4.1. Therapeutic indications

Montelukast is indicated in the treatment of asthma as add-on therapy in those patients with mild to moderate persistent asthma who are inadequately controlled on inhaled corticosteroids and in whom 'as-needed' short-acting beta-agonists provide inadequate clinical control of asthma.

Montelukast may also be an alternative treatment option to low-dose inhaled corticosteroids for patients with mild persistent asthma who do not have a recent history of serious asthma attacks that required oral corticosteroid use, and who have demonstrated that they are not capable of using inhaled corticosteroids (see section 4.2).

Montelukast is also indicated in the prophylaxis of asthma in which the predominant component is exercise-induced bronchoconstriction.

4.2. Posology and method of administration

The dosage for paediatric patients 6-14 years of age is one 5 mg chewable tablet daily to be taken in the evening. The tablets are to be chewed before swallowing. If taken in connection with food, montelukast should be taken 1 hour before or 2 hours after food. No dosage adjustment within this age group is necessary. General recommendations: The therapeutic effect of montelukast on parameters of asthma control occurs within one day. Patients should be advised to continue taking montelukast even if their asthma is under control, as well as during periods of worsening asthma. No dosage adjustment is necessary for patients with renal insufficiency, or mild to moderate hepatic impairment. There are no data on patients with severe hepatic impairment. The dosage is the same for both male and female patients. Montelukast as an alternative treatment option to low-dose inhaled corticosteroids for mild persistent asthma: Montelukast is not recommended as monotherapy in patients with moderate persistent asthma. The use of montelukast as an alternative treatment option to low-dose inhaled corticosteroids for children with mild persistent asthma should only be considered for patients who do not have a recent history of serious asthma attacks that required oral corticosteroid use and who have demonstrated that they are not capable of using inhaled corticosteroids (see section 4.1). Mild persistent asthma is defined as asthma symptoms more than once a week but less than once a day, nocturnal symptoms more than twice a month but less than once a week, normal lung function between episodes. If satisfactory control of asthma is not achieved at follow-up (usually within one month), the need for an additional or different anti-inflammatory therapy based on the step system for asthma therapy should be evaluated. Patients should be periodically evaluated for their asthma control. Therapy with montelukast in relation to other treatments for asthma. When treatment with montelukast is used as add-on therapy to inhaled corticosteroids, montelukast should not be abruptly substituted for inhaled corticosteroids (see section 4.4). The 10 mg film-coated tablets are available for adults and adolescents aged 15 years and older. Paediatric population Do not give montelukast 5 mg chewable tablets to children less than 6 years of age. The safety and efficacy of 5 mg chewable tablets in children less than 6 years of age has not been established. For paediatric patients 2 to 5 years of age, it is recommended to use a paediatric formulation of 4 mg chewable tablets. There are a different forms of this medicine available for paediatric patients based on age range, for children who have problems consuming a chewable tablet. Method of administration For oral use only The tablets are to be chewed before swallowing. <summary id="CONTRAINDICATIONS" data-evt="smpcSectionOpen"

4.3. Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1. <summary id="CLINICAL_PRECAUTIONS" data-evt="smpcSectionOpen"

4.4. Special warnings and precautions for use

Neuropsychiatric events such as behavioural changes, depression and suicidality have been reported in all age groups taking montelukast (see section 4.8). The symptoms may be serious and continue if the treatment is not withdrawn. Therefore the treatment with montelukast should be discontinued if neuropsychiatric symptoms occur during treatment. Advise patients and/or caregivers to be alert for neuropsychiatric events and instruct them to notify their physician if these changes in behaviour occur. There have been post-marketing reports which indicate that some neuropsychiatric symptoms may persist after montelukast is stopped. Advise patients and/or caregivers to be remain vigilant for symptoms that do not resolve following discontinuation of montelukast and to notify their prescriber accordingly. Patients should be advised never to use oral montelukast to treat acute asthma attacks and to keep their usual appropriate rescue medication for this purpose readily available. If an acute attack occurs, a short-acting inhaled β-agonist should be used. Patients should seek their doctor's advice as soon as possible if they need more inhalations of short-acting β-agonists than usual. Montelukast should not be abruptly substituted for inhaled or oral corticosteroids. There are no data demonstrating that oral corticosteroids can be reduced when montelukast is given concomitantly. In rare cases, patients on therapy with anti-asthma agents including montelukast 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 (see section 4.8). These cases have been sometimes associated with the reduction or withdrawal of oral corticosteroid therapy. Although a causal relationship with leukotriene receptor antagonism has not been established, physicians should be alert to eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, and/or neuropathy presenting in their patients. Patients who develop these symptoms should be reassessed and their treatment regimens evaluated. Treatment with montelukast does not alter the need for patients with aspirin-sensitive asthma to avoid taking aspirin and other non-steroidal anti-inflammatory drugs. Montelukast contains aspartame, a source of phenylalanine. Patients with phenylketonuria should take into account that each 5 mg chewable tablets contain phenylalanine in an amount equivalent to 0.842 mg phenylalanine per dose which may be harmful for children with phenylketonuria. This medicine contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially 'sodium-free'. <summary id="INTERACTIONS" data-evt="smpcSectionOpen"

4.5. Interaction with other medicinal products and other forms of interaction

Montelukast may be administered with other therapies routinely used in the prophylaxis and chronic treatment of asthma. In drug-interactions studies, the recommended clinical dose of montelukast did not have clinically important effects on the pharmacokinetics of the following medicinal products: theophylline, prednisone, prednisolone, oral contraceptives (ethinyl oestradiol/norethindrone 35/1), terfenadine, digoxin and warfarin. The area under the plasma concentration curve (AUC) for montelukast was decreased approximately 40% in subjects with co-administration of phenobarbital. Since montelukast is metabolised by CYP 3A4, 2C8, and 2C9, caution should be exercised, particularly in children, when montelukast is co-administered with inducers of CYP 3A4, 2C8, and 2C9, such as phenytoin, phenobarbital and rifampicin. In vitro studies have shown that montelukast is a potent inhibitor of CYP 2C8. However, data from a clinical drug-drug interaction study involving montelukast and rosiglitazone (a probe substrate representative of medicinal products primarily metabolised by CYP 2C8) demonstrated that montelukast does not inhibit CYP 2C8 in vivo. Therefore, montelukast is not anticipated to markedly alter the metabolism of medicinal products metabolised by this enzyme (eg., paclitaxel, rosiglitazone, and repaglinide). In vitro studies have shown that montelukast is a substrate of CYP 2C8, and to a less significant extent, of 2C9, and 3A4. In a clinical drug-drug interaction study involving montelukast and gemfibrozil (an inhibitor of both CYP 2C8 and 2C9) gemfibrozil increased the systemic exposure of montelukast by 4.4-fold. No routine dosage adjustment of montelukast is required upon co-administration with gemfibrozil or other potent inhibitors of CYP 2C8, but the physician should be aware of the potential for an increase in adverse reactions. Based on in vitro data, clinically important drug interactions with less potent inhibitors of CYP 2C8 (e.g., trimethoprim) are not anticipated. Co-administration of montelukast with itraconazole, a strong inhibitor of CYP 3A4, resulted in no significant increase in the systemic exposure of montelukast. <summary id="PREGNANCY" data-evt="smpcSectionOpen"

4.6. Fertility, pregnancy and lactation

Pregnancy

Animal studies do not indicate harmful effects with respect to effects on pregnancy or embryonal/foetal development.

Available data from published prospective and retrospective cohort studies with montelukast use in pregnant women evaluating major birth defects have not established a drug-associated risk. Available studies have methodologic limitations, including small sample size, in some cases retrospective data collection, and inconsistent comparator groups.

Montelukast may be used during pregnancy only if it is considered to be clearly essential..

Breast-feeding

Studies in rats have shown that montelukast is excreted in milk (see section 5.3). It is not known if montelukast/metabolites are excreted in human milk.

Montelukast may be used in breast-feeding mothers only if it is considered to be clearly essential.

4.7. Effects on ability to drive and use machines

Montelukast has no or negligible influence on the ability to drive and use machinery machineries. However, individuals have reported drowsiness or dizziness (see section 4.8).

4.8. Undesirable effects

Montelukast has been evaluated in clinical studies as follows: • 10 mg film-coated tablets in approximately 4,000 adult and adolescent asthmatic patients 15 years of age and older, and • 5 mg chewable tablets in approximately 1,750 paediatric patients 6 to 14 years of age. The following drug-related adverse reactions in clinical studies were reported commonly (≥1/100 to <1/10) in patients treated with montelukast and at a greater incidence than in patients treated with placebo: System Organ Class Adult and Adolescent Patients 15 years and older (two 12-week studies; n=795) Paediatric Patients 6 to 14 years old (one 8-week study; n=201) (two 56-week studies; n=615) Nervous system disorders headache headache Gastro-intestinal disorders abdominal pain With prolonged treatment in clinical trials with a limited number of patients for up to 2 years for adults, and up to 12 months for paediatric patients 6 to 14 years of age, the safety profile did not change. Tabulated list of Adverse Reactions Adverse reactions reported in post-marketing use are listed, by MedDRA System Organ Class and specific Adverse Experience Term, in the table below. Frequency Categories were estimated based on relevant clinical trials and ranked by frequency as follows: Very Common (≥1/10), Common (≥1/100 to <1/10), Uncommon (≥1/1000 to <1/100), Rare (≥1/10,000 to <1/1000), Very Rare (≥1/10,000) and Not known (cannot be estimated from the available data) System Organ Class Adverse Reaction Frequency Category* Infections and infestations upper respiratory infection † Very Common Blood and lymphatic system disorders increased bleeding tendency Rare thrombocytopenia Very Rare Immune system disorder hypersensitivity reactions including anaphylaxis Uncommon hepatic eosinophilic infiltration Very Rare Psychiatric disorders dream abnormalities including nightmares, insomnia, somnambulism, , anxiety, agitation including aggressive behaviour or hostility, depression, psychomotor hyperactivity (including irritability, restlessness, tremor § ) Uncommon disturbance in attention, memory impairment, tic Rare hallucinations, disorientation, suicidal thinking and behaviour (suicidality), obsessive-compulsive symptoms, dysphemia Very Rare Nervous system disorder dizziness, drowsiness paraesthesia/hypoesthesia, seizure Uncommon Cardiac disorders palpitations Rare Respiratory, thoracic and mediastinal disorders epistaxis Uncommon Churg‑Strauss Syndrome (CSS) (see section 4.4) Very Rare Pulmonary eosinophilia Very rare Gastrointestinal disorders diarrhoea ‡ , nausea ‡ , vomiting ‡ Common dry mouth, dyspepsia Uncommon Hepatobiliary disorders elevated levels of serum transaminases (ALT, AST) Common hepatitis (including cholestatic, hepatocellular, and mixed-pattern liver injury). Very Rare Skin and subcutaneous tissue disorders rash ‡ Common bruising, urticaria, pruritus Uncommon angiooedema Rare erythema nodosum, erythema multiforme Very Rare Musculoskeletal and connective tissue disorders arthralgia, myalgia including muscle cramps Uncommon Renal and urinary disorders Enuresis in children Uncommon General disorders and administration site conditions pyrexia ‡ Common asthenia/fatigue, malaise, oedema, Uncommon † This adverse experience, reported as Very Common in the patients who received montelukast, was also reported as Very Common in the patients who received placebo in clinical trials. ‡ This adverse experience, reported as Common in the patients who received montelukast, was also reported as Common in the patients who received placebo in clinical trials. § Frequency Category: Rare Reporting of suspected adverse reactions Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App store. <summary id="OVERDOSE" data-evt="smpcSectionOpen"

4.9. Overdose

In chronic asthma studies, montelukast has been administered at doses up to 200 mg/day to adult patients for 22 weeks and in short-term studies, up to 900 mg/day to patients for approximately one week without clinically important adverse experiences.

There have been reports of acute overdose in post-marketing experience and clinical studies with montelukast. These include reports in adults and children with a dose as high as 1000 mg (approximately 61 mg/kg in a 42 month old child). The clinical and laboratory findings observed were consistent with the safety profile in adults and paediatric patients. There were no adverse experiences in the majority of overdose reports.

Symptoms of overdose

The most frequently occurring adverse experiences were consistent with the safety profile of montelukast and included abdominal pain, somnolence, thirst, headache, vomiting, and psychomotor hyperactivity.

Management of overdose

No specific information is available on the treatment of overdose with montelukast. It is not known whether montelukast is dialysable by peritoneal- or haemo-dialysis.