Montelukast Causes The Prescribing Cascade – Case Study

SM is a 48-year-old female who has new-onset symptoms of restlessness, irritability, insomnia, and vivid nightmares. Over the past 3 months, she has also experienced increasing anxiety and mood swings. She reports a feeling of impending doom and difficulty concentrating, which has begun to affect her daily life and work performance.

She has a past medical history of mild asthma, allergic rhinitis, generalized anxiety disorder, GERD, and iron deficiency anemia. Her current medications include albuterol inhaler as needed, loratadine 10 mg daily, sertraline 50 mg daily, omeprazole 20 mg daily, and ferrous sulfate 325 mg once daily.

The primary care provider is concerned about the increasing anxiety and mood swings and is considering increasing sertraline and adding an antipsychotic to augment the antidepressant and hopefully reduce the mood swings. What did the provider neglect to look at in this situation?

Montelukast was added a few months ago and needs to be ruled out as a potential cause of the psychiatric symptoms. This should be done before escalating psychotropic therapy. Situations like this are common in practice and you must remember to look at possible medication causes of new symptoms prior to escalating therapy and adding new medications that carry many risks. This is how the prescribing cascade perpetuates for patients.

Montelukast (Singulair) carries a boxed warning the FDA’s most stringent warning regarding the risk of serious neuropsychiatric side effects (great board exam question!). This warning was issued to inform healthcare providers and patients about the potential for significant mental health-related issues when taking montelukast. These side effects can occur in both adults and children, and may develop even if the patient has no prior history of psychiatric conditions. We need to be aware of this risk and if the provider was paying attention in this scenario, we could have avoided new medications and higher dosages.

Did you enjoy this blog post? Subscribers are emailed new blog posts TWICE per week! In addition, you’ll get access to the free giveaways below. Over 6,000 healthcare professionals have subscribed for our FREE Giveaways. Why haven’t you?!