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Asthma in adults

Last reviewed: 3 Sep 2024
Last updated: 31 Jul 2024
31 Jul 2024

UK MHRA reiterates montelukast safety warning

A drug safety update from the UK Medicines and Healthcare products Regulatory Agency (MHRA) reminds prescribers of the potential risk of neuropsychiatric adverse events in patients receiving montelukast, including:

  • sleep disorders,

  • hallucinations,

  • anxiety and depression, and

  • changes in behaviour and mood.

See Management: approach

Original source of update

Summary

Definition

History and exam

Key diagnostic factors

  • presence of risk factors
  • expiratory wheezes
  • dyspnoea
  • cough
  • chest tightness
  • diurnal variability of symptoms
  • episodic symptoms
  • historical record of variable peak expiratory flow (PEF) or FEV₁
  • nasal polyposis
  • recent upper respiratory tract infection
Full details

Risk factors

  • family history
  • allergens/irritants
  • atopic disease history
  • cigarette smoking
  • vaping
  • respiratory viral infection early in life
  • nasal polyposis
  • low socioeconomic status
  • obesity
  • gastro-oesophageal reflux
  • obstructive sleep apnoea
Full details

Diagnostic investigations

1st investigations to order

  • spirometry (FEV₁/FVC ratio and BDR)
  • peak expiratory flow (PEF)
Full details

Investigations to consider

  • CXR
  • FBC with differential
  • fractional exhaled nitric oxide (FeNO)
  • bronchial challenge test
  • allergen testing
Full details

Emerging tests

  • sputum eosinophilia

Treatment algorithm

ONGOING

infrequent symptoms

step 1: initial therapy (not controlled by SABA as needed)

step 2: initial add-on therapy (asthma not controlled with low-dose ICS and SABA as needed)

step 3: additional controller therapies (asthma not controlled with step 2)

step 4: specialist therapies (asthma not controlled with step 3)

Contributors

Authors

Onyeka Umerah,

Consultant Respiratory Physician

Glenfield Hospital

Leicester

UK

Disclosures

OU declares that she has no competing interests.

Acknowledgements

Dr Onyeka Umerah would like to gratefully acknowledge Dr Lauren E. Eggert, Dr Sourav Majumdar, Dr Irwani Ibrahim, Dr Kay Choong See, Dr Francis Thien, and Dr Catherine Weiler, previous contributors to this topic.

Disclosures

LEE declares that she has conducted sponsored research with Regeneron Pharmaceuticals. SM, II, KCS, FT, and CW declare that they have no competing interests.

Peer reviewers

F. Runa Ali,

Consultant Allergist & Respiratory Physician

Barts Health NHS Trust

London

UK

Disclosures

FRA declares that she has no competing interests.

Laia Castro Salvador,

Severe Asthma & Allergy Specialist Clinical Pharmacist

Barts Health NHS Trust

London

UK

Disclosures

LCS declares that she has no competing interests.

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