Sunday, July 26, 2009

Sick About Singulair

The New York Times' business section recently reported that despite a second-quarter earnings fall, hurt by lower sales of its cholesterol drugs (specifically Vytorin, see my posts on why you should no longer use this product), Merck actually beat profit forecasts due to good sales of its asthma drug Singulair. Singulair's quarterly sales jumped 16 percent to $1.3 billion. That's a lot of money! Indeed, based on pharmacy data (via drugtopics.com, thanks again Mr. Medsaver for this great resource), Singualir was the 4th most commonly prescribed drug in 2008 at a close to 26 million prescriptions! Moreover, a recent report from the WSJ Health Blog states that Merk is looking to put Singualir over the counter.



I have no ill will towards Merk. It is an American company that has come up with some products that I find beneficial for patients including Fosamax (which is now generic) and Januvia, and they are the makers of two important vaccines: Gardisil and Zostavax. However, I am concerned about high sales of the asthma drug Singulair, because national guidelines state it should not be used as a first line therapy for asthma.



Facts about asthma



According to the American Lung association, in 2007, it was estimated that 22.9 million Americans currently have asthma. Of these, 12.3 million Americans (3.8 million children under 18) had an asthma attack. In 2005, there were 3,884 deaths attributed to asthma. During 2006, 444,000 hospitalizations and close to 1.7 million emergency room visits were attributed to asthma.



In 2007, the NIH released updated guidelines about asthma. Regarding treatment, the guidelines suggest that all asthmatics with persistent asthma (symptoms or rescue medication use more than twice a week) be initiated on inhaled corticosteroids (ICS). ICS's are considered first line treatment for all asthmatics, from babies to children to adults and to the elderly. The reason is based on solid evidence that these agents work the best in improving lung function and decreasing symptoms. Singulair is listed as an alternative agent. Singulair is an anti-leukotriene. Leukotrienes, like histamines, are substances released in an allergic response that cause the airways to tighten up. Thus, Singulair works in the same way that antihistamines work: by treating the symptoms. ICS's work by blocking inflammation which is what causes the release of leukotrienes in the first place. Singulair is not anti-inflammatory, ICS's are. Singulair treats the symptoms, whereas ICS's treat the problem. This is why study after study proves that ICS's are superior to Singulair, and why guidelines place ICS's as first line treatment and Singulair as alternative.





Does Singulair work?
Of course Singulair works. In order for a drug to be approved by the FDA, the drug company has to show that its product is efficacious. The problem is that it has to show that it is efficacious compared to placebo. Thus, Singulair works better than a sugar pill. However, compared to any other asthma medication, it is not as good. Even when added on to an ICS, it is not as good as other add ons, such as long acting beta agonists (LABA's).



Why do physicians prescribe so much Singulair when is not what the guidelines recommend?

This is an extremely important question. Some may chalk it up to drug company marketing. However, all the ICS and ICS/LABA making companies due their job marketing their product as well. I think the main reason has to do with fear of ICS's. Corticosteroids are different than the kind of steroids athletes take. However, they are not without side effects. Earlier studies on older medications showed some growth delay in children, which is why pediatricians may be so reluctant to use ICS's. However, more recent studies showed that for the newer agents, long term use with mild to moderate doses did NOT cause growth delay. In 2002, the NIH reviewed all the literature and determined that at low to medium doses of ICS's, there are NO SIGNIFICANT SIDE EFFECTS. This is when ICS's became considered first line therapy for ALL asthmatics.

The other issue is the convenience factor of a pill vs. an inhaler. Inhaler use is clearly not as easy as taking a pill (Singulair comes chewable for children).

The thought is probably, "it's a once a day pill that might help my patient, and probably won't hurt them, so why not give it try?" The problem with this approach, is the failure to consider the risks of uncontrolled asthma. Uncontrolled asthma leads to ER visits, hospitalizations, and possible even death. Asthma is a serious disease. For patients who have persistent asthma, following the guideline recommendations of ICS's as first line agents is the right thing to do.



What about allergies?

Singulair is also indicated for allergic rhinitis or allergies. As above, like histamine, leukotrienes play a role in allergic rhinitis, and this is why Singulair is used. I have posted about Singulair and allergic rhinitis previously. Basically, there are several treatments for nasal allergies:Non-sedating antihistamines (Claritin, Zyrtec, Allegra), Leukotriene modifiers (Singulair), inhlaed nasal steroids (Flonase or fluticasone, Rhinocort, Nasacort, Veramyst) and inhaled nasal antihistamines (Astepro). Muliple studies that show that fluticasone (Flonase) is better than Singulair, better than Claritin, and several studies that show that the combination of Singulair and Claritin is not better than either agent alone. However, in one study, though the combination of Singulair and Claritin was better than either agent alone, the individual agents were no better than placebo. An excellent review by Dr. Robert Nathan showed that "leukotriene receptor antagonists (Singulair) are sometimes more effective than placebo, are no more effective than nonsedating antihistamines (Claritin) , and are less effective than intranasal corticosteroids in the treatment of allergic rhinitis." Finally, a recent guideline from World Health Organization suggests that for patients with mild, intermittent allergic rhinitis; treatment with non-sedating antihistamines and leukotriene modifiers were both acceptable forms of treatment, but patients with more chronic or bothersome symptoms, inhaled nasal steroids should be used.

Some would argue that having both allergies and asthma together would be a reason to take Singulair. There is no question that treating allergic rhinitis may help with asthma symptoms. However, the killing two birds in one stone approach simply hasn't been proven to be the case. If you have allergic rhinitis that makes your asthma worse, you should take the most effective agent, which is inhaled nasal steroids.





What if I am taking Singulair for asthma?

Singulair has been proven more effective than placebo, and in some individuals controls their asthma and allergies. However, a recent internet survey revealed that about 55% of asthmatics have uncontrolled asthma, and many of them are on regular medications. Asthma control is the key, according to the new NIH guidelines. If your asthma is well controlled on Singulair, then it is probably OK to take. However, there is a theoretical risk that by taking Singulair (treating the symptoms without treating the underlying inflammation), that though you feel well now, your lung function will be worsening over time. More importantly, if you are taking Singulair and your asthma is not well controlled, then you should definitely switch to at least an inhaled corticosteroid, or possibly an agent combining an ICS with a long acting brochodilator (LABA) such as Advair or Symbicort. There are many ways to determine asthma control, including how much rescue medications you are taking and how asthma affects your daily life. The easiest way to determine your asthma control is by taking the Asthma Control Test

45 comments:

Anonymous said...

Before I required ICS and oral corticosteroids, Singulair was the only medication I needed to breathe. As my asthma and other pulmonary disease has worsened, I don't notice a difference so rarely take it unless I have allergy symptoms. I do credit Singulair with having kept me off steroids and other medications for several years. So, perhaps my disease worsened silently while Singulair masked sypmtoms. Bottom line is, I breathed on Singulair, experienced no side effects (such as weight gain or increased susceptibility to infection.) From a patient's perspective, I consider it a great drug and I thank Merck and the fine physicians who provided us with this alternative. (And while Claritin helped my stuffy-runny nose, it did nothing to open my airways.)

I do think it's overprescribed. If benadryl or claritin will handle seasonal allergies, why use a a more potent medication?

I would be alarmed if Singular was to become OTC. Anyone with serious enough illness to require Singulair should be under a physicians' care.

Anonymous said...

_____________________________________________________________________________


FDA RECOGNIZES SINGULAIR'S NEUROPSYCHIATRIC SIDE EFFECTS


On June 12, 2009, the FDA announced that in April 2009, they completed their review of neuropsychiatric events, (mood and behavioral changes) associated with SINGULAIR (montelukast) and other drugs that act through the leukotriene pathway.


FDA stated: "Neuropsychiatric events have been reported in some patients taking montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo and Zyflo CR). FDA has requested that manufacturers include a precaution in the drug prescribing information (drug labeling)."

"The reported neuropsychiatric events include postmarket cases of agitation, aggression, anxiousness, dream abnormalities and hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior (including suicide), and tremor."

FDA advised: "Patients and healthcare professionals should be aware of the potential for neuropsychiatric events with these medications. Patients should talk with their healthcare providers if these events occur. Healthcare professionals should consider discontinuing these medications if patients develop neuropsychiatric symptoms."

Joy said...

There are certain drugs which react with Singulair and increase the side effects. Those drugs are . Carbamazepine
. Phenobarbital
. Phenytoin
. Rifabutin
. Rifampin
. Troglitazone you can have a look at them at http://www.internationaldrugmart.com/Singulair.html

Joy said...

There are certain drugs which interact with singulair, they are . Carbamazepine
. Phenobarbital
. Phenytoin
. Rifabutin
. Rifampin
. Troglitazone you can also find more details at International Drug Mart

Paolo said...

I share your concern about Singulair...but I think it's pretty clear why it's being used as a first line therapy for asthma...I mean wheter you wanna admit it or not some of the doctors have unofficial sponsors..and those sponsors are pharmaceutical companies...the drug gets high sales and the doc's involved get lots of money...or their research gets the funds they needed etc.

Sarah D. said...

Singulair works well to releive my asthma and allergies. When I tried to use an inhaled steroid as a management med for my asthma, I turned into a crazy person, even though I was using the smallest dose. I have experienced tinnitus with Singulair, but have otherwise been very pleased. I call it a *miracle drug* for relief of a lifetime of severe allergies that were not fully treated with zyrtec alone.

Montelukast said...

Although Singulair 10mg tablets work great for me on a daily, regular basis for maintenance issues with asthma, I have found that one of its side effects has appeared. At first it was not connected until recently when information came out that Singulair could cause ear infections. This particular side effect appeared about 3-4 months after starting Singulair but no connectione was made until recently after using it for two years. So be aware of side effects and keep close tabs on usage results.

Random Thoughts and Musings said...

I have been on Singulair for several months (along with allegra and flonase) for seasonal allergies. I generally tolerated these medications well with one exception. I developed tinnitus around the time I started the Singulair. I am not sure (neither are my drs. if the singulair is the culprit. What are your thoughts? Have you heard of singulair causing tinnitus?

Anonymous said...

32m. Have allergies my entire life; have even had sinus surgery. Singulair combined with Claritin or Allegra D is the only medical combination that has nearly eliminates my allergy symptons. Unfortunately, I 100% notice a difference in my mental psyche when taking Singulair, and without it, Allegra D or Claritin do nothing. I am absolutely more prone to feeling melancholy and "down" and I am absolutely irritable on Singulair. The symptons immediately stop within 5 days of stopping it. Unfortunately, the side effects for me forced me to stop taking Singulair, unless I am brutally bad.

Catfish said...

I have been experiencing suicidal thoughts and am eliminating using singulair today. I will keep you posted as to my progress on only my advair. How long does it take(approximately) before I will stop experiencing symptoms? REALLY like your blog!

Dr. Matthew Mintz said...

@Catfish,
Sorry to hear about your suicidal thoughts. It is critical that you contact your physician, primary care provider or mental health provider ASAP. Suicidal thoughts are very serious and need to be addressed ASAP. There is no clear answer to your question, since the link between singulair and suicidality is not clear. However, singulair should be out of your system within 48 hours.
Again, I urge you to contact a health professional (or if you can't go to the ER) ASAP if you have not already done so.

Anonymous said...

The reason that doctors prescribe singular or accolate is because studies show they prevent long-term deterioration of lung-function in people who have asthma. Inhaled corticosteroids do not have this benefit, if they are taken alone. As far as having depressive thoughts, these are often caused by effects on brain chemistry by the allergy itself (or by anything that releases too much histamine in your system. Histamine causes release of other chemicals that travel through the blood-brain barrier and lower the serotonin level in your brain.) Beware also that OTC class 1 anti-histamines cause depression. you should only take class 2, like claritin. Some decongestants can also cause depression in some people.

Dr. Matthew Mintz said...

The only study I am aware of that shows prevention of long term deterioration in lung function is and old pediatric study from Australia or New Zealand, and that was with inhaled steroids not leukotriene modifiers. Please send me any references for studies showing that singular or accolate prevent "long-term deterioration of lung-function in people who have asthma." I would be very interested in this data.

Susan said...

I was having problems sleeping through the night without an inhailer so was prescribed Singular. At some point (embarrassed to admit this but will) the TV Advair commercials caught my attention and asked to switch over. It didn't work - I was back to breathless nights. I then lost insurance and Singular was out of my budget (wasn't Generic yet) and weirdly I started losing weight - a lot of weight fast. In the years I was on Singular I ended up over 200lbs. Once I went off I was down to 165lbs in months. The weight I had gained complicated my asthma. Even though it went generic, I don't want to go back. I have to do some heavy cleaning the next couple months and dust is my lungs worst enemy. Every time I started I was sucking off my inhaler so asked my Dr to go back on a pill temporarily. I opted for Accolate as an alternative. There are many of us who have experienced Singular weight gain - just do a web search and I can only imagine how Merck fought to avoid listing weight gain as a side effect. Really aggravating all that weight and loss of esteem was the result of an asthma med. From now on my first guess will be the meds I take when things change with my body no matter what the pamphlet they give you claims.

Anonymous said...

I have been on Pulmicort for many years, one puff in the AM, with fairly good control of the asthma. I also had tried Advair in the past but had difficulty sleeping. The Pulmicort did not interfere with my sleep. About 3 weeks ago I developed thrush (even though I do a normal saline nasal irrigation every morning after the Pulmicort) so I stopped the Pulmicort. And will NEVER use it again. I didn't realize until I stopped it that it was causing considerable depression, a lot of agitation and anxiety and made me very hypomanic. Very pressured in my speech and activity. I was always angry and distressed, which was causing issues at my job. I am not like this, I had turned into a very nasty, edgy human being without even realizing it. The first 2 weeks after stopping the Pulmicort I also had hot flashes, day and night. It seemed like my body was purging itself of the poison, all of my systems "let go". My breath was good for about 2 weeks, the third week I started having some issues, started taking Claritin 10 mg at bedtime, that helped some. Had to use the Albuteral inhaler several times a day and my Peak Flow had dropped 50 points. This past weekend we visited friends with animals and that really set me off. I found a bottle of Singular 10 mg tabs I had started to take a year ago, but stopped because of muscle cramps after a week and went back on the Pulmicort. I cut one of the Singular tablets in half (5 mg) and after 2 hours finally found relief for the next 24 hours. Last night I took another 5 mg dose of Singulair, went swimming this morning and it was by far the BEST swim I've had in years, I could breath with ease. Even if I have some muscle cramps I am willing to take a low dose of Singular. IT is much better than being a depressed, angry, agitated human being, that which I have never been before in my life. BTW, if I ever have to take oral Prednisone for an exacerbation of the asthma, I have to stay home from work--too manic, labile, agitated, etc. The drug companies report that inhaled steroids do not cause the same side effects as the oral steroids. This is not true, at least not by my experience and many others I have read about on the web.

Anonymous III Now said...

Dr. please advise what I can do for my grandchild. She is 10 years old and was "diagnosed" about a year and half ago with sinus issues and allergies. Her "allergist" doctor prescribed Singulair and she has been taking it daily ever since. She has also gained about 25 pounds in that same time frame. I truly believe it is linked to the Singulair but the allergist says not so. I don't believe it, what case can I make for an alternative treatment? Please advise, her health is at risk with the additional weight!!

Dr. Matthew Mintz said...

AnonymousIII
Sorry to hear about your grandchild. Of course, I can't give specific recommendations over a blog, but a few thoughts:
1. Any medication can cause any side effect in any patient. While weight gain is not a known side effect of Singulair, that doesn't mean it can't cause weight gain.
2. There are many options (non-alternative) to treating allergies including inhaled steroids, oral and nasal antihistamines, and immunotherapy.
3. If you are not satisfied with you allergist's care, it may be time to find another allergist.

Kathy Powers said...

Hello Dr. Mintz,

I am hoping you might be able to help me with my allergy situation. I am a 50 yr old female, have had mild allergies my entire life that lived with mostly due to being pregnant and/or nursing for 17 yrs. The allergies were always a bit intensified during pregnancy, I would only take a sinus medication if I felt like the allergies had turned into a cold or sinus infection. So after I delivered my last baby in Oct. 2012, my allergies seem to be worse, they are a year round, daily nuisance. My symptoms consist of constant runny nose, dripping in my throat and sneezing. I finally went to see an ENT and he prescribed Nasonex which provided mild allergy improvement, but also gave me bloody noses. So the ENT prescribed Patanase, which also gives mild relief, but does not completely get rid of my symptoms. So my latest visit to the ENT, he suggested updated allergy testing, and to try Singulair. I am nervous to try the Singulair because my daughter used it with negative side affects. Is there another medication protocol you can recommend I try before trying Singulair? I have no asthma/lung issues, just a constant runny nose. Help! Thank you!

Dr. Matthew Mintz said...

Kathy,
I can not provide specific recommendations over a blog, but a few things to consider:
1. Nasonex worked but caused bloody noses. There are now many different kinds of medicines like Nasonex and other ways to prevent bloody noses. You can talk to your doctor about options in this area.
2. The point of this original post is that singulair doesn't work all that well, particularly in asthma. However, it does work really well in some patients and is very safe.
3. Other things that treat allergic rhinitis is oral and nasal antihistamines.

Greg and Stephanie Hill said...

I am concerned with the frequency this medication is prescribed and with the amount and type of side effects that occur. I was on Singular for mild asthma and severe allergies for over 3 years. I had side effects that ignored because they didn't last long and I assumed the cure was better than the problem. About a year ago I was having many of the symptoms for a reaction to this drug, but my doctor assured me that wasn't the case. One year later through a series of events I ended up off the drug for several days and I began having a horrible reaction. I struggled to sleep, if I was lucky I might get 4 hours a night. I felt like someone had drugged me, I felt chatty and happy and a little disconnected. My coworkers began to notice absence stares, for which I wouldn't be aware. Throughout the day I had severe anxiety. Before Singulair I had experienced any of these behaviors or symptoms . At night my body would literally seize up in spasms. I am recovering from most of the listed side effects and I am an adult that will be ok. But this medication should not be given to young children! I am day 8 off the medication and feeling better, though still uncomfortable. I am seeing others reporting that their side effects lasted for weeks after stopping.

Anonymous said...

Hello Dr. Mintz
My daughter is 5 and was diagnosed with Asthma at 1 years old. She was prescribed pulmicort 2 times daily. We usually did it in spring and fall. In Sept 2013 she had a very bad asthma attack and was hospitalized for 10 days. She was given flovent and zyrtec. Bad side effects for both. She was then prescribed qvar which doesn't help as she was hospitalized again in May 2014. She is now on Qvar and Singulair and claritan. She had an asthma test today and her numbers are worse with lung function and is feeling tired after shorts bursts of exercise which was never her issue before. Could Singular be making her lung function worse even though no symptoms. She is a typical cough variant asthma. Concerned Mom!

Dr. Matthew Mintz said...

Sorry to hear about your daughter.
I can give specific medical advice over a blog. Singulair should not make lung function worse. The issue is that it does not treat inflammation. However, the Qvar she is on does.
It sounds like she has complicated asthma and I strongly recommend that she see an asthma specialist.

Anonymous said...

My doctor prescribed Singulair today to my allergy regimen (AllegraD, Nasacort and Zatador currently), as my mucus is very thick and pale and I have been very dizzy, off balance and tired lately.

Now, I just read side effects of Singular could include dizziness and fatigue, two of things I am trying to combat... I am confused!

Dr. Matthew Mintz said...

Can't tell whether it is from your new medicine or your allergies.
While Singulair doesn't usually cause these side effects, it can.
I would discuss with your doctor.

Anonymous said...

Through the years I've tried several different inhaled corticosteroids, most made me super emotional always either crying or screaming. Finally was prescribed Dulera, no insanity and it worked great for a couple years. Then I found myself ending up hospitalized about every 4 months. Dr just added singulair and I'm seeing great symptom control between the 2 meds and so far have not noticed any side effects.

Dr. Matthew Mintz said...

@anonymous 7/18- Glad Singulair worked for you. While it is not the best first line agent, it works very well for some people. It's good that we have lots of tools to treat patients with asthma.

Patricia H. said...

I am a 60 year old woman who has had diagnosed allergic asthma for 24 years (and who had untreated allergies and undiagnosed asthma for at least 15 years prior). I also have Common Variable Immunodeficiency, so when I get sick, I get really sick. For asthma and allergies, I take Rhinocort Aqua, Dulera, levoceterizine, nebulized breathing treatments with Xopenex when a ProAir inhaler doesn't cut it, and use a compounded triple antibiotic nasal wash daily. I also took 20 years of allergy shots.

My allergist tried me on Singulair twice in the years right after it came out. I never took it beyond one month, as I always seemed to become sicker on it.

Now, my immunologist (who is also an allergist) has tried to put me on it twice in the past year. Both times, about three weeks in, I have become sick with asthma, more sick and more symptomatic than I had been in the immediate weeks before beginning it. At this point, I feel it is not a coincidence.

My allergist says that there is a subset of patients for whom Singulair not only does not work, it makes them sicker, as it does me. Have you seen this phenomenon, Dr. Mintz? I cannot find anything on the internet about this.

Dr. Matthew Mintz said...

Patricia,
Sorry you are having such a rough time.
I am not aware of studies on patients that get worse on Singulair. However, I would not be surprised if there weren't a small subset of patients like yourself where this is indeed the case. Obviously, you now know that Singulair doesn't work for you. Hopefully, your doctors can find something else. The good news is that there are newer products coming out in the next few years that may help.

Chaseo said...

I have been diagnosed with solar urticaria (sun hives ... Doctor prescribed me singulair at night... Thought it was for allergies, but what I'm reading is telling me it's for asthma... The medicine world confuses me. Tonight was night one of taking it. If it alone doesn't help my allergy to the sun I am to add an antihistamine to my regimen before I go out in the sun. I have a hard time trusting doctors because it's been 5 years since I've been diagnosed and nothing has worked or helped and every doctor I've seen has scratched their head and sent me to someone else. I hope singulair has an unknown usage for my condition....as I don't have asthma out any other allergies.... Except the big ole sun.

Dr. Matthew Mintz said...

@Chaseo,
Can't say that Singulair would help with "sun hives" but it probably won't hurt.
If you have a skin condition that no one seems to know what it is or how to fix it, I would recommend seeing a University based dermatologist. Hopefully, there is a medical school close enough to you that has a Dermatology Department.

Anonymous said...

I have had allergy induced asthma since my twenties, I am now 67. I cannot tolerate any kind of Steroid and I took Singulair three years ago and went off of it after several months. Since there isn't too many things to treat my asthma my doctor tried Singulair again because I did not really remember why I went off. Sadly, I found out this week. After one month on the drug I woke up with swollen sinus and nose and cheeks. I immediately went off and after a few days the swelling went down. I see my doctor next week. I only have albutrol and I wish there was more. Flonase worked wonders but it effected my blood pressure and I ended up in ER.
I will keep losing weight and eating healthy, I am at a loss what to do and my doctor has been great working with me.

Karen said...

This is very helpful information, Dr. Mintz. I appreciate you sharing your perspective. I'm curious if your thinking changes at all when considering exercise-induced asthma (and seasonal allergies). I've found that Singulair daily with Albuterol before activity and seasonally, an antihistamine a day seems to help a bit, but perhaps not enough to offset the risks.

Do your thoughts on Singulair and asthma hold true for EIA/EIB as well? Many thanks!

Dr. Matthew Mintz said...

@Karen- I believe most EIA is really asthma with EIB. What I mean by that is true EIA would be bronchospasm only with exercise due to cold and fast air. At no other times would patients with EIA have wheezing, cough, SOB. If patients get symptoms with exercise, but also have allergies, get symptoms with upper respiratory infections, allergen exposure, etc. then it is likely mild or even moderate asthma with EIB. It is important to make the distinction because in EIA, the role of inflammation is unclear and any treatment can be used. For asthma with EIB, inflammation is critical, and likely inhaled steroids are the best choice.

Anonymous said...

My 7 yr old was prescribed singulaire for bad allergies (ragweed, grass, mold, pollen, dust mites). I am so terrified to let her take it bc of side effects and her sensitivity to med in general. The allergist said if we don't do something, in the long term she could get polyps and completely lose her sense of smell, (the smelling she already struggles with). The dr. said weekly allergy shots are also likely needed. Her sinuses are swollen all the time, and she has allergy shiners. Should I seek a second opinion, or are three other options out there? Is this doctor just using scare tactics and throwing a pharmaceutical company pushed product at us?

Dr. Matthew Mintz said...

Allergies are serious business, especially for children. They can impact learning in school, decrease sleep needed for proper growth, and prevent kids from participating in healthy activities like sports.
The good news is that there are lots of good treatments for allergies. Even better news is that most treatments for allergies don't have serious side effects. The most common treatments are antihistamines. These medicines are very safe, but even the non-sedating ones (Claritin, Zyrtec, and Allegra) can cause some sedation. The most effect medications for allergies, and the best choice for moderate to severe allergic rhinitis are inhaled nasal cortiscosteroids (Flonase, Nasacort, Nasonex). These medicines are effective, and at the usual doses really have no side effects. Most common side effect is drying the mucous membranes in the nose, sometimes leading to nose bleeds- both are usually resolved with a few days of not using them. Singulair is effective at treating allergies as well and also has almost no side effects. My concern voiced in the original post was that doctors were using Singular for asthma instead of inhaled steroids, that later of which is a much better choice. However, for allergies Singulair is a safe and effective drug, and since it is now both generic and a prescription ($5 for most people) may actually be a more cost effective option then some of the non-sedating antihistamines that even the generic over the counter medicines are more expensive.

koikat said...

I was prescribed Singular in May 2015. The Dr. thought I needed it because although I had a an inhaler Proair, she thought I was using it too often. I liked the way I didn't wheeze at all on Singulair. However in July/early August 2015 I noticed extreme hot flashes and weight gain in the belly. I am female 5'2" and usually weigh 125. I gained about five pounds and I can't get it off! I stopped the drug early Aug. and not only is their belly fat, but my chest and back area is bigger as well. I am working out and can't drop a pound at all! This is only after 4 months of use. Since I am in my 50's I thought that the hotflashes and weight gain were menopause. But a few days after I stopped Singulair I don't have hotflashes at all. They used to be about 20 in a day if not more. I had insomnia for months, barely slept an hour at a time. I usually pay close attention to what medication does to my body, but this I attributed to lady old age issues. I am so mad that I didn't pay attention sooner.

OmmMom33 said...

My 8 year son was put on Advair, Singulair, and Nasonex a little over 6 months ago. In addition he uses albuterol via nebulizer and ventolin as needed for his asthma and allergies. Last week his Advair dosage was increased from the 100/50 to 250/100. This morning he told me he didn't want to live anymore. After much discussion he said he's felt this way for some time. He cannot give any reason for these feelings. We are a healthy happy household with no circumstances that would contribute to these feelings. As a mother I am of course heartbroken and extremely concerned. I will of course contact his pediatrician and his allergist. After doing a lot of reading in regard to these meds my concerns have multiplied. I want to take him off all of it. But of course I am unsure of how to proceed safely. Again I will consult his doctors.My question is, is Singular the likely culprit or could the increase in Advair be to blame? Could it be a combination of both? How would you recommend I proceed? Is it safe to remove him from both immediately? Honestly I'd rather spend sleepless nights running the nebulizer than ever hear those words from my child again. Please help.

Dr. Matthew Mintz said...

@OMMmomm33
I am so sorry to hear about your son's struggles. To answer your question, in general it is unlikely that the increase in the Advair dose or the addition of the Singulair would contribute to a mood change, but it is not impossible. However, stopping everything is not the way to go. More than likely, his worsening asthma is contributing to his mental state.
You did not mention this, but if the doctors added prednisone (which may have been appropriate) this can cause mood changes.
Most importantly, an 8 year old saying he doesn't want to live anymore is a very serious situation. It is critical that you contact your child's doctor immediately.
Best of luck. My thoughts and prayers are with you and your family.

SereneNight said...

I am a difficult to treat case. I can't seem to tolerate steroids or inhalers am allergic to antihistamine, and broke out after my first allergy shot. I seem to be unusually sensitive to the current types of medications which is really a challenge for my doctors. And so the doctor tried Singulair.

Singulair upset my stomach and caused insomnia. The effect was immediately evident after my first night. I'm a little surprised they would give this medication to children because the side effects seem extreme. I didn't like it at all.

renee said...

Susan, thank you for this post. I've been taking singulair fir the last 3 months. I was wondering why I can't seem to lose weight. My activity has increased & I'm running 3 days a week 4-6 miles each time and slightly decreased my diet & having actual weight gain. I've stopped singulair yesterday, since having done some searching on this topic. Im just very glad to know that your extra weight came right off when you discontinued this drug. Thanks for this post!
Renee

serazo said...

My 17 yo daughter seems to stay sick lately. she has developed two sinus infection within the last 2 months and is now getting more symptoms since completing antibiotics just two weeks ago. I am starting to think it has something to do with the long term use of montelukast which she has been on since she was 5. She is either down with upper respiratory infections or sinus infection. I am at a loss.

Dr. Matthew Mintz said...

@serazo,
I am of course not able to give you specific medical device over a blog. However, I can tell you that montelukast/singulair doesn't depress the immune system, i.e. it would not likely be the cause of increase sinus infections/symptoms. It might be helping or might not be doing any good, but doubt it is doing any harm.
If you are not seeing a specialist yet, you may want to consider and Ear, Nose and Throat doctor for evaluation.

Anonymous said...

This medication worked great for my asthma & allergies, that often caused me to develop bronchitis, especially in winter months. I was only taking 5mg at the time; once my regular doctor left I was moved to another doctor, he upped my medication to 10mg without telling me. About a month in-a-half later I noticed unusual, vivid dreams, tiredness and severe anxiety. The anxiety was so bad that I avoided places that made me feel safe, like church, all because I couldn't handle crowd of people and the noise of several people talking all at once. I became paranoid of having an anxiety attack, not knowing when it would happen. I have never in my life had anxiety to this extreme. It wasn't until I was running low on the medication that I noticed the milligrams was more than before. I told my doctor and he didn't believe me that the medication was causing my issues; instead, he gave me anxiety medication!! I was paranoid to be off of the Montelukast at first, for fear my allergies and asthma would make me miserable again, but I could not longer deal with the crazy that I was putting myself and my family through. It took me a year to recover mentally, some of which I still struggle with. I just "deal" with my asthma and allergies the best I can.

Thanks for this article-I am going to ask my doctor for some of the things you suggested, but perhaps get another doctor first.

Anonymous said...

I have been told I need a long term asthma medication plan. I have been using my quick emergency inhaler Ventolin four times a day to improve my breathing which works great but Im told that is not good to use so often. After researching my first choice which was Cromolyn Sodium inhaler due to few side effects and no steroids I was told unfortunately it has been discontinued. At 67 years of age Corticrsteroids can increase my risk of cataracts which includes both portable inhaler and pill form which increases the risk much more. It appears Singulair is my first choice to try out although they have a history of cataracts but still think it has to be better than steroids. Will continue my research to make the right choice.

Dr. Matthew Mintz said...

I can obviously not give you specific medical advice over a blog without seeing you or knowing your complete medical history. However, here is some related information that might be of help.
1. Taking albuterol (Ventolin) 4 times a day is not good. It means your asthma is not well controlled. This means you are at risk for asthma attacks, ER visits, hospitalization, and even death. Whoever told you this was not good was 100% correct.
2. Inhaled corticosteroids would be the first line recommended medication for you. The reason why both cromolyn sodium and singulair would not be recommended is that they are not anti-inflammatory and asthma is an inflammatory disease. There are many studies comparing these agents to inhaled steroids, which shows that inhaled steroids reduce all of the above risks; cromolyn and singulair do not.
3. Everything in medicine is about risk and benefit. There is no treatment that is either perfectly safe or 100% effective. Even an antibiotic like penicillin will kill 1 in a million people who take it, but if you have a serious infection that needs and antibiotic, it is clearly worth the risk. It is true that, especially at high doses, inhaled corticosteroids can increase the risk of cataracts. However, at low to medium doses the risk is very low. When using albuterol several times a day, the risk for asthma attacks, ER visits, hospitalization, and even death is high, and dramatically reduced when using inhaled steroids. Thus, in the case of a patient using albuterol multiple times a day, even a patient at risk for cataracts, the benefit of taking inhaled steroids far outweighs the risk.