as assessed by patients on a 0 to 3 categorical scale. † statistically different from placebo (p≤0.001). the other 6-week study evaluated montelukast sodium 10 mg (n=626), placebo (n=609), and an active-control (cetirizine 10 mg; n=120). the primary analysis compared the mean change from baseline in daytime nasal symptoms score for montelukast sodium vs. placebo over the first 4 weeks of treatment; the study was not designed for statistical comparison between montelukast sodium and the active-control. the primary outcome variable included nasal itching in addition to nasal congestion, rhinorrhea, and sneezing. the estimated difference between montelukast sodium and placebo was -0.04 with a 95% ci of (-0.09, 0.01). the estimated difference between the active-control and placebo was -0.10 with a 95% ci of (-0.19, -0.01).