Consumer medicine information

Name of Medicine
SINGULAIR®
montelukast sodium
10 mg tablet
5 mg chewable tablet
4 mg chewable tablet
Presentation
10 mg tablet: A beige rounded square film-coated tablet engraved with SINGULAIR on
one side and MSD117 on the other, containing 10.4 mg of montelukast sodium which is
the molar equivalent of 10.0 mg of free acid. Dimensions: 7.87 x 7.87 mm.
5 mg chewable tablet: A pink round biconvex chewable tablet with a cherry flavour
engraved SINGULAIR on one side and MSD275 on the other, containing 5.2 mg of
montelukast sodium which is the molar equivalent of 5.0 mg of free acid. Dimensions:
9.525 mm diameter.
4 mg chewable tablet: A pink round biconvex tablet with a cherry flavour engraved
SINGULAIR on one side and MSD 711 on the other, containing 4.2 mg montelukast
sodium which is the molar equivalent of 4.0 mg of free acid. (Currently not available in
New Zealand.)
Therapeutic Class
SINGULAIR (montelukast sodium) is a selective and orally active leukotriene receptor
antagonist that specifically inhibits cysteinyl leukotriene CysLT1 receptor.
Indications
SINGULAIR is indicated in adult and paediatric patients 2 years of age and older for the
prophylaxis and chronic treatment of asthma, including the prevention of day- and night-
time symptoms and the prevention of exercise-induced bronchospasm.
SINGULAIR is indicated in adults and paediatric patients 2 years of age and older for the
relief of daytime and nighttime symptoms of seasonal allergic rhinitis and perennial allergic
rhinitis.
Dosage and Administration
SINGULAIR should be taken once daily. For asthma, the dose should be taken in the
evening. For allergic rhinitis, the time of administration may be individualised to suit
patient needs.
Patients with both asthma and allergic rhinitis should take only one tablet daily in the
evening.
Adults 15 Years of Age and Older with Asthma and/or Allergic Rhinitis
The dosage for adults 15 years of age and older is one 10 mg tablet daily.
Paediatric Patients 6 to 14 Years of Age with Asthma and/or Allergic Rhinitis
The dosage for paediatric patients 6 to 14 years of age is one 5 mg chewable tablet daily.
Paediatric Patients 2 to 5 Years of Age with Asthma and/or Allergic Rhinitis
The dosage for paediatric patients 2 to 5 years of age is one 4 mg chewable tablet daily.
General Recommendations
The therapeutic effect of SINGULAIR on parameters of asthma control occurs within one
day. SINGULAIR may be taken with or without food. Patients should be advised to
continue taking SINGULAIR while their asthma is controlled, as well as during periods of
worsening asthma.
No dosage adjustment is necessary for paediatric patients, for the elderly, for patients with
renal insufficiency, or mild-to-moderate hepatic impairment, or for patients of either
gender.
Therapy with SINGULAIR in Relation to Other Treatments for Asthma
SINGULAIR can be added to a patient’s existing treatment regimen.
Reduction in Concomitant Therapy
Bronchodilator Treatments: SINGULAIR can be added to the treatment regimen of patients who are not adequately controlled on bronchodilator alone. When a clinical response is evident (usually after the first dose), the patient’s bronchodilator therapy can be reduced as tolerated. Inhaled Corticosteroids: Treatment with SINGULAIR provides additional clinical benefit to patients treated with inhaled corticosteroids. A reduction in the corticosteroid dose can be made as tolerated. The dose should be reduced gradually with medical supervision. In some patients, the dose of inhaled corticosteroids can be tapered off completely. SINGULAIR should not be abruptly substituted for inhaled corticosteroids. Oral Corticosteroids: Limited data suggest that SINGULAIR may provide additional clinical benefit in patients with oral corticosteroids. Contraindications
Hypersensitivity to any component of this product.
Warnings and Precautions
The efficacy of oral SINGULAIR for the treatment of acute asthma attacks has not been
established. Therefore, oral SINGULAIR should not be used to treat acute asthma
attacks. Patients should be advised to have appropriate rescue medication available.
While the dose of concomitant inhaled corticosteroid may be reduced gradually under
medical supervision, SINGULAIR should not be abruptly substituted for inhaled or oral
corticosteroids.
Neuropsychiatric events have been reported in patients taking SINGULAIR (see Adverse
Effects). Since other factors may have contributed to these events, it is not known if they
are related to SINGULAIR. Physicians should discuss these adverse experiences with
their patients and/or caregivers. Patients and/or caregivers should be instructed to notify
their physician if these changes occur.
The reduction in systemic corticosteroid dose in patients receiving anti-asthma agents
including leukotriene receptor antagonists has been followed in rare cases by the
occurrence of one or more of the following: eosinophilia, vasculitic rash, worsening
pulmonary symptoms, cardiac complications, and/or neuropathy sometimes diagnosed as Churg-Strauss syndrome, a systemic eosinophilic vasculitis. Although a causal relationship with leukotriene receptor antagonism has not been established, caution and appropriate clinical monitoring are recommended when systemic corticosteroid reduction is considered in patients receiving SINGULAIR. Pregnancy
SINGULAIR has not been studied in pregnant women. SINGULAIR should be used during
pregnancy only if clearly needed.
During worldwide marketing experience, congenital limb defects have been rarely reported
in the offspring of women being treated with SINGULAIR during pregnancy. Most of these
women were also taking other asthma medications during their pregnancy. A causal
relationship between these events and SINGULAIR has not been established.
Nursing Mothers
It is not known if SINGULAIR is excreted in human milk. Because many medicines are
excreted in human milk, caution should be exercised when SINGULAIR is given to a
nursing mother.
Paediatric Use
SINGULAIR has been studied in paediatric patients 2 to 14 years of age (see Dosage and
Administration). Safety and effectiveness in paediatric patients younger than 2 years of
age have not been studied. Studies have shown that SINGULAIR does not affect the
growth rate of paediatric patients.
Use in the Elderly
In clinical studies, there were no age-related differences in the efficacy or safety profiles of
SINGULAIR.
Renal/Hepatic Impairment
No dosage adjustment is required for patients with renal insufficiency or mild to moderate
hepatic impairment. (See Pharmacokinetics; Hepatic Insufficiency & Renal Insufficiency.)
Carcinogenicity and Mutagenicity
There were no significant results seen with montelukast sodium in carcinogenicity or
mutagenicity studies.
Reproduction
In pre-clinical studies, there were no significant results in reproduction studies conducted
with montelukast sodium.
Development
In developmental toxicity studies, there were no treatment related adverse effects at doses
up to 400 mg/kg/day in rats and up to 100 mg/kg/day in rabbits. Foetal exposure of
montelukast sodium in rats and rabbits does occur and significant concentrations of
medicine were observed in milk of lactating rats.
Effect on and Ability to Drive and use Machines
There is no evidence that SINGULAIR affects the ability to drive and use machines.
Adverse Effects
SINGULAIR has been generally well tolerated. Adverse effects, which usually were mild, generally did not require discontinuation of therapy. The overall incidence of adverse effects (including laboratory adverse effects) reported with SINGULAIR was comparable to placebo. Adults 15 Years of Age and Older with Asthma
SINGULAIR has been evaluated in approximately 2600 adult patients 15 years of age and
older in clinical studies. In two similarly designed, 12-week placebo-controlled clinical
studies, the only adverse experiences reported as medicine-related in ≥1% of patients
treated with SINGULAIR and at a greater incidence than in patients treated with placebo
were abdominal pain and headache. The incidences of these events were not significantly
different in the two treatment groups.
Cumulatively, 544 patients were treated with SINGULAIR for at least 6 months, 253 for
one year and 21 for 2 years in clinical studies. With prolonged treatment, the adverse
experience profile did not change.
Paediatric Patients 6 to 14 Years of Age with Asthma
SINGULAIR has been evaluated in approximately 475 paediatric patients 6 to 14 years of
age. The safety profile in paediatric patients is generally similar to the adult safety profile
and to placebo.
In an 8-week, placebo-controlled clinical study, the only adverse experience reported as
medicine-related in >1% of patients treated with SINGULAIR and at a greater incidence
than in patients treated with placebo was headache. The incidence of headache was not
significantly different in the two treatment groups.
In studies evaluating the growth rate, the safety profile in these paediatric patients was
consistent with the safety profile previously described for SINGULAIR.
Cumulatively, 263 paediatric patients 6 to 14 years of age were treated with SINGULAIR
for at least 3 months and 164 for 6 months or longer. With prolonged treatment, the
adverse experience profile did not change.
Paediatric Patients 2 to 5 Years of Age with Asthma
SINGULAIR has been evaluated in 573 paediatric patients 2 to 5 years of age. In a 12-
week, placebo-controlled clinical study, the only adverse experience reported as medicine-
related in >1% of patients treated with SINGULAIR and at a greater incidence than in
patients treated with placebo was thirst. The incidence of thirst was not significantly
different in the two treatment groups.
Cumulatively, 426 paediatric 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 12 months or longer.
With prolonged treatment, the adverse experience profile did not change.
Adults 15 Years of Age and Older with Seasonal Allergic Rhinitis
SINGULAIR has been evaluated in 2199 adult patients 15 years of age and older for the
treatment of seasonal allergic rhinitis in clinical studies. SINGULAIR administered once
daily in the morning or in the evening was generally well tolerated with a safety profile
similar to that of placebo. In placebo-controlled clinical studies, no adverse experiences
reported as drug related in ≥1% of patients treated with SINGULAIR and at a greater
incidence than in patients treated with placebo were observed. 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.
Paediatric Patients 2 to 14 Years of Age with Seasonal Allergic Rhinitis
SINGULAIR has been evaluated in 280 paediatric patients 2 to 14 years of age for the
treatment of seasonal allergic rhinitis in a 2-week, placebo-controlled, clinical study.
SINGULAIR administered once daily in the evening was generally well tolerated with a
safety profile similar to that of placebo. In this study, no adverse experiences reported as
drug related in ≥1% of patients treated with SINGULAIR and at a greater incidence than in
patients treated with placebo were observed.
Adults 15 Years of Age and Older with Perennial Allergic Rhinitis
SINGULAIR has been evaluated in 3235 adult and adolescent patients 15 years of age
and older with perennial allergic rhinitis (defined as a history of symptoms for at least two
years and positive skin tests for at least two perennial allergens) in two, 6 week, placebo-
controlled, clinical studies. SINGULAIR administered once daily was generally well
tolerated, with a safety profile consistent with that observed in patients with seasonal
allergic rhinitis and similar to that of placebo. In these two studies, no adverse
experiences reported as drug related in ≥1% of patients treated with SINGULAIR and at a
greater incidence than in patients treated with placebo were observed. The incidence of
somnolence was similar to that of placebo.
Pooled Analyses of Clinical Trials Experience
A pooled analysis of 41 placebo-controlled clinical studies (35 studies in patients 15 years
of age and older; 6 studies in paediatric patients 6 to 14 years of age) was performed
using a validated assessment method of suicidality. Among the 9929 patients who
received SINGULAIR and 7780 patients who received placebo in these studies, there was
one patient with suicidal ideation in the group taking SINGULAIR. There were no
completed suicides, suicide attempts or preparatory acts toward suicidal behaviour in
either treatment group.
A separate pooled analysis of 46 placebo-controlled clinical studies (35 studies in patients
15 years of age and older; 11 studies in paediatric patients 3 months to 14 years of age)
assessing behaviour-related adverse experiences (BRAEs) was performed. Among the
11,673 patients who received SINGULAIR and 8827 patients who received placebo in
these studies, the frequency of patients with at least one BRAE was 2.73% in patients who
received SINGULAIR and 2.27% in patients who received placebo; the odds ratio was
1.12 (95% CI [0.93; 1.36]).
The clinical trials included in these pooled analyses were not designed specifically to
examine suicidality or BRAEs.
Post-Marketing Experience
The following adverse reactions have been reported in post-marketing use:
Infections and infestations: upper respiratory infection
Blood and lymphatic system disorders: increased bleeding tendency
Immune system disorders: hypersensitivity reactions including anaphylaxis, very rarely
hepatic eosinophilic infiltration
Psychiatric disorders: agitation including aggressive behaviour or hostility, anxiousness,
depression, disorientation, dream abnormalities, hallucinations, insomnia, irritability,
restlessness, somnambulism, suicidal thinking and behaviour (suicidality), tremor
Nervous system disorders: dizziness, drowsiness, paraesthesia/hypoesthesia, very rarely
seizure
Cardiac disorders: palpitations Respiratory, thoracic and mediastinal disorders: epistaxis Gastrointestinal disorders: diarrhoea, dyspepsia, nausea, vomiting Hepatobiliary disorders: increased ALT and AST, very rarely hepatitis (including cholestatic, hepatocellular, and mixed-pattern liver injury) Skin and subcutaneous tissue disorders: angioedema, bruising, erythema nodosum, pruritus, rash, urticaria Musculoskeletal and connective tissue disorders: arthralgia, myalgia including muscle cramps General disorders and administration site conditions: asthenia/fatigue, oedema, pyrexia Interactions
SINGULAIR may be administered with other therapies routinely used in the prophylaxis
and chronic treatment of asthma, and in the treatment of allergic rhinitis. In medicine-
interactions studies, the recommended clinical dose of montelukast did not have clinically
important effects on the pharmacokinetics of the following medicines: theophylline,
prednisone, prednisolone, oral contraceptives (ethinyl estradiol/norethindrone 35/1),
terfenadine, digoxin and warfarin.
Although additional specific interaction studies were not performed, SINGULAIR was used
concomitantly with a wide range of commonly prescribed medicines in clinical studies
without evidence of clinical adverse interactions. These medications included thyroid
hormones, sedative hypnotics, nonsteroidal anti-inflammatory agents, benzodiazepines
and decongestants.
The area under the plasma concentration-time curve (AUC) for montelukast was
decreased approximately 40% in subjects with co-administration of phenobarbital. No
dosage adjustment for SINGULAIR is recommended.
In vitro studies have shown that montelukast is an inhibitor of CYP2C8. However, data
from a clinical drug-drug interaction study involving montelukast and rosiglitazone (a probe
substrate representative of drugs primarily metabolised by CYP2C8 demonstrated that
montelukast does not inhibit CYP2C8 in vivo. Therefore, montelukast is not anticipated to
alter the metabolism of drugs metabolised by this enzyme (e.g., paclitaxel, rosiglitazone,
repaglinide).
SINGULAIR may be taken with or without food. There are no data available on the use of
SINGULAIR and alcohol.
Overdosage
No specific information is available on the treatment of overdosage with SINGULAIR. In
chronic asthma studies, SINGULAIR 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 overdosage in post-marketing experience and clinical
studies with SINGULAIR. These include reports in adults and children with a dose as high as 1000 mg. 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 overdosage reports. The most frequently occurring adverse experiences were consistent with the safety profile of SINGULAIR and included abdominal pain, somnolence, thirst, headache, vomiting, and psychomotor hyperactivity. It is not known whether montelukast is dialysable by peritoneal- or haemodialysis. Mechanism of Action
The cysteinyl leukotrienes (LTC4, LTD4, LTE4), are potent inflammatory eicosanoids
released from various cells including mast cells and eosinophils. These important pro-asthmatic mediators bind to cysteinyl leukotriene (CysLT) receptors. The CysLT type-1 (CysLT1) receptor is found in the human airway (including airway smooth muscle cells and airway macrophages) and on other pro-inflammatory cells (including eosinophils and certain myeloid stem cells). CysLTs have been correlated with the pathophysiology of asthma and allergic rhinitis. In asthma, leukotriene-mediated effects include a number of airway actions, including bronchoconstriction, mucous secretion, vascular permeability, and eosinophil recruitment. In allergic rhinitis, CysLTs are released from the nasal mucosa after allergen exposure during both early- and late-phase reactions and are associated with symptoms of allergic rhinitis. Intranasal challenge with CysLTs has been shown to increase nasal airway resistance and symptoms of nasal obstruction. Montelukast is a potent, orally active compound that significantly improves parameters of asthmatic inflammation. Based on biochemical and pharmacological bioassays, it binds with high affinity and selectivity to the CysLT1 receptor (in preference to other pharmacologically important airway receptors such as the prostanoid, cholinergic, or β-adrenergic receptor). Montelukast potently inhibits physiologic actions of LTC4, LTD4, and LTE4 at the CysLT1 receptor without any agonist activity. Pharmacokinetics
Absorption
Montelukast is rapidly and nearly completely absorbed following oral administration. For
the 10 mg film-coated tablet, the mean peak plasma concentration (Cmax) is achieved 3
hours (Tmax) after administration in adults in the fasted state. The mean oral bioavailability is 64%. The oral bioavailability and Cmax are not influenced by a standard meal. For the 5 mg chewable tablet, the Cmax is achieved 2 hours after administration in adults in the fasted state. The mean oral bioavailability is 73%. Food does not have a clinically important influence with chronic administration. For the 4 mg chewable tablet, Cmax is achieved 2 hours after administration in paediatric patients 2 to 5 years of age in the fasted state. Safety and efficacy were demonstrated in clinical studies where the 4 mg chewable tablet, 5 mg chewable tablet, and 10 mg film-coated tablet were administered without regard to the timing of food ingestion. Distribution
Montelukast is more than 99% bound to plasma proteins. The steady-state volume of distribution of montelukast averages 8 to 11 litres. Studies in rats with radiolabelled montelukast indicate minimal distribution across the blood-brain barrier. In addition, concentrations of radiolabelled material at 24 hours post-dose were minimal in all other tissues. Metabolism
Montelukast is extensively metabolised. In studies with therapeutic doses, plasma
concentrations of metabolites of montelukast are undetectable at steady state in adults
and paediatric patients.
In vitro studies using human liver microsomes indicate that cytochrome P450 3A4 and 2C9
are involved in the metabolism of montelukast. Based on further in vitro results in human
liver microsomes, therapeutic plasma concentrations of montelukast do not inhibit
cytochromes P450 3A4, 2C9, 1A2, 2A6, 2C19, or 2D6.
Elimination
The plasma clearance of montelukast averages 45 mL/min in healthy adults. Following an
oral dose of radiolabelled montelukast, 86% of the radioactivity was recovered in 5-day
faecal collections and <0.2% was recovered in urine. Coupled with estimates of
montelukast oral bioavailability, this indicates 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. No difference in pharmacokinetics was noted between dosing in the
morning or in the evening. During once-daily dosing with 10 mg montelukast, there is little
accumulation of the parent medicine in plasma (∼14%).
Characteristics in Patients
Gender The pharmacokinetics of montelukast are similar in males and females. Elderly 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. Race Pharmacokinetic differences due to race have not been studied. In clinical studies, there do not appear to be any differences in clinically important effects. Hepatic Insufficiency
Patients with mild-to-moderate hepatic insufficiency and clinical evidence of cirrhosis had
evidence of decreased metabolism of montelukast resulting in approximately 41% higher
mean montelukast area under the plasma concentration curve (AUC) following a single 10
mg dose. The elimination of montelukast is 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. There are no clinical data in patients with
severe hepatic insufficiency (Child-Pugh score >9).
Renal Insufficiency
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. Adolescents and Paediatric Patients
The plasma concentration profile of montelukast following the 10 mg film-coated tablet is
similar in adolescents ≥15 years old and young adults. The 10 mg film coated tablet is
recommended for use in patients ≥15 years old.
Pharmacokinetic studies using either the chewable tablet or film-coated tablet show that
the plasma profile of the 5 mg chewable tablet in paediatric patients 6 to 14 years of age is
similar to that of the 10 mg film-coated tablet in adults. In a pharmacokinetic study in
paediatric patients 2 to 5 years of age, the plasma profile of the 4 mg chewable tablet was
also similar to that of the 10 mg film-coated tablet in adults. The 5 mg chewable tablet
should be used in paediatric patients 6 to 14 years of age and the 4 mg chewable tablet in
paediatric patients 2 to 5 years of age.
Pharmaceutical Precautions
Store the 10 mg film-coated tablets and the 4 mg and 5 mg chewable tablets at room
temperature 15-30°C (59-86°F), protected from moisture and light.
Medicine Classification
Prescription Medicine
Package Quantities
SINGULAIR Tablets/Chewable Tablets are available in blister packs of 28 tablets.
Further Information
Chemistry
SINGULAIR, (montelukast sodium) is described chemically as [R-(E)]-1-[[[1-[3-[2-(7-
chloro-2-quinolinyl)ethenyl]phenyl]-3-[2-(1-hydroxy-1-methylethyl)
phenyl]propyl]thio]methyl]cyclopropane acetic acid, monosodium salt.
The empirical formula is C35H35ClNNaO3S, and its molecular weight is 608.18. The
Montelukast sodium is a hygroscopic, optically active, white to off-white powder. Montelukast sodium is freely soluble in ethanol, methanol, and water and practically insoluble in acetonitrile. Composition
Active Ingredients Each 10 mg film-coated tablet contains 10.4 mg montelukast sodium, which is the molar equivalent to 10.0 mg of free acid. Each 5 mg chewable tablet contains 5.2 mg montelukast sodium, which is the molar equivalent to 5.0 mg of free acid. Each 4 mg chewable tablet contains 4.2 mg montelukast sodium, which is the molar equivalent to 4.0 mg of free acid. Inactive Ingredients Each 10 mg film-coated tablet contains the following inactive ingredients: microcrystalline cellulose, lactose monohydrate, croscarmellose sodium, hydroxypropyl cellulose, and magnesium stearate. The film coating consists of: hydroxypropyl methylcellulose, hydroxypropyl cellulose, titanium dioxide, red ferric oxide, yellow ferric oxide, and carnauba wax. Each 4 mg and 5 mg chewable tablet contains the following inactive ingredients: mannitol, microcrystalline cellulose, hydroxypropyl cellulose, red ferric oxide, croscarmellose sodium, cherry flavour, aspartame, and magnesium stearate. Name and Address
Merck Sharp & Dohme (NZ) Ltd
P O Box 99 851
Newmarket
Auckland
NEW ZEALAND
Tel: 0800 500 673
Date of Preparation
20 April 2010
DP-SGA-0410(200410)
®Registered Trademark of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Whitehouse
Station, NJ, USA Copyright (1997-2010) Merck Sharp & Dohme Corp., a subsidiary of Merck& Co., Inc., Whitehouse Station,

Source: http://www.nahdicare.com/pictures/products/501135.pdf