itis singulair is indicated for the relief of symptoms of seasonal allergic rhinitis in patients 2 years of age and older and perennial allergic rhinitis in patients 6 months of age and older. because the benefits of singulair may not outweigh the risk of neuropsychiatric symptoms in patients with allergic rhinitis [see warnings and precautions (5.1) ] , reserve use for patients who have an inadequate response or intolerance to alternative therapies. 1.4 limitations of use singulair is not indicated for the treatment of an acute asthma attack.

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 thoughts and behavior (including suicide), tic, and tremor. np events have been reported in adult, adolescent, and pediatric patients with and without a previous history of psychiatric disorder. np events have been reported mostly during singulair treatment, but some were reported after singulair discontinuation. animal studies showed that montelukast distributes into the brain in rats [see clinical pharmacology (12.3) ] ; however, the mechanisms underlying singulair-associated 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 singulair use. because of the risk of np events, the benefits of singulair 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 singulair 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 singulair. discuss the benefits and risks of singulair use with patients and caregivers when prescribing singulair. advise patients and/or caregivers to be alert for changes in behavior or for new np symptoms when taking singulair. if changes in behavior are observed, or if new np symptoms or suicidal thoughts and/or behavior occur, advise patients to discontinue singulair and contact a healthcare provider immediately. in many cases, symptoms resolved after stopping singulair therapy; however, in some cases symptoms persisted after discontinuation of singulair. therefore, continue to monitor and provide supportive care until symptoms resolve. re-evaluate the benefits and risks of restarting treatment with singulair if such events occur. 5.2 acute asthma singulair 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 singulair 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, singulair should not be abruptly substituted for inhaled or oral corticosteroids. 5.4 aspirin sensitivity patients with known aspirin sensitivity should continue avoidance of aspirin or non-steroidal anti-inflammatory agents while taking singulair. although singulair 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 singulair 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 singulair and these underlying conditions has not been established [see adverse reactions (6.2) ]. 5.6 risk in patients with phenylketonuria singulair contains aspartame, a source of phenylalanine. phenylalanine can be harmful to patients with phenylketonuria (pku). each 4 mg and 5 mg chewable tablet contains 0.674 mg and 0.842 mg of phenylalanine, respectively. before prescribing singulair to a patient with pku, consider the combined daily amount of phenylalanine from all sources, including singulair.

no clinical trials in patients with asthma to evaluate the relative efficacy of morning versus evening dosing. the following doses are recommended: table 1: recommended dosage in asthma age dose adult and adolescent patients 15 years of age and older one 10 mg tablet pediatric patients 6 to 14 years of age one 5 mg chewable tablet pediatric patients 2 to 5 years of age one 4 mg chewable tablet or one packet of oral granules pediatric patients 12 to 23 months of age safety and effectiveness in pediatric patients less than 12 months of age with asthma have not been established. one packet 4 mg oral granules patients who miss a dose should take the next dose at their regular time and should not take 2 doses at the same time. 2.2 exercise-induced bronchoconstriction (eib) for prevention of eib, administer a single dose of singulair orally at least 2 hours, before exercise. the following doses are recommended: table 2: recommended dosage in exercise-induced bronchoconstriction (eib) age dose adult and adolescent patients 15 years of age and older one 10 mg tablet pediatric patients 6 to 14 years of age safety and effectiveness in patients younger than 6 years of age have not been established. one 5 mg chewable tablet an additional dose of singulair should not be taken within 24 hours of a previous dose. patients already taking singulair 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. daily administration of singulair for the chronic treatment of asthma has not been established to prevent acute episodes of eib. 2.3 allergic rhinitis for allergic rhinitis, administer singulair orally once daily without regard to time of food ingestion. time of administration in patients with allergic rhinitis can be individualized to suit patient needs. the following doses for the treatment of symptoms of seasonal allergic rhinitis are recommended: table 3: recommended dosage in seasonal allergic rhinitis age dose adult and adolescent patients 15 years of age and older one 10 mg tablet pediatric patients 6 to 14 years of age one 5 mg chewable tablet pediatric patients 2 to 5 years of age safety and effectiveness in pediatric patients younger than 2 years of age with seasonal allergic rhinitis have not been established. one 4 mg chewable tablet or one packet of 4 mg oral granules the following doses for the treatment of symptoms of perennial allergic rhinitis are recommended: table 4: recommended dosage in perennial allergic rhinitis age dose adult and adolescent patients 15 years of age and older one 10 mg tablet pediatric patients 6 to 14 years of age one 5 mg chewable tablet pediatric patients 2 to 5 years of age one 4 mg chewable tablet or one packet of 4 mg oral granules pediatric patients 6 to 23 months of age safety and effectiveness in pediatric patients younger than 6 months of age with perennial allergic rhinitis have not been established. one packet of 4 mg oral granules 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 for patients with both asthma and allergic rhinitis, administer only one singulair dose orally once 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. 2.5 instructions for administration of oral granules singulair 4-mg oral granules can be administered either directly in the mouth, dissolved in 1 teaspoonful (5 ml) of cold or room temperature baby formula or breast milk, or mixed with a spoonful of cold or room temperature soft foods; based on stability studies, only applesauce, carrots, rice, or ice cream should be used. the packet should not be opened until ready to use. after opening the packet, the full dose (with or without mixing with baby formula, breast milk, or food) must be administered within 15 minutes. if mixed with baby formula, breast milk, or food, singulair oral granules must not be stored for future use. discard any unused portion. singulair oral granules are not intended to be dissolved in any liquid other than baby formula or breast milk for administration. however, liquids may be taken subsequent to administration. singulair oral granules can be administered without regard to the time of meals.

e listed regardless of causality assessment. the most common adverse reactions (incidence ≥5% and greater than placebo; listed in descending order of frequency) in controlled clinical trials were: upper respiratory infection, fever, headache, pharyngitis, cough, abdominal pain, diarrhea, otitis media, influenza, rhinorrhea, sinusitis, otitis. adults and adolescents 15 years of age and older with asthma singulair has been evaluated for safety in approximately 2950 adult and adolescent patients 15 years of age and older in clinical trials. in placebo-controlled clinical trials, the following adverse reactions reported with singulair occurred in greater than or equal to 1% of patients and at an incidence greater than that in patients treated with placebo: table 5: adverse reactions occurring in ≥1% of patients with an incidence greater than that in patients treated with placebo singulair 10 mg/day (%) (n=1955) placebo (%) (n=1180) body as a whole pain, abdominal asthenia/fatigue fever trauma 2.9 1.8 1.5 1.0 2.5 1.2 0.9 0.8 digestive system disorders dyspepsia pain, dental gastroenteritis, infectious 2.1 1.7 1.5 1.1 1.0 0.5 nervous system/psychiatric headache dizziness 18.4 1.9 18.1 1.4 respiratory system disorders influenza cough congestion, nasal 4.2 2.7 1.6 3.9 2.4 1.3 skin/skin appendages disorder rash 1.6 1.2 laboratory adverse reactions number of patients tested (singulair and placebo, respectively): alt and ast, 1935, 1170; pyuria, 1924, 1159. alt increased ast increased pyuria 2.1 1.6 1.0 2.0 1.2 0.9 the frequency of less common adverse reactions was comparable between singulair and placebo. the safety profile of singulair, 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 singulair. cumulatively, 569 patients were treated with singulair for at least 6 months, 480 for one year, and 49 for two years in clinical trials. with prolonged treatment, the adverse reaction profile did not significantly change. pediatric patients 6 to 14 years of age with asthma singulair has been evaluated for safety in 476 pediatric patients 6 to 14 years of age. cumulatively, 289 pediatric patients were treated with singulair for at least 6 months, and 241 for one year or longer in clinical trials. the safety profile of singulair 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 singulair, the following reactions 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 reactions was comparable between singulair and placebo. with prolonged treatment, the adverse reaction profile did not significantly change. the safety profile of singulair, 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 singulair. in studies evaluating growth rate, the safety profile in these pediatric patients was consistent with the safety profile previously described for singulair. in a 56-week, double-blind study evaluating growth rate in pediatric patients 6 to 8 years of age receiving singulair, the following reactions not previously observed with the use of singulair 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 singulair 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 singulair 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 singulair, the following reactions 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. pediatric patients 6 to 23 months of age with asthma safety and effectiveness in pediatric patients younger than 12 months of age with asthma have not been established. singulair has been evaluated for safety in 175 pediatric patients 6 to 23 months of age. the safety profile of singulair in a 6-week, double-blind, placebo-controlled clinical study was generally similar to the safety profile in adults and pediatric patients 2 to 14 years of age. in pediatric patients 6 to 23 months of age receiving singulair, the following reactions occurred with a frequency ≥2% and more frequently than in pediatric patients who received placebo: upper respiratory infection, wheezing; otitis media; pharyngitis, tonsillitis, cough; and rhinitis. the frequency of less common adverse reactions was comparable between singulair and placebo. adults and adolescents 15 years of age and older with seasonal allergic rhinitis singulair has been evaluated for safety in 2199 adult and adolescent patients 15 years of age and older in clinical trials. singulair 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 reaction was reported with singulair with a frequency ≥1% and at an incidence greater than placebo: upper respiratory infection, 1.9% of patients receiving singulair 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 singulair 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. singulair administered once daily in the evening had a safety profile similar to that of placebo. in this study, the following reactions 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 singulair 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 singulair in two, 6-week, clinical studies. singulair 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 reactions were reported with singulair 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. the safety in patients 6 to 23 months of age is supported by data from pharmacokinetic and safety and efficacy studies in asthma in this pediatric population and from adult pharmacokinetic studies. 6.2 postmarketing experience the following adverse reactions have been identified during post-approval use of singulair. 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 warning , 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 singulair. most of these occurred in combination with other confounding factors, such as use of other medications, or when singulair 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 singulair 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 reactions 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) ].

r embryo/fetal risk poorly 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 singulair 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 reactions from exposure to singulair. 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 singulair and any potential adverse reactions on the breastfed infant from singulair or from the underlying maternal condition. 8.4 pediatric use safety and effectiveness of singulair for asthma have been established in pediatric patients 6 to 14 years of age. use of singulair for this indication is supported by evidence from well-controlled studies. safety and efficacy data in this age group are similar to those seen in adults [see adverse reactions (6.1) , clinical pharmacology, specific populations (12.3) , and clinical studies (14.1 , 14.2 )]. the effectiveness of singulair 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 6 months to 14 years of age have been established and is supported by extrapolation from the demonstrated effectiveness 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 singulair 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) ]. effectiveness of singulair in this age group is extrapolated from the demonstrated effectiveness 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. effectiveness 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 singulair 4-mg oral granules in pediatric patients 12 to 23 months of age with asthma has been demonstrated in an analysis of 172 pediatric patients, 124 of whom were treated with singulair, in a 6-week, double-blind, placebo-controlled study [see adverse reactions (6.1) ]. effectiveness of singulair in this age group is extrapolated from the demonstrated effectiveness in patients 6 years of age and older with asthma based on similar mean systemic exposure (auc), and that the disease course, pathophysiology and the drug's effect are substantially similar among these populations, supported by efficacy data from a safety trial in which efficacy was an exploratory assessment. the safety of singulair 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 of singulair 4-mg oral granules in pediatric patients as young as 6 months of age with perennial allergic rhinitis is supported by extrapolation from safety data obtained from studies conducted in pediatric patients 6 months to 23 months of age with asthma and from pharmacokinetic data comparing systemic exposures in patients 6 months to 23 months of age to systemic exposures in adults. 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 singulair on growth rate in 360 patients with mild asthma, aged 6 to 8 years. treatment groups included singulair 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 singulair and placebo groups. growth rates, expressed as least-squares (ls) mean (95% ci) in cm/year, for the singulair, 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 singulair minus placebo, beclomethasone minus placebo, and singulair 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 the standard errors of the treatment group means in change in height are too small to be visible on the plot of the mean) 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 impairment no dosage adjustment is recommended in patients with mild-to-moderate hepatic insufficiency [see clinical pharmacology (12.3) ] . 8.7 renal impairment no dosage adjustment is recommended in patients with renal insufficiency [see clinical pharmacology (12.3) ]. image of figure 1

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 singulair 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).

diatric patients 2 to 5 years of age with asthma has been demonstrated by adequate and well-controlled data [see adverse reactions (6.1) ]. effectiveness of singulair in this age group is extrapolated from the demonstrated effectiveness 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. effectiveness 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 singulair 4-mg oral granules in pediatric patients 12 to 23 months of age with asthma has been demonstrated in an analysis of 172 pediatric patients, 124 of whom were treated with singulair, in a 6-week, double-blind, placebo-controlled study [see adverse reactions (6.1) ]. effectiveness of singulair in this age group is extrapolated from the demonstrated effectiveness in patients 6 years of age and older with asthma based on similar mean systemic exposure (auc), and that the disease course, pathophysiology and the drug's effect are substantially similar among these populations, supported by efficacy data from a safety trial in which efficacy was an exploratory assessment. the safety of singulair 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 of singulair 4-mg oral granules in pediatric patients as young as 6 months of age with perennial allergic rhinitis is supported by extrapolation from safety data obtained from studies conducted in pediatric patients 6 months to 23 months of age with asthma and from pharmacokinetic data comparing systemic exposures in patients 6 months to 23 months of age to systemic exposures in adults. 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 singulair on growth rate in 360 patients with mild asthma, aged 6 to 8 years. treatment groups included singulair 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 singulair and placebo groups. growth rates, expressed as least-squares (ls) mean (95% ci) in cm/year, for the singulair, 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 singulair minus placebo, beclomethasone minus placebo, and singulair 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 the standard errors of the treatment group means in change in height are too small to be visible on the plot of the mean)

igh affinity and selectivity to the cyslt 1 receptor (in preference to other pharmacologically important airway receptors, such as the prostanoid, cholinergic, or β-adrenergic receptor). montelukast inhibits physiologic actions of ltd 4 at the cyslt 1 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 ltd 4 in asthmatics. doses as low as 5 mg cause substantial blockage of ltd 4 -induced bronchoconstriction. in a placebo-controlled, crossover study (n=12), singulair inhibited early- and late-phase bronchoconstriction due to antigen challenge by 75% and 57%, respectively. the effect of singulair on eosinophils in the peripheral blood was examined in clinical trials. in patients with asthma aged 2 years and older who received singulair, 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 singulair, 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 singulair. the relationship between these observations and the clinical benefits of montelukast noted in the clinical trials is not known [see clinical studies (14) ]. 12.3 pharmacokinetics absorption montelukast is rapidly absorbed following oral administration. after administration of the 10-mg film-coated tablet to fasted adults, the mean peak montelukast plasma concentration (c max ) is achieved in 3 to 4 hours (t max ). the mean oral bioavailability is 64%. the oral bioavailability and c max are not influenced by a standard meal in the morning. for the 5-mg chewable tablet, the mean c max is achieved in 2 to 2.5 hours after administration to adults in the fasted state. the mean oral bioavailability is 73% in the fasted state versus 63% when administered with a standard meal in the morning. for the 4-mg chewable tablet, the mean c max is achieved 2 hours after administration in pediatric patients 2 to 5 years of age in the fasted state. the 4-mg oral granule formulation is bioequivalent to the 4-mg chewable tablet when administered to adults in the fasted state. the co-administration of the oral granule formulation with applesauce did not have a clinically significant effect on the pharmacokinetics of montelukast. a high fat meal in the morning did not affect the auc of montelukast oral granules; however, the meal decreased c max by 35% and prolonged t max from 2.3 ± 1.0 hours to 6.4 ± 2.9 hours. the safety and effectiveness of singulair in patients with asthma were demonstrated in clinical trials in which the 10-mg film-coated tablet and 5-mg chewable tablet formulations were administered in the evening without regard to the time of food ingestion. the safety of singulair in patients with asthma was also demonstrated in clinical trials in which the 4-mg chewable tablet and 4-mg oral granule formulations were administered in the evening without regard to the time of food ingestion. the safety and effectiveness of singulair in patients with seasonal allergic rhinitis were demonstrated in clinical trials in which the 10-mg film-coated tablet was administered in the morning or evening without regard to the time of food ingestion. the comparative pharmacokinetics of montelukast when administered as two 5-mg chewable tablets versus one 10-mg film-coated tablet have not been evaluated. distribution montelukast is more than 99% bound to plasma proteins. the steady state volume of distribution of montelukast averages 8 to 11 liters. orally administered montelukast distributes into the brain in rats. elimination the plasma clearance of montelukast averages 45 ml/min in healthy adults. following an oral dose of radiolabeled montelukast, 86% of the radioactivity was recovered in 5-day fecal collections and <0.2% was recovered in urine. coupled with estimates of montelukast oral bioavailability, this indicates that montelukast and its metabolites are excreted almost exclusively via the bile. in several studies, the mean plasma half-life of montelukast ranged from 2.7 to 5.5 hours in healthy young adults. the pharmacokinetics of montelukast are nearly linear for oral doses up to 50 mg. during once-daily dosing with 10-mg montelukast, there is little accumulation of the parent drug in plasma (14%). metabolism montelukast is extensively metabolized. in studies with therapeutic doses, plasma concentrations of metabolites of montelukast are undetectable at steady state in adults and pediatric patients. in vitro studies using human liver microsomes indicate that cyp3a4, 2c8, and 2c9 are involved in the metabolism of montelukast. at clinically relevant concentrations, 2c8 appears to play a major role in the metabolism of montelukast. specific populations patients with hepatic impairment patients with mild-to-moderate hepatic insufficiency and clinical evidence of cirrhosis had evidence of decreased metabolism of montelukast resulting in 41% (90% ci=7%, 85%) higher mean montelukast auc following a single 10-mg dose. the elimination of montelukast was slightly prolonged compared with that in healthy subjects (mean half-life, 7.4 hours). no dosage adjustment is required in patients with mild-to-moderate hepatic insufficiency. the pharmacokinetics of singulair in patients with more severe hepatic impairment or with hepatitis have not been evaluated. patients with renal impairment since montelukast and its metabolites are not excreted in the urine, the pharmacokinetics of montelukast were not evaluated in patients with renal insufficiency. no dosage adjustment is recommended in these patients . male and female patients the pharmacokinetics of montelukast are similar in males and females. racial groups pharmacokinetic differences due to race have not been studied. adolescents and pediatric patients pharmacokinetic studies evaluated the systemic exposure of the 4-mg oral granule formulation in pediatric patients 6 to 23 months of age, the 4-mg chewable tablets in pediatric patients 2 to 5 years of age, the 5-mg chewable tablets in pediatric patients 6 to 14 years of age, and the 10-mg film-coated tablets in young adults and adolescents ≥15 years of age. the plasma concentration profile of montelukast following administration of the 10-mg film-coated tablet is similar in adolescents ≥15 years of age and young adults. the 10-mg film-coated tablet is recommended for use in patients ≥15 years of age. the mean systemic exposure of the 4-mg chewable tablet in pediatric patients 2 to 5 years of age and the 5-mg chewable tablets in pediatric patients 6 to 14 years of age is similar to the mean systemic exposure of the 10-mg film-coated tablet in adults. the 5-mg chewable tablet should be used in pediatric patients 6 to 14 years of age and the 4-mg chewable tablet should be used in pediatric patients 2 to 5 years of age. in children 6 to 11 months of age, the systemic exposure to montelukast and the variability of plasma montelukast concentrations were higher than those observed in adults. based on population analyses, the mean auc (4296 ng•hr/ml [range 1200 to 7153]) was 60% higher and the mean c max (667 ng/ml [range 201 to 1058]) was 89% higher than those observed in adults (mean auc 2689 ng•hr/ml [range 1521 to 4595]) and mean c max (353 ng/ml [range 180 to 548]). the systemic exposure in children 12 to 23 months of age was less variable, but was still higher than that observed in adults. the mean auc (3574 ng•hr/ml [range 2229 to 5408]) was 33% higher and the mean c max (562 ng/ml [range 296 to 814]) was 60% higher than those observed in adults. safety and tolerability of montelukast in a single-dose pharmacokinetic study in 26 children 6 to 23 months of age were similar to that of patients two years and above [see adverse reactions (6.1) ]. the 4-mg oral granule formulation should be used for pediatric patients 12 to 23 months of age for the treatment of asthma, or for pediatric patients 6 to 23 months of age for the treatment of perennial allergic rhinitis. since the 4-mg oral granule formulation is bioequivalent to the 4-mg chewable tablet, it can also be used as an alternative formulation to the 4-mg chewable tablet in pediatric patients 2 to 5 years of age. drug interaction studies theophylline, prednisone, and prednisolone singulair has been administered with other therapies routinely used in the prophylaxis and chronic treatment of asthma with no apparent increase in adverse reactions. in drug-interaction studies, the recommended clinical dose of montelukast did not have clinically important effects on the pharmacokinetics of the following drugs: theophylline, prednisone, and prednisolone. montelukast at a dose of 10 mg once daily dosed to pharmacokinetic steady state, did not cause clinically significant changes in the kinetics of a single intravenous dose of theophylline [predominantly a cytochrome p450 (cyp) 1a2 substrate]. montelukast at doses of ≥100 mg daily dosed to pharmacokinetic steady state, did not cause any clinically significant change in plasma profiles of prednisone or prednisolone following administration of either oral prednisone or intravenous prednisolone. oral contraceptives, fexofenadine, digoxin, and warfarin in drug interaction studies, the recommended clinical dose of montelukast did not have clinically important effects on the pharmacokinetics of the following drugs: oral contraceptives (norethindrone 1 mg/ethinyl estradiol 35 mcg), digoxin, and warfarin. montelukast at doses of ≥100 mg daily dosed to pharmacokinetic steady state did not significantly alter the plasma concentrations of either component of an oral contraceptive containing norethindrone 1 mg/ethinyl estradiol 35 mcg. montelukast at a dose of 10 mg once daily dosed to pharmacokinetic steady state did not change the plasma concentration profile of fexofenadine, did not change the pharmacokinetic profile or urinary excretion of immunoreactive digoxin; did not change the pharmacokinetic profile of warfarin (primarily a substrate of cyp2c9, 3a4 and 1a2) or influence the effect of a single 30-mg oral dose of warfarin on prothrombin time or the international normalized ratio (inr). thyroid hormones, sedative hypnotics, non-steroidal anti-inflammatory agents, benzodiazepines, and decongestants although additional specific interaction studies were not performed, singulair was used concomitantly with a wide range of commonly prescribed drugs in clinical studies without evidence of clinical adverse interactions. these medications included thyroid hormones, sedative hypnotics, non-steroidal anti-inflammatory agents, benzodiazepines, and decongestants. cytochrome p450 (cyp) enzyme inducers phenobarbital, which induces hepatic metabolism, decreased the area under the plasma concentration curve (auc) of montelukast approximately 40% following a single 10-mg dose of montelukast. no dosage adjustment for singulair is recommended. it is reasonable to employ appropriate clinical monitoring when potent cyp enzyme inducers, such as phenobarbital or rifampin, are co-administered with singulair. effect of montelukast on cytochrome p450 (cyp) enzymes montelukast is a potent inhibitor of cyp2c8 in vitro. however, data from a clinical drug-drug interaction study involving montelukast and rosiglitazone (a probe substrate representative of drugs primarily metabolized by cyp2c8) in 12 healthy individuals demonstrated that the pharmacokinetics of rosiglitazone are not altered when the drugs are coadministered, indicating that montelukast does not inhibit cyp2c8 in vivo . therefore, montelukast is not anticipated to alter the metabolism of drugs metabolized by this enzyme (e.g., paclitaxel, rosiglitazone, and repaglinide). based on further in vitro results in human liver microsomes, therapeutic plasma concentrations of montelukast do not inhibit cyp 3a4, 2c9, 1a2, 2a6, 2c19, or 2d6. cytochrome p450 (cyp) enzyme inhibitors in vitro studies have shown that montelukast is a substrate of cyp 2c8, 2c9, and 3a4. co-administration of montelukast with itraconazole, a strong cyp 3a4 inhibitor, resulted in no significant increase in the systemic exposure of montelukast. data from a clinical drug interaction study involving montelukast and gemfibrozil (an inhibitor of both cyp 2c8 and 2c9) demonstrated that gemfibrozil, at a therapeutic dose, increased the systemic exposure of montelukast by 4.4-fold. co-administration of itraconazole, gemfibrozil, and montelukast did not further increase the systemic exposure of montelukast. based on available clinical experience, no dosage adjustment of montelukast is required upon co-administration with gemfibrozil [see overdosage (10) ] .

clinically significant effect on the pharmacokinetics of montelukast. a high fat meal in the morning did not affect the auc of montelukast oral granules; however, the meal decreased c max by 35% and prolonged t max from 2.3 ± 1.0 hours to 6.4 ± 2.9 hours. the safety and effectiveness of singulair in patients with asthma were demonstrated in clinical trials in which the 10-mg film-coated tablet and 5-mg chewable tablet formulations were administered in the evening without regard to the time of food ingestion. the safety of singulair in patients with asthma was also demonstrated in clinical trials in which the 4-mg chewable tablet and 4-mg oral granule formulations were administered in the evening without regard to the time of food ingestion. the safety and effectiveness of singulair in patients with seasonal allergic rhinitis were demonstrated in clinical trials in which the 10-mg film-coated tablet was administered in the morning or evening without regard to the time of food ingestion. the comparative pharmacokinetics of montelukast when administered as two 5-mg chewable tablets versus one 10-mg film-coated tablet have not been evaluated. distribution montelukast is more than 99% bound to plasma proteins. the steady state volume of distribution of montelukast averages 8 to 11 liters. orally administered montelukast distributes into the brain in rats. elimination the plasma clearance of montelukast averages 45 ml/min in healthy adults. following an oral dose of radiolabeled montelukast, 86% of the radioactivity was recovered in 5-day fecal collections and <0.2% was recovered in urine. coupled with estimates of montelukast oral bioavailability, this indicates that montelukast and its metabolites are excreted almost exclusively via the bile. in several studies, the mean plasma half-life of montelukast ranged from 2.7 to 5.5 hours in healthy young adults. the pharmacokinetics of montelukast are nearly linear for oral doses up to 50 mg. during once-daily dosing with 10-mg montelukast, there is little accumulation of the parent drug in plasma (14%). metabolism montelukast is extensively metabolized. in studies with therapeutic doses, plasma concentrations of metabolites of montelukast are undetectable at steady state in adults and pediatric patients. in vitro studies using human liver microsomes indicate that cyp3a4, 2c8, and 2c9 are involved in the metabolism of montelukast. at clinically relevant concentrations, 2c8 appears to play a major role in the metabolism of montelukast. specific populations patients with hepatic impairment patients with mild-to-moderate hepatic insufficiency and clinical evidence of cirrhosis had evidence of decreased metabolism of montelukast resulting in 41% (90% ci=7%, 85%) higher mean montelukast auc following a single 10-mg dose. the elimination of montelukast was slightly prolonged compared with that in healthy subjects (mean half-life, 7.4 hours). no dosage adjustment is required in patients with mild-to-moderate hepatic insufficiency. the pharmacokinetics of singulair in patients with more severe hepatic impairment or with hepatitis have not been evaluated. patients with renal impairment since montelukast and its metabolites are not excreted in the urine, the pharmacokinetics of montelukast were not evaluated in patients with renal insufficiency. no dosage adjustment is recommended in these patients . male and female patients the pharmacokinetics of montelukast are similar in males and females. racial groups pharmacokinetic differences due to race have not been studied. adolescents and pediatric patients pharmacokinetic studies evaluated the systemic exposure of the 4-mg oral granule formulation in pediatric patients 6 to 23 months of age, the 4-mg chewable tablets in pediatric patients 2 to 5 years of age, the 5-mg chewable tablets in pediatric patients 6 to 14 years of age, and the 10-mg film-coated tablets in young adults and adolescents ≥15 years of age. the plasma concentration profile of montelukast following administration of the 10-mg film-coated tablet is similar in adolescents ≥15 years of age and young adults. the 10-mg film-coated tablet is recommended for use in patients ≥15 years of age. the mean systemic exposure of the 4-mg chewable tablet in pediatric patients 2 to 5 years of age and the 5-mg chewable tablets in pediatric patients 6 to 14 years of age is similar to the mean systemic exposure of the 10-mg film-coated tablet in adults. the 5-mg chewable tablet should be used in pediatric patients 6 to 14 years of age and the 4-mg chewable tablet should be used in pediatric patients 2 to 5 years of age. in children 6 to 11 months of age, the systemic exposure to montelukast and the variability of plasma montelukast concentrations were higher than those observed in adults. based on population analyses, the mean auc (4296 ng•hr/ml [range 1200 to 7153]) was 60% higher and the mean c max (667 ng/ml [range 201 to 1058]) was 89% higher than those observed in adults (mean auc 2689 ng•hr/ml [range 1521 to 4595]) and mean c max (353 ng/ml [range 180 to 548]). the systemic exposure in children 12 to 23 months of age was less variable, but was still higher than that observed in adults. the mean auc (3574 ng•hr/ml [range 2229 to 5408]) was 33% higher and the mean c max (562 ng/ml [range 296 to 814]) was 60% higher than those observed in adults. safety and tolerability of montelukast in a single-dose pharmacokinetic study in 26 children 6 to 23 months of age were similar to that of patients two years and above [see adverse reactions (6.1) ]. the 4-mg oral granule formulation should be used for pediatric patients 12 to 23 months of age for the treatment of asthma, or for pediatric patients 6 to 23 months of age for the treatment of perennial allergic rhinitis. since the 4-mg oral granule formulation is bioequivalent to the 4-mg chewable tablet, it can also be used as an alternative formulation to the 4-mg chewable tablet in pediatric patients 2 to 5 years of age. drug interaction studies theophylline, prednisone, and prednisolone singulair has been administered with other therapies routinely used in the prophylaxis and chronic treatment of asthma with no apparent increase in adverse reactions. in drug-interaction studies, the recommended clinical dose of montelukast did not have clinically important effects on the pharmacokinetics of the following drugs: theophylline, prednisone, and prednisolone. montelukast at a dose of 10 mg once daily dosed to pharmacokinetic steady state, did not cause clinically significant changes in the kinetics of a single intravenous dose of theophylline [predominantly a cytochrome p450 (cyp) 1a2 substrate]. montelukast at doses of ≥100 mg daily dosed to pharmacokinetic steady state, did not cause any clinically significant change in plasma profiles of prednisone or prednisolone following administration of either oral prednisone or intravenous prednisolone. oral contraceptives, fexofenadine, digoxin, and warfarin in drug interaction studies, the recommended clinical dose of montelukast did not have clinically important effects on the pharmacokinetics of the following drugs: oral contraceptives (norethindrone 1 mg/ethinyl estradiol 35 mcg), digoxin, and warfarin. montelukast at doses of ≥100 mg daily dosed to pharmacokinetic steady state did not significantly alter the plasma concentrations of either component of an oral contraceptive containing norethindrone 1 mg/ethinyl estradiol 35 mcg. montelukast at a dose of 10 mg once daily dosed to pharmacokinetic steady state did not change the plasma concentration profile of fexofenadine, did not change the pharmacokinetic profile or urinary excretion of immunoreactive digoxin; did not change the pharmacokinetic profile of warfarin (primarily a substrate of cyp2c9, 3a4 and 1a2) or influence the effect of a single 30-mg oral dose of warfarin on prothrombin time or the international normalized ratio (inr). thyroid hormones, sedative hypnotics, non-steroidal anti-inflammatory agents, benzodiazepines, and decongestants although additional specific interaction studies were not performed, singulair was used concomitantly with a wide range of commonly prescribed drugs in clinical studies without evidence of clinical adverse interactions. these medications included thyroid hormones, sedative hypnotics, non-steroidal anti-inflammatory agents, benzodiazepines, and decongestants. cytochrome p450 (cyp) enzyme inducers phenobarbital, which induces hepatic metabolism, decreased the area under the plasma concentration curve (auc) of montelukast approximately 40% following a single 10-mg dose of montelukast. no dosage adjustment for singulair is recommended. it is reasonable to employ appropriate clinical monitoring when potent cyp enzyme inducers, such as phenobarbital or rifampin, are co-administered with singulair. effect of montelukast on cytochrome p450 (cyp) enzymes montelukast is a potent inhibitor of cyp2c8 in vitro. however, data from a clinical drug-drug interaction study involving montelukast and rosiglitazone (a probe substrate representative of drugs primarily metabolized by cyp2c8) in 12 healthy individuals demonstrated that the pharmacokinetics of rosiglitazone are not altered when the drugs are coadministered, indicating that montelukast does not inhibit cyp2c8 in vivo . therefore, montelukast is not anticipated to alter the metabolism of drugs metabolized by this enzyme (e.g., paclitaxel, rosiglitazone, and repaglinide). based on further in vitro results in human liver microsomes, therapeutic plasma concentrations of montelukast do not inhibit cyp 3a4, 2c9, 1a2, 2a6, 2c19, or 2d6. cytochrome p450 (cyp) enzyme inhibitors in vitro studies have shown that montelukast is a substrate of cyp 2c8, 2c9, and 3a4. co-administration of montelukast with itraconazole, a strong cyp 3a4 inhibitor, resulted in no significant increase in the systemic exposure of montelukast. data from a clinical drug interaction study involving montelukast and gemfibrozil (an inhibitor of both cyp 2c8 and 2c9) demonstrated that gemfibrozil, at a therapeutic dose, increased the systemic exposure of montelukast by 4.4-fold. co-administration of itraconazole, gemfibrozil, and montelukast did not further increase the systemic exposure of montelukast. based on available clinical experience, no dosage adjustment of montelukast is required upon co-administration with gemfibrozil [see overdosage (10) ] .

produced reductions in fertility 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).

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).

ne percent of predicted forced expiratory volume in 1 second (fev 1 ) of 66% (approximate range, 40 to 90%). the co-primary endpoints in these trials were fev 1 and daytime asthma symptoms. in both studies after 12 weeks, a random subset of patients receiving singulair 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 fev 1 , 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 singulair 10-mg tablet daily in the evening resulted in a statistically significant increase in fev 1 percent change from baseline (13.0%-change in the group treated with singulair vs. 4.2%-change in the placebo group, p<0.001); the change from baseline in fev 1 for singulair 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 fev 1 were similar. figure 2: fev 1 mean percent change from baseline (u.s. trial: singulair n=406; placebo n=270) (anova model) the effect of singulair on other primary and secondary endpoints, represented by the multinational study is shown in table 6 . results on these endpoints were similar in the us study. table 6: effect of singulair on primary and secondary endpoints in a multinational placebo-controlled trial (anova model) singulair 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 p<0.001, compared with placebo 245 2.40 -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 both studies evaluated the effect of singulair 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 singulair experienced asthma attacks compared with patients on placebo (27.3%, p<0.001). in the us study, 7.8% of patients on singulair 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 singulair 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 singulair 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 singulair, 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 singulair 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 singulair 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 singulair and 135 treated with placebo) using an inhaled β-agonist on an "as-needed" basis. the patients had a mean baseline percent predicted fev 1 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 singulair chewable tablet daily resulted in a significant improvement in mean morning fev 1 percent change from baseline (8.7% in the group treated with singulair 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 singulair 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 singulair 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 singulair. 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 singulair 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 singulair 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 singulair 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 fev 1 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 singulair 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 singulair to beclomethasone resulted in statistically significant improvements in fev 1 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 singulair alone or placebo alone as indicated by fev 1 , 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 singulair, compared with placebo, resulted in significant improvement in parameters of asthma control. the magnitude of effect of singulair in aspirin-sensitive patients was similar to the effect observed in the general population of asthma patients studied. the effect of singulair 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 singulair, 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 (singulair 10 mg or placebo). the primary endpoint was the mean maximum percent fall in fev 1 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 singulair 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 7 and are representative of the results from the other two studies. table 7: mean maximum percent fall in fev 1 following exercise challenge in study a (n=47) anova model time of exercise challenge following medication administration mean maximum percent fall in fev 1 least squares-mean treatment difference % for singulair versus placebo (95% ci) singulair placebo 2 hours 13 22 -9 (-12, -5) 8.5 hours 12 17 -5 (-9, -2) 24 hours 10 14 -4 (-7, -1) the efficacy of singulair 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 (singulair 5 mg or placebo). the primary endpoint was the mean maximum percent fall in fev 1 following the 2 hours post-dose exercise challenge. a single dose of singulair 5 mg demonstrated a statistically significant protective benefit against eib when taken 2 hours prior to exercise ( table 8 ). 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 8: mean maximum percent fall in fev 1 following exercise challenge in pediatric patients (n=64) anova model time of exercise challenge following medication administration mean maximum percent fall in fev 1 least squares-mean treatment difference % for singulair versus placebo (95% ci) singulair placebo 2 hours 15 20 -5 (-9, -1) 24 hours 13 17 -4 (-7, -1) the efficacy of singulair for prevention of eib in patients below 6 years of age has not been established. daily administration of singulair 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 fev 1 percent of predicted of 83% and with documented exercise-induced exacerbation of asthma, treatment with singulair, 10 mg, once daily in the evening, resulted in a statistically significant reduction in mean maximal percent fall in fev 1 and mean time to recovery to within 5% of the pre-exercise fev 1 . 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. singulair did not, however, prevent clinically significant deterioration in maximal percent fall in fev 1 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 singulair. 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 singulair 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 singulair 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 0-3 categorical scale. four of the five trials showed a significant reduction in daytime nasal symptoms scores with singulair 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 singulair tablets, loratadine, and placebo are shown in table 9 . the remaining three trials that demonstrated efficacy showed similar results. efficacy was demonstrated for seasonal allergic rhinitis when montelukast was administered in the morning or the evening. table 9: effects of singulair on daytime nasal symptoms score average of individual scores of nasal congestion, rhinorrhea, nasal itching, sneezing as assessed by patients on a 0-3 categorical scale. 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 singulair 10 mg (344) 2.09 -0.39 -0.13 statistically different from placebo (p≤0.001). (-0.21, -0.06) placebo (351) 2.10 -0.26 n.a. active control the study was not designed for statistical comparison between singulair and the active control (loratadine). (loratadine 10 mg) (599) 2.06 -0.46 -0.24 (-0.31, -0.17) perennial allergic rhinitis the efficacy of singulair 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 singulair 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. singulair 10-mg tablets once daily was shown to significantly reduce symptoms of perennial allergic rhinitis over a 6-week treatment period ( table 10 ); 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 10: effects of singulair on daytime nasal symptoms score average of individual scores of nasal congestion, rhinorrhea, sneezing as assessed by patients on a 0-3 categorical scale. 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 singulair 10 mg (1000) 2.09 -0.42 -0.08 statistically different from placebo (p≤0.001). (-0.12, -0.04) placebo (980) 2.10 -0.35 n.a. the other 6-week study evaluated singulair 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 singulair vs. placebo over the first 4 weeks of treatment; the study was not designed for statistical comparison between singulair and the active-control. the primary outcome variable included nasal itching in addition to nasal congestion, rhinorrhea, and sneezing. the estimated difference between singulair 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). image of figure 2

e (hdpe) bottles of 30 with a polypropylene child-resistant cap, an aluminum foil induction seal, and silica gel desiccant ndc 78206-172-02 unit of use high-density polyethylene (hdpe) bottles of 90 with a polypropylene child-resistant cap, an aluminum foil induction seal, and silica gel desiccant. storage store singulair 4-mg oral granules, 4-mg chewable tablets, 5-mg chewable tablets and 10-mg film-coated tablets at 20°c to 25°c (68°f to 77°f), excursions permitted to 15°c to 30°c (59°f to 86°f) [see usp controlled room temperature]. protect from moisture and light. store in original package.

suicidal behavior [see warnings and precautions (5.1) ] . advise patients to take singulair daily as prescribed, even when they are asymptomatic, as well as during periods of worsening asthma, and to contact their physicians if their asthma is not well controlled. advise patients that oral singulair is not for the treatment of acute asthma attacks. they should have appropriate short-acting inhaled β-agonist medication available to treat asthma exacerbations. patients who have exacerbations of asthma after exercise should be instructed to have available for rescue a short-acting inhaled β-agonist. daily administration of singulair for the chronic treatment of asthma has not been established to prevent acute episodes of eib [see warnings and precautions (5.2) ] . advise patients to seek medical attention if short-acting inhaled bronchodilators are needed more often than usual, or if more than the maximum number of inhalations of short-acting bronchodilator treatment prescribed for a 24-hour period are needed. instruct patients to continue other anti-asthma medications as prescribed unless instructed by a physician. instruct patients with known aspirin sensitivity to continue avoidance of aspirin or non-steroidal anti-inflammatory agents while taking singulair [see warnings and precautions (5.4) ] . inform phenylketonuric patients that the 4-mg and 5-mg chewable tablets contain phenylalanine (a source of aspartame) [see warnings and precautions (5.6) ] .