By Dr. Larry Chiaramonte
It was one of those headlines that really get me: “Asthma drug Singulair linked to suicidal thoughts in young people”. I don’t mean to pick on Australia, but as elsewhere, their headline writers have so sense of proportion when it comes to public health risks. The nation’s “medicine watchdog” Therapeutic Goods Administration (TGA) recorded 58 adverse affects associated with 20,000 children and teenagers who took the drug between 2000 and 2013, including “five reports of suicidal ideation, five reports of depression, and five reports of agitation.” The numbers, they caution, could be higher, but they are limited by doctor reporting. This is a country with over 400 actual asthma deaths per year, which is a much higher rate than the United States, although it is less than half the peak figure of 964 recorded in 1989. Deaths of children under 15, however, rose from seven in 2005 to 17 in 2009.
Merck, which brought Singulair—montelukast–to market (although it is now also made generically) lists psychiatric symptoms among the side effects, and the FDA has been warning about them since 2009. Doesn’t it stand to reason that a drug that acts on the immune system to block production of a powerful mediator—leukotrienes–could also have a dramatic effect on psychology and behavior in some?
Singulair has a significant place in the pharmacopeia of asthma treatment. We use it in our book as an example of how a drug can burst on the scene as an apparent panacea, only to recede into the medicine cabinet as its limitations emerge in a wider patient population:
“There’s a big difference between 5,000–10,000 patients and the hundreds of thousands who will get the drug after its release. The drug may be ineffective or may have bad side effects for a statistically insignificant number of people in a trial, but even if it’s just one percent, when 100,000 people are taking it, that leaves 1,000 who need something else. For those people, the new miracle drug is no miracle at all. And over a period of time, its shortcomings are likely to become magnified. Every time referrals to our offices dry up from one doctor or another, it usually coincides with some new drug release, but over time, new patients start to trickle in as the miracle starts to wear off.
“This was certainly the case with a drug called Singulair, which pediatricians loved because it could be taken orally—you sometimes have to hold a kid down to teach him to use an inhaler—and because it had no steroids. But while a useful drug, its great wave of popularity crested as it showed its limitations; it was not the panacea it first appeared to be. Many patients still needed the combination of treatments allergists offer.”
Obviously, side effects also show up in a population of millions. As I have written before, mental health should always be a concern with asthma treatment or with any other chronic disease. Apart from both body and brain chemistry, there are tangible effects on family chemistry. How parents relate to their children and how children relate to one another come into play. By all means, doctors, be on the lookout for suicidal ideation, but don’t stop there. Patient and family mental health should be a routine part of asthma treatment.