A 15-year-old female is seen for a follow-up visit after being started 3 months ago on montelukast (Singulair) for mild persistent asthma and seasonal allergic rhinitis. In addition to reviewing asthma control, which assessment is most important for the nurse practitioner to complete at every visit?

Question

Accepted Answer

✅ B. Screen for depression, anxiety, agitation, sleep disturbance, and suicidal ideation
Montelukast carries a BOXED WARNING (added by FDA in March 2020) for serious neuropsychiatric events, including depression, suicidal thoughts and behavior, agitation, aggression, hallucinations, sleep disturbance, and tremor. Adolescents are a particularly vulnerable group. The AANP-aligned approach is to screen for these symptoms at every visit while the patient is on montelukast, counsel the patient and family about what to watch for, and discontinue the drug if symptoms emerge. Because of this warning, montelukast is no longer first-line for allergic rhinitis when other options (intranasal steroids, antihistamines) are appropriate.

❌ A. Obtain annual liver function tests
Montelukast is generally well tolerated hepatically; routine LFT monitoring is not recommended. LFT monitoring is standard for drugs like isoniazid, methotrexate, and statins — not montelukast.

❌ C. Measure serum drug level and adjust dose
Montelukast does not require serum level monitoring. It is dosed by age/weight category (4 mg chewable ages 2–5, 5 mg chewable ages 6–14, 10 mg tablet age 15+), and levels are not used clinically.

❌ D. Monitor for QT prolongation with annual ECG
Montelukast has no known effect on the QT interval and does not require cardiac monitoring. QT monitoring applies to drugs like certain antipsychotics, macrolides, fluoroquinolones, and methadone.

:::danger
Montelukast has an FDA boxed warning (2020) for neuropsychiatric events — depression, suicidal ideation, agitation, sleep disturbance. Ask teens AND parents about mood and sleep at every visit, and stop the drug if symptoms appear.
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Montelukast

✅ Indications

⚙️ Mechanism of Action

📏 Dosing

🚫 Contraindications

⚠️ Adverse Effects

🔬 Monitoring

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