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MONTELUKAST

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Montelukast sodium is a selective and active leukotriene (LTD4, LTE4) receptor antagonist. It binds to cysteinyl leukotrienes (CysLT) type-1 receptors found in the human airway (smooth muscle cells and macrophages), which prevents airway edema, smooth muscle contraction and other respiratory inflammation.

Specific Substances

    1) L-706631
    2) MK-476
    3) CAS 158966-92-8 (montelukast)
    4) CAS 151767-02-1 (montelukast sodium)

Available Forms Sources

    A) FORMS
    1) Montelukast is available in the United States as 4 mg white granules; 4 and 5 mg pink chewable tablets; and a 10 mg tablet (Prod Info SINGULAIR(R) oral tablets, chewable tablets, granules, 2010a).
    B) USES
    1) Montelukast is indicated for the prophylaxis and chronic treatment of asthma and acute prevention of exercise-induced bronchoconstriction. It is also indicated for the relief of symptoms of seasonal or perennial allergic rhinitis (Prod Info SINGULAIR(R) oral tablets, chewable tablets, granules, 2010a).

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) USES: Montelukast is indicated for the prophylaxis and chronic treatment of asthma and acute prevention of exercise-induced bronchoconstriction. It is also indicated for the relief of symptoms of seasonal or perennial allergic rhinitis.
    B) PHARMACOLOGY: Montelukast sodium is a selective and active leukotriene (LTD4, LTE4) receptor antagonist. It binds to cysteinyl leukotrienes (CysLT) type-1 receptors found in the human airway (smooth muscle cells and macrophages), which prevents airway edema, smooth muscle contraction and other respiratory inflammation. The leukotrienes are also released from the nasal mucosa after allergen exposure where montelukast sodium may inhibit symptoms of allergic rhinitis.
    C) EPIDEMIOLOGY: Exposure is common but significant toxicity is rare.
    D) WITH THERAPEUTIC USE
    1) Adverse effects associated with therapeutic montelukast use include fatigue, maculopapular rash, fever, dyspepsia, gastroenteritis, headache, nasal congestion, upper respiratory infection, cough, eosinophilia, elevated liver enzymes, palpitations, vomiting, pancreatitis, paresthesia, hypoesthesia, insomnia, tremor, drowsiness, abnormal dreams, seizures, agitation, suicidal thinking and behavior, and hallucinations. Montelukast and the other leukotriene antagonists have rarely been associated with the development of Churg-Strauss syndrome, a potentially fatal eosinophilic vasculitis, during therapeutic use. This occurred in adult asthma patients, in most of whom concomitant oral steroid doses were reduced. Effects have included worsening pulmonary symptoms, eosinophilia, vasculitic rash, cardiac complications, and neuropathy.
    E) WITH POISONING/EXPOSURE
    1) No clinical effects have been reported in the majority of overdose reports. The most common effects following pediatric overdose include thirst, somnolence, mydriasis, hyperkinesia, and abdominal pain. In postmarketing experience and clinical studies, abdominal pain, somnolence, thirst, headache, vomiting, and psychomotor hyperactivity were reported in adults and children after ingesting montelukast doses as high as 1000 mg.
    0.2.3) VITAL SIGNS
    A) WITH THERAPEUTIC USE
    1) Fever has been reported with chronic use.
    0.2.20) REPRODUCTIVE
    A) Montelukast has been classified as FDA pregnancy category B. The safety and efficacy of montelukast have not been determined in pregnant women. Rarely, congenital limb defects have been reported during postmarketing surveillance; however, causality has not been established. Montelukast crosses the placenta and is found in breast milk in animal studies. The manufacturer recommends caution when montelukast is used during pregnancy and lactation.
    0.2.21) CARCINOGENICITY
    A) At the time of this review, the manufacturer does not report any carcinogenic potential.

Laboratory Monitoring

    A) Serum montelukast levels are not readily available and are not clinically useful.
    B) Monitor vital signs and liver enzymes in all symptomatic patients.
    C) Monitor fluid and electrolyte levels in patients with severe vomiting.
    D) In rare cases, systemic eosinophilia has been reported, sometimes presenting with the clinical features of Churg-Strauss syndrome. Monitor CBC in patients with worsening of pulmonary symptoms, vasculitic rash, or cardiac complications while receiving montelukast therapy.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    1) Treatment is symptomatic and supportive.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) Treatment is symptomatic and supportive; treat seizures with benzodiazepines.
    C) DECONTAMINATION
    1) PREHOSPITAL: Serious toxicity is not expected after ingestion of montelukast alone, and prehospital gastrointestinal decontamination is not routinely required.
    2) HOSPITAL: Significant toxicity is not expected after overdose; gastrointestinal decontamination is generally not necessary. Activated charcoal should be considered after extremely large ingestions or if more toxic coingestants are involved.
    D) AIRWAY MANAGEMENT
    1) Endotracheal intubation and mechanical ventilation may be required in patients with severe allergic reactions, but this is rare.
    E) ANTIDOTE
    1) None.
    F) ACUTE ALLERGIC REACTION
    1) MILD to MODERATE EFFECTS: Monitor airway. Administer antihistamines with or without inhaled beta agonists, corticosteroids or epinephrine. SEVERE EFFECTS: Administer oxygen, aggressive airway management may be necessary. Administer antihistamines, epinephrine, corticosteroids as needed. Treatment includes IV fluids and ECG monitoring.
    G) ENHANCED ELIMINATION
    1) Hemodialysis and hemoperfusion are UNLIKELY to be of value because of the high degree of protein binding and large volume of distribution.
    H) PATIENT DISPOSITION
    1) HOME CRITERIA: Patients with a minor unintentional exposure who are asymptomatic or have mild symptoms can likely be managed at home. In studies, pediatric ingestions of up to 536 mg (33.71 mg/kg) did not produce any serious adverse events.
    2) OBSERVATION CRITERIA: Patients with inadvertent overdoses who have more than mild symptoms and patients with deliberate self harm ingestions should be sent to a health care facility for evaluation and treated until symptoms resolve.
    3) ADMISSION CRITERIA: Patients who remain symptomatic despite adequate treatment should be admitted.
    4) CONSULT CRITERIA: Consult a Poison Center for assistance in managing patients with severe toxicity or in whom the diagnosis is unclear.
    I) PITFALLS
    1) Pitfalls in managing these patients include missing alternative diagnoses or not recognizing iatrogenic overdoses. When managing a suspected montelukast overdose, the possibility of multi-drug involvement should be considered. If patient has more than mild toxicity search carefully for an alternative explanation.
    J) PHARMACOKINETICS
    1) Montelukast is more than 99% bound to plasma proteins. The steady-state volume of distribution is in the range of 8 to 11 L. Montelukast is extensively metabolized in the liver.
    K) DIFFERENTIAL DIAGNOSIS
    1) Differential diagnosis included other drugs and conditions that can cause altered mental status, elevated liver enzymes, or symptoms similar to Churg-Strauss syndrome (eg; rash, vasculitis, fever, seizures).

Range Of Toxicity

    A) TOXICITY: Overdose information is limited. It is not expected to produce severe toxicity in adults. In postmarketing experience and clinical studies, most adults and children did not experience any toxicity following montelukast doses as high as 1000 mg. The most common reported adverse effects were abdominal pain, somnolence, thirst, headache, vomiting, and psychomotor hyperactivity. In a large pediatric case series, montelukast ingestions of up to 536 mg resulted in minimal or no adverse events.
    B) A 19-month-old female child ingested montelukast 112 mg (without decontamination) and developed no adverse effects.
    C) THERAPEUTIC DOSE: ADULTS AND ADOLESCENTS (15 years or older): 10 mg once daily. PEDIATRIC: 6 to 14 years: 5 mg once daily; 2 to 5 years: 4-mg chewable tablet or 1 packet of 4-mg oral granules; 6 to 23 months: 1 packet of 4-mg oral granules.

Clinical Effects

Summary Of Exposure

    A) USES: Montelukast is indicated for the prophylaxis and chronic treatment of asthma and acute prevention of exercise-induced bronchoconstriction. It is also indicated for the relief of symptoms of seasonal or perennial allergic rhinitis.
    B) PHARMACOLOGY: Montelukast sodium is a selective and active leukotriene (LTD4, LTE4) receptor antagonist. It binds to cysteinyl leukotrienes (CysLT) type-1 receptors found in the human airway (smooth muscle cells and macrophages), which prevents airway edema, smooth muscle contraction and other respiratory inflammation. The leukotrienes are also released from the nasal mucosa after allergen exposure where montelukast sodium may inhibit symptoms of allergic rhinitis.
    C) EPIDEMIOLOGY: Exposure is common but significant toxicity is rare.
    D) WITH THERAPEUTIC USE
    1) Adverse effects associated with therapeutic montelukast use include fatigue, maculopapular rash, fever, dyspepsia, gastroenteritis, headache, nasal congestion, upper respiratory infection, cough, eosinophilia, elevated liver enzymes, palpitations, vomiting, pancreatitis, paresthesia, hypoesthesia, insomnia, tremor, drowsiness, abnormal dreams, seizures, agitation, suicidal thinking and behavior, and hallucinations. Montelukast and the other leukotriene antagonists have rarely been associated with the development of Churg-Strauss syndrome, a potentially fatal eosinophilic vasculitis, during therapeutic use. This occurred in adult asthma patients, in most of whom concomitant oral steroid doses were reduced. Effects have included worsening pulmonary symptoms, eosinophilia, vasculitic rash, cardiac complications, and neuropathy.
    E) WITH POISONING/EXPOSURE
    1) No clinical effects have been reported in the majority of overdose reports. The most common effects following pediatric overdose include thirst, somnolence, mydriasis, hyperkinesia, and abdominal pain. In postmarketing experience and clinical studies, abdominal pain, somnolence, thirst, headache, vomiting, and psychomotor hyperactivity were reported in adults and children after ingesting montelukast doses as high as 1000 mg.

Vital Signs

    3.3.1) SUMMARY
    A) WITH THERAPEUTIC USE
    1) Fever has been reported with chronic use.
    3.3.3) TEMPERATURE
    A) WITH THERAPEUTIC USE
    1) Fever has been reported with chronic use (Prod Info SINGULAIR(R) oral tablets, chewable tablets, granules, 2010).

Heent

    3.4.3) EYES
    A) WITH POISONING/EXPOSURE
    1) Mydriasis has been reported with overdose (Prod Info SINGULAIR(R), 2003).

Cardiovascular

    3.5.2) CLINICAL EFFECTS
    A) PALPITATIONS
    1) WITH THERAPEUTIC USE
    a) Palpitations have been reported in patients receiving montelukast in postmarketing evaluations; however, the causal relationship to montelukast is not clear (Prod Info SINGULAIR(R) oral tablets, chewable tablets, granules, 2010).

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) DISORDER OF RESPIRATORY SYSTEM
    1) WITH THERAPEUTIC USE
    a) Upper respiratory tract infections, congestion, and cough have been reported with chronic use (Prod Info SINGULAIR(R) oral tablets, chewable tablets, granules, 2010; Reiss et al, 1996).

Neurologic

    3.7.2) CLINICAL EFFECTS
    A) CENTRAL NERVOUS SYSTEM FINDING
    1) WITH THERAPEUTIC USE
    a) Paresthesia, Hypoesthesia, insomnia, tremor, drowsiness, abnormal dreams, seizures, and agitation have been reported during the postmarketing use of montelukast; however, the causal relationship to montelukast is not clear (Prod Info SINGULAIR(R) oral tablets, chewable tablets, granules, 2010).
    2) WITH POISONING/EXPOSURE
    a) In postmarketing experience and clinical studies, somnolence and psychomotor hyperactivity were reported in adults and children after ingesting montelukast doses as high as 1000 mg (Prod Info SINGULAIR(R) oral tablets, chewable tablets, granules, 2010).
    B) HEADACHE
    1) WITH THERAPEUTIC USE
    a) Headache has been reported in patients receiving montelukast (Prod Info SINGULAIR(R) oral tablets, chewable tablets, granules, 2010; Cheng et al, 1996).
    2) WITH POISONING/EXPOSURE
    a) In postmarketing experience and clinical studies, headache was reported in adults and children after ingesting montelukast doses as high as 1000 mg (Prod Info SINGULAIR(R) oral tablets, chewable tablets, granules, 2010).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) DRUG-INDUCED GASTROINTESTINAL DISTURBANCE
    1) WITH THERAPEUTIC USE
    a) Dyspepsia and gastroenteritis have been reported with chronic use (Prod Info SINGULAIR(R) oral tablets, chewable tablets, granules, 2010).
    b) Vomiting and pancreatitis have been reported in patients receiving montelukast in postmarketing evaluations; however, the causal relationship to montelukast is not clear (Prod Info SINGULAIR(R) oral tablets, chewable tablets, granules, 2010).
    2) WITH POISONING/EXPOSURE
    a) In postmarketing experience and clinical studies, abdominal pain and vomiting were reported in adults and children after ingesting montelukast doses as high as 1000 mg (Prod Info SINGULAIR(R) oral tablets, chewable tablets, granules, 2010).

Hepatic

    3.9.2) CLINICAL EFFECTS
    A) LIVER ENZYMES ABNORMAL
    1) WITH THERAPEUTIC USE
    a) Although cases of hepatotoxicity caused by another leukotriene-receptor antagonist, zafirlukast, have been reported, there are few reported cases of liver injury from montelukast.
    1) Elevated total biliary and aminotransferases (ALT, AST) have been reported with chronic use (Prod Info SINGULAIR(R) oral tablets, chewable tablets, granules, 2010; Reiss et al, 1998; Reiss et al, 1996).
    2) CASE REPORT: A 42-year-old man developed anorexia, nausea, jaundice, and severe itching 10 months after starting a daily dose of montelukast 10 mg . Liver function tests revealed hyperbilirubinemia and elevated liver aminotransferases. Other causes were ruled out. Symptoms resolved and liver enzymes normalized 4 months after drug discontinuation (Sass et al, 2003).

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) ERUPTION
    1) WITH THERAPEUTIC USE
    a) Maculopapular rash has been reported (Reiss et al, 1996).
    1) CASE REPORT: A 46-year-old man developed painful, nodular subcutaneous lesions and mild arthralgias within a month of starting zileuton. His work-up was consistent with erythema nodosum. The event completely resolved over several months after discontinuation of zileuton. The symptoms returned within 3 months of starting montelukast and completely resolved when montelukast was discontinued (Dellaripa et al, 2000).
    2) CASE REPORT: An 8-year-old girl developed a reddened and blistering rash affecting the lower extremities after taking montelukast 5 mg daily for 5 months. Skin biopsy revealed epidermal eosinophilic spongiosis. Eosinophilia (15% to 40% eosinophils) was found in the blood. The diagnosis of pemphigus was made. Montelukast was discontinued, corticosteroid therapy was started, and the patient recovered after 2 months (Cetkovska & Pizinger, 2003).
    b) CHURG-STRAUSS SYNDROME: Cutaneous skin lesions commonly occur in Churg-Strauss syndrome and may precede the development of systemic complications.
    1) CASE REPORT: A 50-year-old asthmatic man treated with montelukast 10 mg daily developed a bilateral erythematous leg rash 1 month after tapering his prednisone. Knee pain, left foot numbness, and left wrist and foot drop also occurred. Skin biopsy revealed leukocytoclastic vasculitis with eosinophilia. Skin lesions improved after treatment with corticosteroids, but the wrist and foot drop were still present after 2 years (Gal et al, 2002).

Immunologic

    3.19.2) CLINICAL EFFECTS
    A) HYPERSENSITIVITY REACTION
    1) WITH THERAPEUTIC USE
    a) Hypersensitivity reactions, including anaphylaxis, have been reported in patients receiving montelukast in postmarketing evaluations (Prod Info SINGULAIR(R) oral tablets, chewable tablets, granules, 2010).

Reproductive

    3.20.1) SUMMARY
    A) Montelukast has been classified as FDA pregnancy category B. The safety and efficacy of montelukast have not been determined in pregnant women. Rarely, congenital limb defects have been reported during postmarketing surveillance; however, causality has not been established. Montelukast crosses the placenta and is found in breast milk in animal studies. The manufacturer recommends caution when montelukast is used during pregnancy and lactation.
    3.20.2) TERATOGENICITY
    A) ANIMAL STUDIES
    1) RATS AND RABBITS
    a) There was no teratogenicity observed in rats and rabbits in oral doses up to 400 mg/kg/day and 300 mg/kg/day, respectively (Prod Info SINGULAIR(R) chewable tablets, oral granules, oral tablets, 2009).
    b) Montelukast crosses the placenta following oral dosing in rats and rabbits (Prod Info SINGULAIR(R) chewable tablets, oral granules, oral tablets, 2009).
    3.20.3) EFFECTS IN PREGNANCY
    A) FETAL DISTRESS
    1) A prospective analysis of 180 pregnant women during pregnancy revealed a shorter gestational age at birth (37.8 weeks; p=0.045) as well as a lower mean birth weight of 3214.1 g (p=0.038) in women administered montelukast sodium compared with the non-teratogen exposed group. In addition, significantly higher rates of fetal distress at delivery were reported in the montelukast group (p=0.007). Infants exposed to montelukast during pregnancy differed significantly from non-exposed infants in the areas of birth weight and fetal distress. Of 143 infants exposed to montelukast during organogenesis, one case of major malformation was reported (Koren et al, 2010).
    B) MATERNAL TOXICITY
    1) There was no association between use of leukotriene receptor antagonists (LTRAs) and increased risk of perinatal adverse effects according to a clinical study of participants of the Asthma Medications in Pregnancy Study conducted by the Organization of Teratology Information Specialists (OTIS) from 1998 to 2003. Of the 564 pregnant women studied, 96 treated asthma with an LTRA (72, montelukast 10 mg/day; 22, zafirlukast 20 mg twice daily) with or without other medications, 122 treated asthma exclusively with a short-acting beta(2)-agonist, and 346 women without asthma served as a comparison group. There was no significant difference between the LTRA, beta(2)-agonist, and comparison groups for percentage of overall pregnancy loss (6.7%, 5.6%, and 3.4%, respectively [p=0.338]), including loss due to spontaneous abortion (5.6%, 5.6%, and 2.5%, respectively), ectopic pregnancy (0%, 0%, and 0.3%, respectively), and stillbirth (1.1%, 0%, and 0.6%, respectively). In addition, LTRA use was not associated with an increased risk of preterm delivery, low Apgar scores, or reduced infant birth length and head circumference. The incidence of major structural anomalies was significantly higher in the LTRA group compared with the no-treatment group (p=0.007), but was similar compared with the beta(2)-agonist group (p=0.524) (Bakhireva et al, 2007).
    C) PREGNANCY CATEGORY
    1) Montelukast has been classified as FDA pregnancy category B (Prod Info SINGULAIR(R) chewable tablets, oral granules, oral tablets, 2009).
    2) The safety and efficacy of montelukast have not been determined in pregnant women. Rarely, congenital limb defects have been reported during postmarketing surveillance; however, causality has not been established. Due to the lack of human safety information, montelukast should be used in pregnant women only if the potential benefit outweighs the potential risk to the fetus. The manufacturer maintains a registry to monitor the pregnancy outcomes of pregnant women exposed to the drug. Clinicians are encouraged to report any prenatal exposure to montelukast by calling 1-800-986-8999 (Prod Info SINGULAIR(R) chewable tablets, oral granules, oral tablets, 2009).
    3.20.4) EFFECTS DURING BREAST-FEEDING
    A) ANIMAL STUDIES
    1) BREAST MILK
    a) Montelukast is excreted in the milk of lactating rats. The excretion of montelukast in human breast milk has not been established. Caution is recommended when administering montelukast to nursing mothers (Prod Info SINGULAIR(R) chewable tablets, oral granules, oral tablets, 2009).
    3.20.5) FERTILITY
    A) ANIMAL STUDIES
    1) Reductions in fertility and fecundity indices were seen only in female rats. No fertility effects were observed in male rats (Prod Info SINGULAIR(R) chewable tablets, oral granules, oral tablets, 2009).

Carcinogenicity

    3.21.1) IARC CATEGORY
    A) IARC Carcinogenicity Ratings for CAS158966-92-8 (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004):
    1) Not Listed
    B) IARC Carcinogenicity Ratings for CAS151767-02-1 (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004):
    1) Not Listed
    3.21.2) SUMMARY/HUMAN
    A) At the time of this review, the manufacturer does not report any carcinogenic potential.
    3.21.4) ANIMAL STUDIES
    A) LACK OF EFFECT
    1) No evidence of tumorigenicity was seen in either a 2-year study in Sprague-Dawley rats with oral gavage doses up to 200 mg/kg/day (approximately 120 and 75 times the AUC for adults and children, respectively, at the maximum recommended daily oral dose) or in a 92-week study in mice at oral gavage doses up to 100 mg/kg/day (approximately 45 and 25 times the AUC for adults and children, respectively, at the maximum recommended daily oral dose) (Prod Info SINGULAIR(R) chewable tablets, oral granules, oral tablets, 2009).

Genotoxicity

    A) Montelukast demonstrated no evidence of mutagenicity or clastogenic activity in the microbial mutagenesis assay, the V-79 mammalian cell mutagenesis assay, or the alkaline elution assay in rat hepatocytes. Chromosome aberrations were not seen in the Chinese hamster ovary cell assay or the in vivo mouse bone marrow chromosomal aberration assay (Prod Info SINGULAIR(R) chewable tablets, oral granules, oral tablets, 2009).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Serum montelukast levels are not readily available and are not clinically useful.
    B) Monitor vital signs and liver enzymes in all symptomatic patients.
    C) Monitor fluid and electrolyte levels in patients with severe vomiting.
    D) In rare cases, systemic eosinophilia has been reported, sometimes presenting with the clinical features of Churg-Strauss syndrome. Monitor CBC in patients with worsening of pulmonary symptoms, vasculitic rash, or cardiac complications while receiving montelukast therapy.
    4.1.2) SERUM/BLOOD
    A) TOXICITY
    1) Serum montelukast levels are not readily available and are not clinically useful.
    B) BLOOD/SERUM CHEMISTRY
    1) Monitor fluid and electrolyte levels in patients with severe vomiting.
    2) In rare cases, systemic eosinophilia has been reported, sometimes presenting with the clinical features of Churg-Strauss syndrome (Prod Info SINGULAIR(R), 2003). Monitor CBC in patients with worsening of pulmonary symptoms, vasculitic rash, or cardiac complications while receiving montelukast therapy.
    C) LIVER FUNCTION
    1) Elevation of total bilirubin and liver aminotransferases (ALT, AST) have been reported during montelukast therapy (Prod Info SINGULAIR(R), 2003).

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.1) DISPOSITION/ORAL EXPOSURE
    6.3.1.1) ADMISSION CRITERIA/ORAL
    A) Patients who remain symptomatic despite adequate treatment should be admitted.
    6.3.1.2) HOME CRITERIA/ORAL
    A) SUMMARY: Patients with a minor unintentional exposure who are asymptomatic or have mild symptoms can likely be managed at home. In studies, pediatric ingestions of up to 536 mg (33.71 mg/kg) did not produce any serious adverse events.
    B) Based on a retrospective review of 3698 pediatric (age range: 0 to 5 years) montelukast-only ingestions reported to the Texas Poison Control Centers during 2000 to 2005, 95% of all cases reported no adverse events, with 80% of the cases safely managed at home. Pediatric ingestions of up to 536 mg (33.71 mg/kg) did not produce any serious adverse events; asymptomatic (or minimally symptomatic) children with inadvertent ingestions in this range can likely be monitored in the home setting (Forrester, 2007).
    C) In a retrospective study of 165 pediatric (age range, 10 months to 5 years) montelukast ingestions, children with ingestions up to 96 mg (24 times the daily dose) were safely observed at home (McKee & Rose, 2002).
    6.3.1.3) CONSULT CRITERIA/ORAL
    A) Consult a Poison Center for assistance in managing patients with severe toxicity or in whom the diagnosis is unclear.
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) Patients with inadvertent overdoses who have more than mild symptoms and patients with deliberate self harm ingestionsshould be sent to a health care facility for evaluation and treated until symptoms resolve.

Monitoring

    A) Serum montelukast levels are not readily available and are not clinically useful.
    B) Monitor vital signs and liver enzymes in all symptomatic patients.
    C) Monitor fluid and electrolyte levels in patients with severe vomiting.
    D) In rare cases, systemic eosinophilia has been reported, sometimes presenting with the clinical features of Churg-Strauss syndrome. Monitor CBC in patients with worsening of pulmonary symptoms, vasculitic rash, or cardiac complications while receiving montelukast therapy.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) Serious toxicity is not expected after ingestion of montelukast alone, and prehospital gastrointestinal decontamination is not routinely required.
    6.5.2) PREVENTION OF ABSORPTION
    A) SUMMARY
    1) Significant toxicity is not expected after overdose; gastrointestinal decontamination is generally not necessary. Activated charcoal should be considered after extremely large ingestions or if more toxic coingestants are involved.
    B) ACTIVATED CHARCOAL
    1) CHARCOAL ADMINISTRATION
    a) Consider administration of activated charcoal after a potentially toxic ingestion (Chyka et al, 2005). Administer charcoal as an aqueous slurry; most effective when administered within one hour of ingestion.
    2) CHARCOAL DOSE
    a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
    1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    6.5.3) TREATMENT
    A) MONITORING OF PATIENT
    1) Serum montelukast levels are not readily available and are not clinically useful.
    2) Monitor vital signs and liver enzymes in all symptomatic patients.
    3) Monitor fluid and electrolyte levels in patients with severe vomiting.
    4) In rare cases, systemic eosinophilia has been reported, sometimes presenting with the clinical features of Churg-Strauss syndrome. Monitor CBC in patients with worsening of pulmonary symptoms, vasculitic rash, or cardiac complications while receiving montelukast therapy.
    B) SEIZURE
    1) SUMMARY
    a) Attempt initial control with a benzodiazepine (eg, diazepam, lorazepam). If seizures persist or recur, administer phenobarbital or propofol.
    b) Monitor for respiratory depression, hypotension, and dysrhythmias. Endotracheal intubation should be performed in patients with persistent seizures.
    c) Evaluate for hypoxia, electrolyte disturbances, and hypoglycemia (or, if immediate bedside glucose testing is not available, treat with intravenous dextrose).
    2) DIAZEPAM
    a) ADULT DOSE: Initially 5 to 10 mg IV, OR 0.15 mg/kg IV up to 10 mg per dose up to a rate of 5 mg/minute; may be repeated every 5 to 20 minutes as needed (Brophy et al, 2012; Prod Info diazepam IM, IV injection, 2008; Manno, 2003).
    b) PEDIATRIC DOSE: 0.1 to 0.5 mg/kg IV over 2 to 5 minutes; up to a maximum of 10 mg/dose. May repeat dose every 5 to 10 minutes as needed (Loddenkemper & Goodkin, 2011; Hegenbarth & American Academy of Pediatrics Committee on Drugs, 2008).
    c) Monitor for hypotension, respiratory depression, and the need for endotracheal intubation. Consider a second agent if seizures persist or recur after repeated doses of diazepam .
    3) NO INTRAVENOUS ACCESS
    a) DIAZEPAM may be given rectally or intramuscularly (Manno, 2003). RECTAL DOSE: CHILD: Greater than 12 years: 0.2 mg/kg; 6 to 11 years: 0.3 mg/kg; 2 to 5 years: 0.5 mg/kg (Brophy et al, 2012).
    b) MIDAZOLAM has been used intramuscularly and intranasally, particularly in children when intravenous access has not been established. ADULT DOSE: 0.2 mg/kg IM, up to a maximum dose of 10 mg (Brophy et al, 2012). PEDIATRIC DOSE: INTRAMUSCULAR: 0.2 mg/kg IM, up to a maximum dose of 7 mg (Chamberlain et al, 1997) OR 10 mg IM (weight greater than 40 kg); 5 mg IM (weight 13 to 40 kg); INTRANASAL: 0.2 to 0.5 mg/kg up to a maximum of 10 mg/dose (Loddenkemper & Goodkin, 2011; Brophy et al, 2012). BUCCAL midazolam, 10 mg, has been used in adolescents and older children (5-years-old or more) to control seizures when intravenous access was not established (Scott et al, 1999).
    4) LORAZEPAM
    a) MAXIMUM RATE: The rate of intravenous administration of lorazepam should not exceed 2 mg/min (Brophy et al, 2012; Prod Info lorazepam IM, IV injection, 2008).
    b) ADULT DOSE: 2 to 4 mg IV initially; repeat every 5 to 10 minutes as needed, if seizures persist (Manno, 2003; Brophy et al, 2012).
    c) PEDIATRIC DOSE: 0.05 to 0.1 mg/kg IV over 2 to 5 minutes, up to a maximum of 4 mg/dose; may repeat in 5 to 15 minutes as needed, if seizures continue (Brophy et al, 2012; Loddenkemper & Goodkin, 2011; Hegenbarth & American Academy of Pediatrics Committee on Drugs, 2008; Sreenath et al, 2010; Chin et al, 2008).
    5) PHENOBARBITAL
    a) ADULT LOADING DOSE: 20 mg/kg IV at an infusion rate of 50 to 100 mg/minute IV. An additional 5 to 10 mg/kg dose may be given 10 minutes after loading infusion if seizures persist or recur (Brophy et al, 2012).
    b) Patients receiving high doses will require endotracheal intubation and may require vasopressor support (Brophy et al, 2012).
    c) PEDIATRIC LOADING DOSE: 20 mg/kg may be given as single or divided application (2 mg/kg/minute in children weighing less than 40 kg up to 100 mg/min in children weighing greater than 40 kg). A plasma concentration of about 20 mg/L will be achieved by this dose (Loddenkemper & Goodkin, 2011).
    d) REPEAT PEDIATRIC DOSE: Repeat doses of 5 to 20 mg/kg may be given every 15 to 20 minutes if seizures persist, with cardiorespiratory monitoring (Loddenkemper & Goodkin, 2011).
    e) MONITOR: For hypotension, respiratory depression, and the need for endotracheal intubation (Loddenkemper & Goodkin, 2011; Manno, 2003).
    f) SERUM CONCENTRATION MONITORING: Monitor serum concentrations over the next 12 to 24 hours. Therapeutic serum concentrations of phenobarbital range from 10 to 40 mcg/mL, although the optimal plasma concentration for some individuals may vary outside this range (Hvidberg & Dam, 1976; Choonara & Rane, 1990; AMA Department of Drugs, 1992).
    6) OTHER AGENTS
    a) If seizures persist after phenobarbital, propofol or pentobarbital infusion, or neuromuscular paralysis with general anesthesia (isoflurane) and continuous EEG monitoring should be considered (Manno, 2003). Other anticonvulsants can be considered (eg, valproate sodium, levetiracetam, lacosamide, topiramate) if seizures persist or recur; however, there is very little data regarding their use in toxin induced seizures, controlled trials are not available to define the optimal dosage ranges for these agents in status epilepticus (Brophy et al, 2012):
    1) VALPROATE SODIUM: ADULT DOSE: An initial dose of 20 to 40 mg/kg IV, at a rate of 3 to 6 mg/kg/minute; may give an additional dose of 20 mg/kg 10 minutes after loading infusion. PEDIATRIC DOSE: 1.5 to 3 mg/kg/minute (Brophy et al, 2012).
    2) LEVETIRACETAM: ADULT DOSE: 1000 to 3000 mg IV, at a rate of 2 to 5 mg/kg/min IV. PEDIATRIC DOSE: 20 to 60 mg/kg IV (Brophy et al, 2012; Loddenkemper & Goodkin, 2011).
    3) LACOSAMIDE: ADULT DOSE: 200 to 400 mg IV; 200 mg IV over 15 minutes (Brophy et al, 2012). PEDIATRIC DOSE: In one study, median starting doses of 1.3 mg/kg/day and maintenance doses of 4.7 mg/kg/day were used in children 8 years and older (Loddenkemper & Goodkin, 2011).
    4) TOPIRAMATE: ADULT DOSE: 200 to 400 mg nasogastric/orally OR 300 to 1600 mg/day orally divided in 2 to 4 times daily (Brophy et al, 2012).
    C) ACUTE ALLERGIC REACTION
    1) SUMMARY
    a) Mild to moderate allergic reactions may be treated with antihistamines with or without inhaled beta adrenergic agonists, corticosteroids or epinephrine. Treatment of severe anaphylaxis also includes oxygen supplementation, aggressive airway management, epinephrine, ECG monitoring, and IV fluids.
    2) BRONCHOSPASM
    a) ALBUTEROL
    1) ADULT: 2.5 to 5 milligrams in 2 to 4.5 milliliters of normal saline delivered per nebulizer every 20 minutes up to 3 doses. If incomplete response administer 2.5 to 10 mg every 1 to 4 hours as needed, or 10 to 15 mg/hr by continuous nebulization as needed (National Heart,Lung,and Blood Institute, 2007). CHILD: 0.15 milligram/kilogram (minimum 2.5 milligrams) per nebulizer every 20 minutes up to 3 doses. If incomplete response administer 0.15 to 0.3 mg/kg (up to 10 mg) every 1 to 4 hours as needed, or 0.5 mg/kg/hr by continuous nebulization (National Heart,Lung,and Blood Institute, 2007).
    3) CORTICOSTEROIDS
    a) Consider systemic corticosteroids in patients with significant bronchospasm.
    b) PREDNISONE: ADULT: 40 to 80 milligrams/day. CHILD: 1 to 2 milligrams/kilogram/day (maximum 60 mg) in 1 to 2 divided doses divided twice daily (National Heart,Lung,and Blood Institute, 2007).
    4) MILD CASES
    a) DIPHENHYDRAMINE
    1) SUMMARY: Oral diphenhydramine, as well as other H1 antihistamines can be used as indicated (Lieberman et al, 2010).
    2) ADULT: 50 milligrams orally, or 10 to 50 mg intravenously at a rate not to exceed 25 mg/min or may be given by deep intramuscular injection. A total of 100 mg may be administered if needed. Maximum daily dosage is 400 mg (Prod Info diphenhydramine HCl intravenous injection solution, intramuscular injection solution, 2013).
    3) CHILD: 5 mg/kg/24 hours or 150 mg/m(2)/24 hours. Divided into 4 doses, administered intravenously at a rate not exceeding 25 mg/min or by deep intramuscular injection. Maximum daily dosage is 300 mg (Prod Info diphenhydramine HCl intravenous injection solution, intramuscular injection solution, 2013).
    5) MODERATE CASES
    a) EPINEPHRINE: INJECTABLE SOLUTION: It should be administered early in patients by IM injection. Using a 1:1000 (1 mg/mL) solution of epinephrine. Initial Dose: 0.01 mg/kg intramuscularly with a maximum dose of 0.5 mg in adults and 0.3 mg in children. The dose may be repeated every 5 to 15 minutes, if no clinical improvement. Most patients respond to 1 or 2 doses (Nowak & Macias, 2014).
    6) SEVERE CASES
    a) EPINEPHRINE
    1) INTRAVENOUS BOLUS: ADULT: 1 mg intravenously as a 1:10,000 (0.1 mg/mL) solution; CHILD: 0.01 mL/kg intravenously to a maximum single dose of 1 mg given as a 1:10,000 (0.1 mg/mL) solution. It can be repeated every 3 to 5 minutes as needed. The dose can also be given by the intraosseous route if IV access cannot be established (Lieberman et al, 2015). ALTERNATIVE ROUTE: ENDOTRACHEAL ADMINISTRATION: If IV/IO access is unavailable. DOSE: ADULT: Administer 2 to 2.5 mg of 1:1000 (1 mg/mL) solution diluted in 5 to 10 mL of sterile water via endotracheal tube. CHILD: DOSE: 0.1 mg/kg to a maximum of 2.5 mg administered as a 1:1000 (1 mg/mL) solution diluted in 5 to 10 mL of sterile water via endotracheal tube (Lieberman et al, 2015).
    2) INTRAVENOUS INFUSION: Intravenous administration may be considered in patients poorly responsive to IM or SubQ epinephrine. An epinephrine infusion may be prepared by adding 1 mg (1 mL of 1:1000 (1 mg/mL) solution) to 250 mL D5W, yielding a concentration of 4 mcg/mL, and infuse this solution IV at a rate of 1 mcg/min to 10 mcg/min (maximum rate). CHILD: A dosage of 0.01 mg/kg (0.1 mL/kg of a 1:10,000 (0.1 mg/mL) solution up to 10 mcg/min (maximum dose 0.3 mg) is recommended for children (Lieberman et al, 2010). Careful titration of a continuous infusion of IV epinephrine, based on the severity of the reaction, along with a crystalloid infusion can be considered in the treatment of anaphylactic shock. It appears to be a reasonable alternative to IV boluses, if the patient is not in cardiac arrest (Vanden Hoek,TL,et al).
    7) AIRWAY MANAGEMENT
    a) OXYGEN: 5 to 10 liters/minute via high flow mask.
    b) INTUBATION: Perform early if any stridor or signs of airway obstruction.
    c) CRICOTHYROTOMY: Use if unable to intubate with complete airway obstruction (Vanden Hoek,TL,et al).
    d) BRONCHODILATORS are recommended for mild to severe bronchospasm.
    e) ALBUTEROL: ADULT: 2.5 to 5 milligrams in 2 to 4.5 milliliters of normal saline delivered per nebulizer every 20 minutes up to 3 doses. If incomplete response administer 2.5 to 10 mg every 1 to 4 hours as needed, or 10 to 15 mg/hr by continuous nebulization as needed (National Heart,Lung,and Blood Institute, 2007).
    f) ALBUTEROL: CHILD: 0.15 milligram/kilogram (minimum 2.5 milligrams) per nebulizer every 20 minutes up to 3 doses. If incomplete response administer 0.15 to 0.3 milligram/kilogram (maximum 10 milligrams) every 1 to 4 hours as needed OR administer 0.5 mg/kg/hr by continuous nebulization (National Heart,Lung,and Blood Institute, 2007).
    8) MONITORING
    a) CARDIAC MONITOR: All complicated cases.
    b) IV ACCESS: Routine in all complicated cases.
    9) HYPOTENSION
    a) If hypotensive give 500 to 2000 milliliters crystalloid initially (20 milliliters/kilogram in children) and titrate to desired effect (stabilization of vital signs, mentation, urine output); adults may require up to 6 to 10 L/24 hours. Central venous or pulmonary artery pressure monitoring is recommended in patients with persistent hypotension.
    1) VASOPRESSORS: Should be used in refractory cases unresponsive to repeated doses of epinephrine and after vigorous intravenous crystalloid rehydration (Lieberman et al, 2010).
    2) DOPAMINE: Initial Dose: 2 to 20 micrograms/kilogram/minute intravenously; titrate to maintain systolic blood pressure greater than 90 mm Hg (Lieberman et al, 2010).
    10) H1 and H2 ANTIHISTAMINES
    a) SUMMARY: Antihistamines are second-line therapy and are used as supportive therapy and should not be used in place of epinephrine (Lieberman et al, 2010).
    1) DIPHENHYDRAMINE: ADULT: 25 to 50 milligrams via a slow intravenous infusion or IM. PEDIATRIC: 1 milligram/kilogram via slow intravenous infusion or IM up to 50 mg in children (Lieberman et al, 2010).
    b) RANITIDINE: ADULT: 1 mg/kg parenterally; CHILD: 12.5 to 50 mg parenterally. If the intravenous route is used, ranitidine should be infused over 10 to 15 minutes or diluted in 5% dextrose to a volume of 20 mL and injected over 5 minutes (Lieberman et al, 2010).
    c) Oral diphenhydramine, as well as other H1 antihistamines, can also be used as indicated (Lieberman et al, 2010).
    11) DYSRHYTHMIAS
    a) Dysrhythmias and cardiac dysfunction may occur primarily or iatrogenically as a result of pharmacologic treatment (epinephrine) (Vanden Hoek,TL,et al). Monitor and correct serum electrolytes, oxygenation and tissue perfusion. Treat with antiarrhythmic agents as indicated.
    12) OTHER THERAPIES
    a) There have been a few reports of patients with anaphylaxis, with or without cardiac arrest, that have responded to vasopressin therapy that did not respond to standard therapy. Although there are no randomized controlled trials, other alternative vasoactive therapies (ie, vasopressin, norepinephrine, methoxamine, and metaraminol) may be considered in patients in cardiac arrest secondary to anaphylaxis that do not respond to epinephrine (Vanden Hoek,TL,et al).

Range Of Toxicity

Summary

    A) TOXICITY: Overdose information is limited. It is not expected to produce severe toxicity in adults. In postmarketing experience and clinical studies, most adults and children did not experience any toxicity following montelukast doses as high as 1000 mg. The most common reported adverse effects were abdominal pain, somnolence, thirst, headache, vomiting, and psychomotor hyperactivity. In a large pediatric case series, montelukast ingestions of up to 536 mg resulted in minimal or no adverse events.
    B) A 19-month-old female child ingested montelukast 112 mg (without decontamination) and developed no adverse effects.
    C) THERAPEUTIC DOSE: ADULTS AND ADOLESCENTS (15 years or older): 10 mg once daily. PEDIATRIC: 6 to 14 years: 5 mg once daily; 2 to 5 years: 4-mg chewable tablet or 1 packet of 4-mg oral granules; 6 to 23 months: 1 packet of 4-mg oral granules.

Therapeutic Dose

    7.2.1) ADULT
    A) One 10 mg tablet once daily; not to exceed 1 dose in 24 hours (Prod Info SINGULAIR(R) oral tablets, oral chewable tablets, oral granules, 2012).
    7.2.2) PEDIATRIC
    A) PERENNIAL ALLERGIC RHINITIS: 6 TO 23 MONTHS OF AGE: One 4 mg packet of oral granules once daily. LESS THAN 6 MONTHS OF AGE: Safety and efficacy of montelukast have not been established (Prod Info SINGULAIR(R) oral tablets, oral chewable tablets, oral granules, 2012).
    B) SEASONAL ALLERGIC RHINITIS: LESS THAN 2 YEARS OF AGE: Safety and efficacy of montelukast have not been established (Prod Info SINGULAIR(R) oral tablets, oral chewable tablets, oral granules, 2012).
    C) ASTHMA: 12 TO 23 MONTHS OF AGE: One 4 mg packet of oral granules once daily. LESS THAN 12 MONTHS OF AGE: Safety and efficacy of montelukast have not been established (Prod Info SINGULAIR(R) oral tablets, oral chewable tablets, oral granules, 2012).
    D) EXERCISE-INDUCED BRONCHOCONSTRICTION: LESS THAN 6 YEARS OF AGE: Safety and efficacy of montelukast have not been established (Prod Info SINGULAIR(R) oral tablets, oral chewable tablets, oral granules, 2012).
    E) 2 TO 5 YEARS OF AGE: One 4 mg chewable tablet or one 4 mg packet of oral granules once daily (Prod Info SINGULAIR(R) oral tablets, oral chewable tablets, oral granules, 2012).
    F) 6 TO 14 YEARS OF AGE: One 5 mg chewable tablet once daily or at least 2 hours prior to exercise for exercise-induced bronchoconstriction (Prod Info SINGULAIR(R) oral tablets, oral chewable tablets, oral granules, 2012).
    G) 15 TO 18 YEARS OF AGE: One 10 mg tablet once daily or at least 2 hours prior to exercise for exercise-induced bronchoconstriction (Prod Info SINGULAIR(R) oral tablets, oral chewable tablets, oral granules, 2012).

Minimum Lethal Exposure

    A) SUMMARY
    1) No acute ingestions of montelukast resulting in death have been reported.

Maximum Tolerated Exposure

    A) In postmarketing experience and clinical studies, most adults and children did not experience any toxicity following montelukast doses as high as 1000 mg. The most common reported adverse effects were abdominal pain, somnolence, thirst, headache, vomiting, and psychomotor hyperactivity (Prod Info SINGULAIR(R) oral tablets, chewable tablets, granules, 2010).
    B) PEDIATRIC
    1) CASE REPORTS
    a) A healthy 19-month-old child developed no adverse effects following a 112 mg (28 montelukast 4 mg tablets) ingestion. The toddler was monitored for 4 hours in the emergency department (ED), and a follow-up telephone call was made 1 week after exposure; activated charcoal was not used, because more than 30 minutes had elapsed prior to arrival (Cantrell & Farson-Collier, 2004).
    b) No signs or symptoms of toxicity, except for thirst, occurred in a 3-year-old asthmatic boy who ingested 65 mg (13 montelukast 5 mg cherry chewable tablets). He was discharged 18 hours later, following supportive therapy (Geller et al, 2000).
    c) Unintentional ingestions of montelukast 80 mg (5.87 mg/kg) and 135 mg (3.75 mg/kg) were reported in a 3-year-old and 5-year-old boy, respectively. Both children were asymptomatic. The 5-year-old was given a single dose of activated charcoal/sorbitol and was discharged home after 4 hours observation. The authors suggested that doses up to 4.5 mg/kg are not expected to produce toxic effects (Cobb et al, 2002).
    2) CASE SERIES
    a) In a retrospective review of 3698 pediatric (age range: 0 to 5 years) montelukast-only ingestions reported to the Texas Poison Control Centers during 2000 to 2005, 95% of all cases reported no adverse events, with the remaining 5% reporting only minor adverse effects. Of the 392 cases where the final medical outcome and dose were known, the mean dose was 3.36 mg/kg (range 0.18 to 33.71 mg/kg). The highest dose reported in this study was 536 mg (33.71 mg/kg). The most frequently reported adverse effects included drowsiness, agitation, nausea, vomiting, and abdominal pain. However, these events were observed in less than 2% of the cases. In the majority (80%) of cases, the patient was safely managed at home (Forrester, 2007).
    b) In a retrospective review of 165 pediatric (age range, 10 months to 5 years) montelukast ingestions reported to poison centers, ingestions ranging from 4 to 96 mg were reported in patients who were observed without any treatment. The highest dose was 330 mg (15 mg/kg) in a child who was treated with ipecac at home. No clinical effects were observed in any of the 165 patients. The authors concluded that ingestions up to 96 mg can be safely observed at home (McKee & Rose, 2002).
    c) In a prospective study of calls placed to the poison center involving ingestions of montelukast in children, the largest estimated ingestions with decontamination (charcoal) and without decontamination were 96 mg and 60 mg, respectively. For the 15 cases not sent to the ED, the average ingestion was 18.2 mg; no signs or symptoms of toxicity were observed in any of the patients (Barko et al, 2001).
    d) In a retrospective assessment of the treatment of montelukast exposures, dose variation following ingestions ranged from 0.12 to 4.78 mg/kg (patients' ages ranged from 12 months to 67 years); no patients reported adverse or toxic symptoms. Patients reporting to the ED received a single dose of activated charcoal (Franck & Simon, 2001).

Workplace Standards

    A) ACGIH TLV Values for CAS158966-92-8 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Not Listed

    B) ACGIH TLV Values for CAS151767-02-1 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Not Listed

    C) NIOSH REL and IDLH Values for CAS158966-92-8 (National Institute for Occupational Safety and Health, 2007):
    1) Not Listed

    D) NIOSH REL and IDLH Values for CAS151767-02-1 (National Institute for Occupational Safety and Health, 2007):
    1) Not Listed

    E) Carcinogenicity Ratings for CAS158966-92-8 :
    1) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed
    2) EPA (U.S. Environmental Protection Agency, 2011): Not Listed
    3) IARC (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004): Not Listed
    4) NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed
    5) MAK (DFG, 2002): Not Listed
    6) NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

    F) Carcinogenicity Ratings for CAS151767-02-1 :
    1) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed
    2) EPA (U.S. Environmental Protection Agency, 2011): Not Listed
    3) IARC (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004): Not Listed
    4) NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed
    5) MAK (DFG, 2002): Not Listed
    6) NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

    G) OSHA PEL Values for CAS158966-92-8 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Not Listed

    H) OSHA PEL Values for CAS151767-02-1 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Not Listed

Pharmacology Toxicology

Pharmacologic Mechanism

    A) The cysteinyl leukotriene type-1 (CysLT type-1) receptor is found in the human airway (airway smooth muscle cells and airway macrophages) and on other proinflammatory cells (including eosinophils and certain myeloid stem cells) and has a correlation with the pathophysiology of asthma and allergic rhinitis. Cysteinyl leukotrienes, including LTD(4), are produced by arachidonic acid metabolism and then bind to CysLT receptors, causing an inflammatory process. Montelukast binds with high affinity and selectivity to the CysLT type-1 receptor and inhibits physiologic actions of LTD(4) at the CysLT type-1 receptor without any agonist activity (Prod Info SINGULAIR(R), 2003).

References

General Bibliography

    1) 40 CFR 372.28: Environmental Protection Agency - Toxic Chemical Release Reporting, Community Right-To-Know, Lower thresholds for chemicals of special concern. National Archives and Records Administration (NARA) and the Government Printing Office (GPO). Washington, DC. Final rules current as of Apr 3, 2006.
    2) 40 CFR 372.65: Environmental Protection Agency - Toxic Chemical Release Reporting, Community Right-To-Know, Chemicals and Chemical Categories to which this part applies. National Archives and Records Association (NARA) and the Government Printing Office (GPO), Washington, DC. Final rules current as of Apr 3, 2006.
    3) 49 CFR 172.101 - App. B: Department of Transportation - Table of Hazardous Materials, Appendix B: List of Marine Pollutants. National Archives and Records Administration (NARA) and the Government Printing Office (GPO), Washington, DC. Final rules current as of Aug 29, 2005.
    4) 62 FR 58840: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 1997.
    5) 65 FR 14186: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2000.
    6) 65 FR 39264: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2000.
    7) 65 FR 77866: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2000.
    8) 66 FR 21940: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2001.
    9) 67 FR 7164: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2002.
    10) 68 FR 42710: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2003.
    11) 69 FR 54144: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2004.
    12) AIHA: 2006 Emergency Response Planning Guidelines and Workplace Environmental Exposure Level Guides Handbook, American Industrial Hygiene Association, Fairfax, VA, 2006.
    13) AMA Department of DrugsAMA Department of Drugs: AMA Evaluations Subscription, American Medical Association, Chicago, IL, 1992.
    14) American Conference of Governmental Industrial Hygienists : ACGIH 2010 Threshold Limit Values (TLVs(R)) for Chemical Substances and Physical Agents and Biological Exposure Indices (BEIs(R)), American Conference of Governmental Industrial Hygienists, Cincinnati, OH, 2010.
    15) Anon: Letter to Healthcare Professional (MedWatch). U.S. Food and Drug Administration. Rockville, MD, USA. 1998. Available from URL: http://www.fda.gov/medwatch/safety/1998/singul.htm.
    16) Bakhireva LN, Jones KL, Schatz M, et al: Safety of leukotriene receptor antagonists in pregnancy. J Allergy Clin Immunol 2007; 119(3):618-625.
    17) Barko I, McCormick M, & Bayer M: A new chewable-Singulair(R). J Toxicol Clin Toxicol 2001; 39:502.
    18) Brophy GM, Bell R, Claassen J, et al: Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 2012; 17(1):3-23.
    19) Cantrell FL & Farson-Collier M: The benign clinical course following a large pediatric montelukast ingestion (letter). J Toxicol - Clin Toxicol 2004; 42(3) :333-334.
    20) Cetkovska P & Pizinger K: Childhood pemphigus associated with montelukast administration. Clin Exp Dermatol 2003; 28:328-329.
    21) Chamberlain JM, Altieri MA, & Futterman C: A prospective, randomized study comparing intramuscular midazolam with intravenous diazepam for the treatment of seizures in children. Ped Emerg Care 1997; 13:92-94.
    22) Cheng H, Leff JA, Amin R, et al: Pharmacokinetics, bioavailability, and safety of montelukast sodium (MK-0476) in healthy males and females. Pharm Res 1996; 13:445-448.
    23) Chin RF , Neville BG , Peckham C , et al: Treatment of community-onset, childhood convulsive status epilepticus: a prospective, population-based study. Lancet Neurol 2008; 7(8):696-703.
    24) Choonara IA & Rane A: Therapeutic drug monitoring of anticonvulsants state of the art. Clin Pharmacokinet 1990; 18:318-328.
    25) Chyka PA, Seger D, Krenzelok EP, et al: Position paper: Single-dose activated charcoal. Clin Toxicol (Phila) 2005; 43(2):61-87.
    26) Cobb DB, Abbott CL, Watson WA, et al: High-dose montelukast exposures in a 3-year-old and a 5-year-old child. Vet Human Toxicol 2002; 44:91-92.
    27) DFG: List of MAK and BAT Values 2002, Report No. 38, Deutsche Forschungsgemeinschaft, Commission for the Investigation of Health Hazards of Chemical Compounds in the Work Area, Wiley-VCH, Weinheim, Federal Republic of Germany, 2002.
    28) Dellaripa PF, Wechsler ME, & Roth ME: Recurrent panniculitis in a man with asthma receiving treatment with leukotriene-modifying agents. Mayo Clin Proc 2000; 75:643-645.
    29) EPA: Search results for Toxic Substances Control Act (TSCA) Inventory Chemicals. US Environmental Protection Agency, Substance Registry System, U.S. EPA's Office of Pollution Prevention and Toxics. Washington, DC. 2005. Available from URL: http://www.epa.gov/srs/.
    30) Elliot CG, Colby TV, & Kelly TM: Charcoal lung. Bronchiolitis obliterans after aspiration of activated charcoal. Chest 1989; 96:672-674.
    31) FDA: FDA Talk Paper: Health advisory for new asthma drug, US Food and Drug Administration Press Office, Washington, DC, 1997.
    32) FDA: Poison treatment drug product for over-the-counter human use; tentative final monograph. FDA: Fed Register 1985; 50:2244-2262.
    33) Forrester MB: Pediatric montelukast ingestions reported to Texas poison control centers, 2000-2005. J Toxicol Environ Health A 2007; 70(21):1792-1797.
    34) Franck K & Simon R: Thirty-month retrospective assessment of the treatment of Singulair(R) exposures. J Toxicol Clin Toxicol 2001; 39:502.
    35) Gal AA, Morris RJ, Pine JR, et al: Cutaneous lesions of Churg-Strauss syndrome associated with montelukast therapy. Br J Dermatol 2002; 147:618-619.
    36) Geller M, Melo RCV, & Coutinho SV: Successful outcome of montelukast overdosage in an asthmatic child (letter). Ann Allergy Asthma Immun 2000; 84:370.
    37) Geller M: Marked peripheral edema associated with montelukast and prednisone. Ann Intern Med 2000; 132:924.
    38) Golej J, Boigner H, Burda G, et al: Severe respiratory failure following charcoal application in a toddler. Resuscitation 2001; 49:315-318.
    39) Graff GR, Stark J, & Berkenbosch JW: Chronic lung disease after activated charcoal aspiration. Pediatrics 2002; 109:959-961.
    40) Harris CR & Filandrinos D: Accidental administration of activated charcoal into the lung: aspiration by proxy. Ann Emerg Med 1993; 22:1470-1473.
    41) Hegenbarth MA & American Academy of Pediatrics Committee on Drugs: Preparing for pediatric emergencies: drugs to consider. Pediatrics 2008; 121(2):433-443.
    42) Hvidberg EF & Dam M: Clinical pharmacokinetics of anticonvulsants. Clin Pharmacokinet 1976; 1:161.
    43) IARC Working Group on the Evaluation of Carcinogenic Risks to Humans : IARC Monographs on the Evaluation of Carcinogenic Risks to Humans: 1,3-Butadiene, Ethylene Oxide and Vinyl Halides (Vinyl Fluoride, Vinyl Chloride and Vinyl Bromide), 97, International Agency for Research on Cancer, Lyon, France, 2008.
    44) IARC Working Group on the Evaluation of Carcinogenic Risks to Humans : IARC Monographs on the Evaluation of Carcinogenic Risks to Humans: Formaldehyde, 2-Butoxyethanol and 1-tert-Butoxypropan-2-ol, 88, International Agency for Research on Cancer, Lyon, France, 2006.
    45) IARC Working Group on the Evaluation of Carcinogenic Risks to Humans : IARC Monographs on the Evaluation of Carcinogenic Risks to Humans: Household Use of Solid Fuels and High-temperature Frying, 95, International Agency for Research on Cancer, Lyon, France, 2010a.
    46) IARC Working Group on the Evaluation of Carcinogenic Risks to Humans : IARC Monographs on the Evaluation of Carcinogenic Risks to Humans: Smokeless Tobacco and Some Tobacco-specific N-Nitrosamines, 89, International Agency for Research on Cancer, Lyon, France, 2007.
    47) IARC Working Group on the Evaluation of Carcinogenic Risks to Humans : IARC Monographs on the Evaluation of Carcinogenic Risks to Humans: Some Non-heterocyclic Polycyclic Aromatic Hydrocarbons and Some Related Exposures, 92, International Agency for Research on Cancer, Lyon, France, 2010.
    48) IARC: List of all agents, mixtures and exposures evaluated to date - IARC Monographs: Overall Evaluations of Carcinogenicity to Humans, Volumes 1-88, 1972-PRESENT. World Health Organization, International Agency for Research on Cancer. Lyon, FranceAvailable from URL: http://monographs.iarc.fr/monoeval/crthall.html. As accessed Oct 07, 2004.
    49) International Agency for Research on Cancer (IARC): IARC monographs on the evaluation of carcinogenic risks to humans: list of classifications, volumes 1-116. International Agency for Research on Cancer (IARC). Lyon, France. 2016. Available from URL: http://monographs.iarc.fr/ENG/Classification/latest_classif.php. As accessed 2016-08-24.
    50) International Agency for Research on Cancer: IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. World Health Organization. Geneva, Switzerland. 2015. Available from URL: http://monographs.iarc.fr/ENG/Classification/. As accessed 2015-08-06.
    51) Koren G, Sarkar M, Einarson A, et al: Safety of using montelukast during pregnancy. Can Fam Physician 2010; 56(9):881-882.
    52) Lieberman P, Nicklas R, Randolph C, et al: Anaphylaxis-a practice parameter update 2015. Ann Allergy Asthma Immunol 2015; 115(5):341-384.
    53) Lieberman P, Nicklas RA, Oppenheimer J, et al: The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol 2010; 126(3):477-480.
    54) Loddenkemper T & Goodkin HP: Treatment of Pediatric Status Epilepticus. Curr Treat Options Neurol 2011; Epub:Epub.
    55) Manno EM: New management strategies in the treatment of status epilepticus. Mayo Clin Proc 2003; 78(4):508-518.
    56) McKee DB & Rose SR: Safety of montelukast in accidental ingestions by children. J Toxicol Clin Toxicol 2002; 40:619.
    57) NFPA: Fire Protection Guide to Hazardous Materials, 13th ed., National Fire Protection Association, Quincy, MA, 2002.
    58) NRC: Acute Exposure Guideline Levels for Selected Airborne Chemicals - Volume 1, Subcommittee on Acute Exposure Guideline Levels, Committee on Toxicology, Board on Environmental Studies and Toxicology, Commission of Life Sciences, National Research Council. National Academy Press, Washington, DC, 2001.
    59) NRC: Acute Exposure Guideline Levels for Selected Airborne Chemicals - Volume 2, Subcommittee on Acute Exposure Guideline Levels, Committee on Toxicology, Board on Environmental Studies and Toxicology, Commission of Life Sciences, National Research Council. National Academy Press, Washington, DC, 2002.
    60) NRC: Acute Exposure Guideline Levels for Selected Airborne Chemicals - Volume 3, Subcommittee on Acute Exposure Guideline Levels, Committee on Toxicology, Board on Environmental Studies and Toxicology, Commission of Life Sciences, National Research Council. National Academy Press, Washington, DC, 2003.
    61) NRC: Acute Exposure Guideline Levels for Selected Airborne Chemicals - Volume 4, Subcommittee on Acute Exposure Guideline Levels, Committee on Toxicology, Board on Environmental Studies and Toxicology, Commission of Life Sciences, National Research Council. National Academy Press, Washington, DC, 2004.
    62) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for 1,2,3-Trimethylbenzene (Proposed). United States Environmental Protection Agency. Washington, DC. 2006k. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d68a&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    63) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for 1,2,4-Trimethylbenzene (Proposed). United States Environmental Protection Agency. Washington, DC. 2006m. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d68a&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    64) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for 1,2-Butylene Oxide (Proposed). United States Environmental Protection Agency. Washington, DC. 2008d. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648083cdbb&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    65) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for 1,2-Dibromoethane (Proposed). United States Environmental Protection Agency. Washington, DC. 2007g. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064802796db&disposition=attachment&contentType=pdf. As accessed 2010-08-18.
    66) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for 1,3,5-Trimethylbenzene (Proposed). United States Environmental Protection Agency. Washington, DC. 2006l. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d68a&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    67) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for 2-Ethylhexyl Chloroformate (Proposed). United States Environmental Protection Agency. Washington, DC. 2007b. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648037904e&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    68) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Acrylonitrile (Proposed). United States Environmental Protection Agency. Washington, DC. 2007c. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648028e6a3&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    69) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Adamsite (Proposed). United States Environmental Protection Agency. Washington, DC. 2007h. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020fd29&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    70) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Agent BZ (3-quinuclidinyl benzilate) (Proposed). United States Environmental Protection Agency. Washington, DC. 2007f. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064803ad507&disposition=attachment&contentType=pdf. As accessed 2010-08-18.
    71) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Allyl Chloride (Proposed). United States Environmental Protection Agency. Washington, DC. 2008. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648039d9ee&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    72) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Aluminum Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005b. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    73) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Arsenic Trioxide (Proposed). United States Environmental Protection Agency. Washington, DC. 2007m. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480220305&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    74) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Automotive Gasoline Unleaded (Proposed). United States Environmental Protection Agency. Washington, DC. 2009a. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7cc17&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    75) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Biphenyl (Proposed). United States Environmental Protection Agency. Washington, DC. 2005j. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064801ea1b7&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    76) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Bis-Chloromethyl Ether (BCME) (Proposed). United States Environmental Protection Agency. Washington, DC. 2006n. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648022db11&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    77) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Boron Tribromide (Proposed). United States Environmental Protection Agency. Washington, DC. 2008a. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064803ae1d3&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    78) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Bromine Chloride (Proposed). United States Environmental Protection Agency. Washington, DC. 2007d. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648039732a&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    79) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Bromoacetone (Proposed). United States Environmental Protection Agency. Washington, DC. 2008e. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064809187bf&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    80) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Calcium Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005d. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    81) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Carbonyl Fluoride (Proposed). United States Environmental Protection Agency. Washington, DC. 2008b. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064803ae328&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    82) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Carbonyl Sulfide (Proposed). United States Environmental Protection Agency. Washington, DC. 2007e. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648037ff26&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    83) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Chlorobenzene (Proposed). United States Environmental Protection Agency. Washington, DC. 2008c. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064803a52bb&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    84) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Cyanogen (Proposed). United States Environmental Protection Agency. Washington, DC. 2008f. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064809187fe&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    85) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Dimethyl Phosphite (Proposed). United States Environmental Protection Agency. Washington, DC. 2009. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7cbf3&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    86) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Diphenylchloroarsine (Proposed). United States Environmental Protection Agency. Washington, DC. 2007l. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020fd29&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    87) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Ethyl Isocyanate (Proposed). United States Environmental Protection Agency. Washington, DC. 2008h. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648091884e&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    88) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Ethyl Phosphorodichloridate (Proposed). United States Environmental Protection Agency. Washington, DC. 2008i. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480920347&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    89) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Ethylbenzene (Proposed). United States Environmental Protection Agency. Washington, DC. 2008g. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064809203e7&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    90) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Ethyldichloroarsine (Proposed). United States Environmental Protection Agency. Washington, DC. 2007j. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020fd29&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    91) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Germane (Proposed). United States Environmental Protection Agency. Washington, DC. 2008j. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480963906&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    92) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Hexafluoropropylene (Proposed). United States Environmental Protection Agency. Washington, DC. 2006. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064801ea1f5&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    93) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Ketene (Proposed). United States Environmental Protection Agency. Washington, DC. 2007. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020ee7c&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    94) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Magnesium Aluminum Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005h. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    95) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Magnesium Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005g. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    96) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Malathion (Proposed). United States Environmental Protection Agency. Washington, DC. 2009k. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064809639df&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    97) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Mercury Vapor (Proposed). United States Environmental Protection Agency. Washington, DC. 2009b. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a8a087&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    98) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Methyl Isothiocyanate (Proposed). United States Environmental Protection Agency. Washington, DC. 2008k. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480963a03&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    99) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Methyl Parathion (Proposed). United States Environmental Protection Agency. Washington, DC. 2008l. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480963a57&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    100) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Methyl tertiary-butyl ether (Proposed). United States Environmental Protection Agency. Washington, DC. 2007a. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064802a4985&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    101) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Methylchlorosilane (Proposed). United States Environmental Protection Agency. Washington, DC. 2005. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5f4&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    102) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Methyldichloroarsine (Proposed). United States Environmental Protection Agency. Washington, DC. 2007i. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020fd29&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    103) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Methyldichlorosilane (Proposed). United States Environmental Protection Agency. Washington, DC. 2005a. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c646&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    104) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Nitrogen Mustard (HN1 CAS Reg. No. 538-07-8) (Proposed). United States Environmental Protection Agency. Washington, DC. 2006a. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d6cb&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    105) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Nitrogen Mustard (HN2 CAS Reg. No. 51-75-2) (Proposed). United States Environmental Protection Agency. Washington, DC. 2006b. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d6cb&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    106) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Nitrogen Mustard (HN3 CAS Reg. No. 555-77-1) (Proposed). United States Environmental Protection Agency. Washington, DC. 2006c. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d6cb&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    107) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Nitrogen Tetroxide (Proposed). United States Environmental Protection Agency. Washington, DC. 2008n. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648091855b&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    108) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Nitrogen Trifluoride (Proposed). United States Environmental Protection Agency. Washington, DC. 2009l. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480963e0c&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    109) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Parathion (Proposed). United States Environmental Protection Agency. Washington, DC. 2008o. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480963e32&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    110) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Perchloryl Fluoride (Proposed). United States Environmental Protection Agency. Washington, DC. 2009c. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7e268&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    111) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Perfluoroisobutylene (Proposed). United States Environmental Protection Agency. Washington, DC. 2009d. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7e26a&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    112) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Phenyl Isocyanate (Proposed). United States Environmental Protection Agency. Washington, DC. 2008p. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648096dd58&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    113) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Phenyl Mercaptan (Proposed). United States Environmental Protection Agency. Washington, DC. 2006d. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020cc0c&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    114) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Phenyldichloroarsine (Proposed). United States Environmental Protection Agency. Washington, DC. 2007k. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020fd29&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    115) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Phorate (Proposed). United States Environmental Protection Agency. Washington, DC. 2008q. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648096dcc8&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    116) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Phosgene (Draft-Revised). United States Environmental Protection Agency. Washington, DC. 2009e. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a8a08a&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    117) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Phosgene Oxime (Proposed). United States Environmental Protection Agency. Washington, DC. 2009f. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7e26d&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    118) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Potassium Cyanide (Proposed). United States Environmental Protection Agency. Washington, DC. 2009g. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7cbb9&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    119) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Potassium Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005c. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    120) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Propargyl Alcohol (Proposed). United States Environmental Protection Agency. Washington, DC. 2006e. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020ec91&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    121) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Selenium Hexafluoride (Proposed). United States Environmental Protection Agency. Washington, DC. 2006f. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020ec55&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    122) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Silane (Proposed). United States Environmental Protection Agency. Washington, DC. 2006g. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d523&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    123) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Sodium Cyanide (Proposed). United States Environmental Protection Agency. Washington, DC. 2009h. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7cbb9&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    124) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Sodium Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005i. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    125) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Strontium Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005f. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    126) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Sulfuryl Chloride (Proposed). United States Environmental Protection Agency. Washington, DC. 2006h. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020ec7a&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    127) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Tear Gas (Proposed). United States Environmental Protection Agency. Washington, DC. 2008s. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648096e551&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    128) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Tellurium Hexafluoride (Proposed). United States Environmental Protection Agency. Washington, DC. 2009i. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7e2a1&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    129) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Tert-Octyl Mercaptan (Proposed). United States Environmental Protection Agency. Washington, DC. 2008r. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648096e5c7&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    130) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Tetramethoxysilane (Proposed). United States Environmental Protection Agency. Washington, DC. 2006j. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d632&disposition=attachment&contentType=pdf. As accessed 2010-08-17.
    131) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Trimethoxysilane (Proposed). United States Environmental Protection Agency. Washington, DC. 2006i. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d632&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    132) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Trimethyl Phosphite (Proposed). United States Environmental Protection Agency. Washington, DC. 2009j. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7d608&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    133) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Trimethylacetyl Chloride (Proposed). United States Environmental Protection Agency. Washington, DC. 2008t. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648096e5cc&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    134) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Zinc Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005e. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    135) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for n-Butyl Isocyanate (Proposed). United States Environmental Protection Agency. Washington, DC. 2008m. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064808f9591&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    136) National Heart,Lung,and Blood Institute: Expert panel report 3: guidelines for the diagnosis and management of asthma. National Heart,Lung,and Blood Institute. Bethesda, MD. 2007. Available from URL: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.
    137) National Institute for Occupational Safety and Health: NIOSH Pocket Guide to Chemical Hazards, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Cincinnati, OH, 2007.
    138) National Research Council : Acute exposure guideline levels for selected airborne chemicals, 5, National Academies Press, Washington, DC, 2007.
    139) National Research Council: Acute exposure guideline levels for selected airborne chemicals, 6, National Academies Press, Washington, DC, 2008.
    140) National Research Council: Acute exposure guideline levels for selected airborne chemicals, 7, National Academies Press, Washington, DC, 2009.
    141) National Research Council: Acute exposure guideline levels for selected airborne chemicals, 8, National Academies Press, Washington, DC, 2010.
    142) None Listed: Position paper: cathartics. J Toxicol Clin Toxicol 2004; 42(3):243-253.
    143) Nowak RM & Macias CG : Anaphylaxis on the other front line: perspectives from the emergency department. Am J Med 2014; 127(1 Suppl):S34-S44.
    144) Pollack MM, Dunbar BS, & Holbrook PR: Aspiration of activated charcoal and gastric contents. Ann Emerg Med 1981; 10:528-529.
    145) Product Information: SINGULAIR(R) chewable tablets, oral granules, oral tablets, montelukast sodium chewable tablets, oral granules, oral tablets. Merck & Co., Inc, Whitehouse Station, NJ, 2009.
    146) Product Information: SINGULAIR(R) oral tablets, chewable tablets, granules, montelukast sodium oral tablets, chewable tablets, granules. Merck & Co Inc, Whitehouse Station, NJ, 2010.
    147) Product Information: SINGULAIR(R) oral tablets, chewable tablets, granules, montelukast sodium oral tablets, chewable tablets, granules. Merck & Co., Inc, Whitehouse Station, NJ, 2010a.
    148) Product Information: SINGULAIR(R) oral tablets, oral chewable tablets, oral granules, montelukast sodium oral tablets, oral chewable tablets, oral granules. Merck & Co (Per FDA), Whitehouse Station, NJ, 2012.
    149) Product Information: SINGULAIR(R), montelukast sodium tablets, chewable tablets. Merck & Co, Inc, Whitehouse Station, NJ, 2003.
    150) Product Information: diazepam IM, IV injection, diazepam IM, IV injection. Hospira, Inc (per Manufacturer), Lake Forest, IL, 2008.
    151) Product Information: diphenhydramine HCl intravenous injection solution, intramuscular injection solution, diphenhydramine HCl intravenous injection solution, intramuscular injection solution. Hospira, Inc. (per DailyMed), Lake Forest, IL, 2013.
    152) Product Information: lorazepam IM, IV injection, lorazepam IM, IV injection. Akorn, Inc, Lake Forest, IL, 2008.
    153) Rau NR, Nagaraj MV, Prakash PS, et al: Fatal pulmonary aspiration of oral activated charcoal. Br Med J 1988; 297:918-919.
    154) Reiss TF, Altman LC, & Chervinsky P: Effects of montelukast (MK-0476), a new potent cysteinyl leukotriene (LTD4) receptor antagonist, in patients with chronic asthma. J Allergy Clin Immunol 1996; 98:528-534.
    155) Reiss TF, Chervinsky P, & Dockhorn RJ: Montelukast, a once-daily leukotriene receptor antagonist, in the treatment of chronic asthma. Arch Intern Med 1998; 158:1213-1220.
    156) Sass DA, Chopra KB, & Wu T: A case of montelukast-induced hepatotoxicity. Am J Gastroenterol 2003; 98:704-705.
    157) Scott R, Besag FMC, & Neville BGR: Buccal midazolam and rectal diazepam for treatment of prolonged seizures in childhood and adolescence: a randomized trial. Lancet 1999; 353:623-626.
    158) Sreenath TG, Gupta P, Sharma KK, et al: Lorazepam versus diazepam-phenytoin combination in the treatment of convulsive status epilepticus in children: A randomized controlled trial. Eur J Paediatr Neurol 2010; 14(2):162-168.
    159) Tuggey JM & Hosker HSR: Churg-Strauss syndrome associated with montelukast therapy. Thorax 2000; 55:805-806.
    160) U.S. Department of Energy, Office of Emergency Management: Protective Action Criteria (PAC) with AEGLs, ERPGs, & TEELs: Rev. 26 for chemicals of concern. U.S. Department of Energy, Office of Emergency Management. Washington, DC. 2010. Available from URL: http://www.hss.doe.gov/HealthSafety/WSHP/Chem_Safety/teel.html. As accessed 2011-06-27.
    161) U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project : 11th Report on Carcinogens. U.S. Department of Health and Human Services, Public Health Service, National Toxicology Program. Washington, DC. 2005. Available from URL: http://ntp.niehs.nih.gov/INDEXA5E1.HTM?objectid=32BA9724-F1F6-975E-7FCE50709CB4C932. As accessed 2011-06-27.
    162) U.S. Environmental Protection Agency: Discarded commercial chemical products, off-specification species, container residues, and spill residues thereof. Environmental Protection Agency's (EPA) Resource Conservation and Recovery Act (RCRA); List of hazardous substances and reportable quantities 2010b; 40CFR(261.33, e-f):77-.
    163) U.S. Environmental Protection Agency: Integrated Risk Information System (IRIS). U.S. Environmental Protection Agency. Washington, DC. 2011. Available from URL: http://cfpub.epa.gov/ncea/iris/index.cfm?fuseaction=iris.showSubstanceList&list_type=date. As accessed 2011-06-21.
    164) U.S. Environmental Protection Agency: List of Radionuclides. U.S. Environmental Protection Agency. Washington, DC. 2010a. Available from URL: http://www.gpo.gov/fdsys/pkg/CFR-2010-title40-vol27/pdf/CFR-2010-title40-vol27-sec302-4.pdf. As accessed 2011-06-17.
    165) U.S. Environmental Protection Agency: List of hazardous substances and reportable quantities. U.S. Environmental Protection Agency. Washington, DC. 2010. Available from URL: http://www.gpo.gov/fdsys/pkg/CFR-2010-title40-vol27/pdf/CFR-2010-title40-vol27-sec302-4.pdf. As accessed 2011-06-17.
    166) U.S. Environmental Protection Agency: The list of extremely hazardous substances and their threshold planning quantities (CAS Number Order). U.S. Environmental Protection Agency. Washington, DC. 2010c. Available from URL: http://www.gpo.gov/fdsys/pkg/CFR-2010-title40-vol27/pdf/CFR-2010-title40-vol27-part355.pdf. As accessed 2011-06-17.
    167) U.S. Occupational Safety and Health Administration: Part 1910 - Occupational safety and health standards (continued) Occupational Safety, and Health Administration's (OSHA) list of highly hazardous chemicals, toxics and reactives. Subpart Z - toxic and hazardous substances. CFR 2010 2010; Vol6(SEC1910):7-.
    168) U.S. Occupational Safety, and Health Administration (OSHA): Process safety management of highly hazardous chemicals. 29 CFR 2010 2010; 29(1910.119):348-.
    169) United States Environmental Protection Agency Office of Pollution Prevention and Toxics: Acute Exposure Guideline Levels (AEGLs) for Vinyl Acetate (Proposed). United States Environmental Protection Agency. Washington, DC. 2006. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d6af&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    170) United States Food and Drug Administration: 2008 Safety alerts for drugs, biologics, medical devices and dietary supplements: Singulair (montelukast). United States Food and Drug Administration. Rockville, MD. 2008. Available from URL: http://www.fda.gov/medwatch/safety/2008/safety08.htm#Singulair.
    171) Vanden Hoek,TL; Morrison LJ; Shuster M; et al: Part 12: Cardiac Arrest in Special Situations 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. American Heart Association. Dallas, TX. 2010. Available from URL: http://circ.ahajournals.org/cgi/reprint/122/18_suppl_3/S829. As accessed 2010-10-21.