Montelukast acts as a cysteinyl leukotriene receptor-1 (CysLT1) antagonist. In which clinical scenario is it MOST appropriate as an add-on to inhaled corticosteroids?

• A Aspirin-exacerbated respiratory disease (Samter's triad) with asthma and nasal polyps ✓
• B Moderate-to-severe persistent asthma requiring step-up from high-dose ICS
• C Severe acute asthma exacerbation in the emergency department
• D Exercise-induced bronchospasm not controlled by SABA alone

Explanation

In aspirin-exacerbated respiratory disease (AERD/Samter's triad — asthma, nasal polyps, aspirin sensitivity), there is a constitutively elevated 5-lipoxygenase pathway producing excess cysteinyl leukotrienes. Montelukast blocking CysLT1 receptors is particularly effective in this condition. While montelukast can be used in exercise-induced bronchospasm and mild persistent asthma, AERD is the paradigm scenario where leukotriene receptor antagonists provide superior disease-specific benefit as an ICS add-on.

Reference: KD Tripathi, Essentials of Medical Pharmacology, 8th ed.

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