BRIEFING 61: Montelukast and zafirlukast Clinical evidence and nationalguidance Recommendations for continuedneed. area areaimedatensuringprescribingisgenericandalsoreviewing treatmenttoassess which over £700,000isspentonthebranded productSingulair®. QIPPprojectsinthis (ePACT November 2013).Themajorityofthisspend(£2.8million)isformontelukast for theleukotriene receptorantagonistsmontelukastandzafirlukastis almost£3million Across thePrescQIPPmembership(20.2millionpatients,November 2013),annualspend Weblink: Resources available: Leukotriene receptorantagonists:Montelukastandzafirlukast • • • • • • • • ineffective. Montelukast shouldalways beprescribedgenerically andinitiallyonan acuteprescription.Effectiveness shouldbereviewed and treatmentdiscontinued if management ofasthmawhichrecommends alimitedrolefor leukotriene receptor antagonistsinchildren andadolescentsaged5 years andabove. outcomes suchasexacerbations requiringoral corticosteroids,prescribersshouldcontinue tofollowtheNICE-accreditedBTS/SIGNguideline onthe A NICEMedicinesEvidence Commentarysuggestedthatuntilstudiesare publishedthatshowleukotriene receptorantagonists improve patient-oriented moderate asthma. in theneedforrescueoral corticosteroidsorhospitaladmission comparedtothesameoranincreaseddoseofICS inchildrenandadolescentswithmildto Evidence suggeststheaddition ofleukotriene receptor antagoniststoinhaledcorticosteroids(ICS)isnot associatedwithastatisticallysignificantreduction guidelines foradultsandchildrenover 5years ofage Montelukast isaleukotriene receptorantagonistwhich canbeaddedtotreatmentusedinsteps3and4oftheBTS/SIGNmanagementchronicasthma available inawiderrange ofproductstotreat bothadultsandchildren. montelukast shouldbethetreatmentofchoiceas itislesscostlythanzafirlukastand When initiatingtreatment,ifaleukotriene receptorantagonistisappropriate, treatment inlinewiththeBTS/SIGNasthmamanagement guidelines. established. Review patientson longtermmontelukastforsuitabilitytostepdown and onlyputonshorttermrepeatifeffective andaneedtocontinuetherapy is Leukotriene receptorantagonistprescriptionsshouldbestartedasacute the ManagementofAsthmawhichsuggestsalimitedroleintherapy. Thoracic Society/Scottish IntercollegiateGuidelinesNetwork(BTS/SIGN)Guidelineon Ensure prescribingofleukotriene receptorantagonistsisinlinewiththeBritish savings arerealised. Ensure allprescriptionsformontelukastareprescribedgenericallysothatmaximum Bulletin http://www.prescqipp.info/montelukast/viewcategory/179 3 Data pack 1,2 andinsteps2or3childrenunder5years ofage. Patient letter Audit £1.2 million treatment pathway, a50%reductioninprescribingwouldsave If montelukastisdiscontinuedaspartofastepdown ontheasthma £565,000 Switching allmontelukastprescribingtogenericwillsave Table 1:28day costsofleukotriene receptorantagonists tablets (one daily) Montelukast (generic)5mgchewable tablets (one daily) Montelukast (generic)4mgchewable Product anddose (one daily) Montelukast (Singulair®) 10mgtablets paediatric granules (one scahetdaily) Montelukast (Singulair®) 4mg chewable tablets(one daily) Montelukast (Singulair®) 5mg chewable tablets(one daily) Montelukast (Singulair®) 4mg (one twicedaily) Zafirlukast (Accolate®) 20mgtablets granules (one sachetdaily) Montelukast (generic)4mgpaediatric (one daily) Montelukast (generic)10mgtablets across thePrescQIPPmembership. acrossthePrescQIPPmembership. Costs andsavings 15 years Adults andchildrenover to 5years Children ages6months years Children aged6to14 years Children aged2to5 Adults only to 5years Children ages6months 15 years Adults andchildrenover years Children aged6to14 years Children aged2to5 Treatment agerange 4 28 day cost 5,6 £26.97 £25.69 £25.69 £25.69 £17.75 £4.02 £2.52 £2.37 £2.21

BRIEFING 61: Montelukast and zafirlukast 6. 5. 4. 3. 2. 1. References Prescription PricingDivision.NHSElectronicDrugTariff. December2013. Haymarket Publishing.MIMSonline.December2013. leukotriene receptorantagonists.November 2013. National InstituteofHealthandCareExcellence MedicinesPrescribingCentre.EvidenceCommentary:Asthmainchildren andadolescents: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009585.pub2/abstract of SystematicReviews 2013,Issue 10.Art.No.:CD009585.DOI:10.1002/14651858.CD009585.pub2. Chauhan BF, BenSalahR,DucharmeFM.Additionofanti-leukotriene agentstoinhaledcorticosteroidsinchildrenwithpersistentasthma.Cochrane Database Martin, JEditor. BritishNational Formulary No66.September2013. BTS/SIGN. BritishGuidelineontheManagementofAsthma.Guideline101.Lastrevised January2012 http://arms.evidence.nhs.uk/resources/hub/1030388/attachment http://www.sign.ac.uk/guidelines/fulltext/101/contents.html