New agitation, depression, hallucinations, or suicidal thoughts — notify the provider now and keep the client safe.
Before you read
Test yourself first: 4 questions
Question 1 of 4
A client with asthma is prescribed montelukast. The nurse explains that this medication is used for which purpose?
Answer: A. Montelukast is a leukotriene receptor antagonist used for long-term maintenance control of asthma; it is taken daily, often in the evening, to prevent symptoms. It is not a rescue inhaler and does not relieve acute bronchospasm, so the client must keep a short-acting bronchodilator for acute attacks.
Question 2 of 4
A client with asthma is prescribed montelukast. The nurse explains that this medication is used for which purpose?
Answer: B. Montelukast is a leukotriene receptor antagonist used for long-term control and prevention of asthma symptoms, including exercise-induced bronchospasm and allergic rhinitis. It is taken daily and is not a rescue medication. It has no role in relieving an acute attack because it does not produce rapid bronchodilation.
Question 3 of 4
A nurse is caring for a child taking montelukast for asthma. The nurse should teach the caregiver to monitor for and report which adverse effect associated with this medication?
Answer: A. Montelukast carries a boxed warning for neuropsychiatric events, including mood changes, agitation, depression, sleep disturbances, and suicidal thinking. Caregivers should be taught to monitor for and report new behavioral or mood changes. The other listed effects are not characteristic concerns for this leukotriene receptor antagonist.
Question 4 of 4
A nurse is reviewing new prescriptions for a client with COPD. Which medication, if prescribed, should the nurse question due to its anticholinergic effects in a client with a history of narrow-angle glaucoma and benign prostatic hyperplasia?
Answer: B. Inhaled anticholinergics such as ipratropium and tiotropium are used cautiously in clients with narrow-angle glaucoma and benign prostatic hyperplasia because anticholinergic effects can raise intraocular pressure and worsen urinary retention. The nurse should question the anticholinergic. Albuterol, fluticasone, and montelukast do not carry these specific anticholinergic precautions.
Keep the streak going with more questions like these, each with a full rationale.
What is montelukast?
It blocks cysteinyl leukotriene receptors, so leukotrienes cannot trigger airway smooth-muscle contraction, airway swelling, and eosinophilic inflammation. It prevents bronchoconstriction rather than reversing it, so it never replaces a rescue inhaler during an attack. It carries a boxed warning for neuropsychiatric effects, so the nurse watches mood, sleep, and behavior, including suicidal thinking.
Key points to remember
- Controller, not rescue: montelukast is not used for acute asthma attacks and does not replace a short-acting bronchodilator.
- Asthma: once daily, best in the evening. Doses: 10 mg for ages 15 and older, 5 mg for ages 6–14, 4 mg for 12 months–5 years (oral granules only under 2 years).
- Exercise-induced bronchoconstriction (age 6 and older): take at least 2 hours before exercise. Doses must be at least 24 hours apart, so a client already on a daily dose takes no extra dose.
- Approved ages: asthma from 12 months; seasonal allergic rhinitis from 2 years; perennial allergic rhinitis from 6 months. For allergic rhinitis it is reserved for clients who cannot tolerate or don't respond to other treatments.
- Boxed warning: agitation, aggression, anxiety, depression, sleep problems and abnormal dreams, hallucinations, and suicidal thoughts or behavior.
- Other effects: headache, upper respiratory symptoms, and GI upset; rarely eosinophilia with vasculitis (Churg-Strauss) or mild liver enzyme rises.
- Chewable tablets contain phenylalanine, a concern in phenylketonuria (PKU).
Nursing priorities
- Confirm the client has a short-acting rescue inhaler and can use it, because montelukast will not stop an attack.
- Record baseline mood, sleep, and behavior and reassess at each contact, because neuropsychiatric effects need prompt reporting.
- Give the asthma dose in the evening, because that aligns with overnight and early-morning symptoms.
- Check for PKU before giving chewable tablets, because they contain phenylalanine.
- Evaluate control (night symptoms, activity limits, and rescue-inhaler use), because the drug works by prevention.
Worked example
- Cue: A school-age child on evening montelukast has new nightmares and irritability and says, 'I don't want to be here anymore.'
- Meaning: These fit the boxed-warning neuropsychiatric effects, and the statement may be suicidal ideation.
- Action: Keep the child safe and supervised, notify the provider right away, and document when the symptoms started relative to the drug.
- Evaluation: The provider decides whether to stop the drug; the family can name the mood changes to report.
Patient teaching
- Take it every day, even when you feel well. It prevents symptoms; it does not stop an attack.
- Always carry your rescue inhaler for sudden breathing trouble.
- For exercise, take it at least 2 hours before. If you already take it daily, don't take an extra dose.
- Call your provider about mood changes, bad dreams, trouble sleeping, or thoughts of harming yourself. Family members should watch for these too.
Memory tricks
- '-lukast' = leukotriene blocker: it prevents, it doesn't rescue.
Common mistakes
- Choosing montelukast for an acute asthma attack. The answer is a short-acting bronchodilator.
- Giving an extra pre-exercise dose to a client already on daily montelukast.
- Dismissing nightmares or irritability as unrelated to an asthma drug.
- Forgetting PKU screening with chewable tablets.
Red flags: report now
- New agitation, depression, hallucinations, or suicidal thoughts — notify the provider now and keep the client safe.
- Acute wheezing or shortness of breath — give the short-acting rescue inhaler, not montelukast; escalate if it does not resolve.
- Wheezing that keeps getting worse despite daily use — report it; the asthma plan needs review.
References
Clinical references for this topic
