When an athlete can’t catch his breath
A patient who’s fine during practice but runs out of breath before the game’s over may have exercise-induced bronchoconstriction. This practical guide can help.
Or try empiric treatment
Empiric treatment is a reasonable strategy for athletes with EIB symptoms, worth trying both for athletes who have underlying asthma and for those who do not. If the athlete with asthma responds to treatment, the problem is solved. For the athlete who does not have asthma, however, there are some exceptions to this approach—specifically, the elite athlete.
In the elite athlete, you will need to confirm the diagnosis because many of the substances used to treat EIB are restricted by governing bodies such as the International Olympic Committee (IOC) and require provocative testing to obtain a therapeutic use exemption.8 There is some debate as to whether nonelite athletes also need bronchoprovocative testing. Some recommendations advise testing all elite and competitive athletes and restricting empiric treatment to recreational athletes.1 For more information on banned or restricted medications, see “Is that drug banned from competition?”.
If you take the empiric approach and the athlete does not respond to treatment, consider further testing to rule out other, more serious problems. In Luke’s case, where empiric treatment with albuterol has failed, indirect testing would be the next step.
Certain medications used in the treatment of asthma and exercise-induced bronchoconstriction (EIB) are considered performance-enhancing drugs and either banned or restricted in athletic competition. The regulatory bodies that make these designations in the United States are the National Collegiate Athletic Association (NCAA) and the International Olympic Committee World Anti-Doping Agency (IOC-WADA). These organizations update their list of banned substances yearly and make the current list available on the Web. You can find the NCAA list at www.pace.edu/emplibrary/NCAA%20LIST%20OF%20BANNED%20SUBSTANCESb.doc and the IOC-WADA list at www.wada-ama.org/rtecontent/document/2009_Prohibited_List_ENG_Final_20_Sept_08.pdf.
The IOC-WADA allows competing athletes to use inhaled corticosteroids and β2 agonists, but requires athletes with asthma to provide documentation that the medication is for therapeutic use. Glucocorticosteroids and oral β2 agonists remain prohibited by the IOC-WADA, but only oral β2 agonists are banned by the NCAA. The NCAA warns that student athletes are responsible for knowing which substances are on the banned list and advises them to consult www.drugfreesport.com for more information. To avoid disqualifying a patient from sports participation, check medications you prescribe with the official lists and be sure your EIB patient has the documentation he or she needs to qualify for a therapeutic use exemption.
Medicate before exercise: SABAs and LABAs
Prophylaxis for EIB usually starts with an inhaled short-acting β2 agonist (SABA) such as albuterol or pirbuterol, taken 15 minutes before starting to exercise.9,10 The effectiveness of both short- and long-acting β2 agonists decreases with frequent use, which may be Luke’s problem. For that reason, patients with mild EIB may choose to use pretreatment medication only for more demanding exercise sessions.11 Advise EIB patients who need daily pretreatment to try adjunctive maintenance therapy (discussed at greater length, below.)
Longer-acting β2 agonists (LABAs) such as salmeterol or formoterol may be effective for prolonged or all-day exercise, but may lose their prophylactic effect with prolonged use.12 Furthermore, the US Food and Drug Administration (FDA) has advised against using LABAs alone because of the possibility of severe asthma episodes or death. LABAs should be used only in conjunction with daily maintenance therapy with inhaled corticosteroids. The properties of these and other EIB medications are summarized in TABLE 2.
TABLE 2
EIB medications
| MEDICATION | INDICATION | DOSE | CAUTIONS | COMMENT |
|---|---|---|---|---|
| Short-acting β2 agonists (SABAs) | ||||
| Albuterol, pirbuterol | Pre-exercise prophylaxis, acute treatment | 2 puffs pre-exercise or 2 puffs every 4-6 h as needed | May cause tachycardia, hypokalemia. Tachyphylaxis can develop with frequent use. | First-line treatment |
| Mast cell stabilizers | ||||
| Cromolyn | Pre-exercise treatment | 2 puffs 30-45 min before exercise | None | Best combined with SABA. Tell patients not to use for rescue. |
| Inhaled corticosteroids | ||||
| Flunisolide, fluticasone, budesonide, triamcinolone, beclomethasone, mometasone | Daily maintenance | Variable | Can cause oral candidiasis, hoarseness. | Tell patients this is not a rescue inhaler. |
| Leukotriene inhibitors | ||||
| Zafirlukast | Daily maintenance | 20 mg PO, bid | None | Variable response. Works well with inhaled corticosteroids. Low side-effect profile. |
| Montelukast | Daily maintenance, pre-exercise prophylaxis | 10 mg PO daily or up to 2 h pre-exercise | None | Variable response. Works well with inhaled corticosteroids. Low side-effect profile. |
| Zileuton | Daily maintenance | 1200 mg PO, bid | Risk of elevated liver function tests. | Variable response. Low side-effect profile. |
| Combinations | ||||
| Inhaled fluticasone and salmeterol | Daily maintenance | Variable doses (100/50, 250/50, 500/50 mcg/spray); 1 puff bid | Can cause oral candidiasis, hoarseness, tachycardia, hypokalemia. Tachyphylaxis can develop with frequent use. | Tell patients this is not a rescue inhaler. |
| Inhaled budesonide and formoterol | Daily maintenance | Variable doses (80/4.5, 160/4.5 mcg/spray); 1 puff bid | Can cause oral candidiasis, hoarseness, tachycardia, hypokalemia. Tachyphylaxis can develop with frequent use. | Tell patients this is not a rescue inhaler. |
| EIB, exercise-induced bronchoconstriction. | ||||
| Adapted from the National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the diagnosis and management of asthma.9 | ||||
