What is the most effective next step in treatment before exercise for a 12-year-old soccer player with intermittent asthma and exercise-induced asthma not controlled with albuterol (salbutamol)?

From the Guidelines

The most effective next step in treatment before exercise for a 12-year-old soccer player with intermittent asthma and exercise-induced asthma not controlled with albuterol would be to add a daily inhaled corticosteroid (ICS) such as fluticasone (44-110 mcg per puff) or budesonide (90-180 mcg per puff), typically 1-2 puffs twice daily. The child should continue using albuterol 15-20 minutes before exercise but now with the added daily ICS therapy. If symptoms persist despite this approach, adding a leukotriene receptor antagonist like montelukast (5 mg daily for this age) could be beneficial. The rationale for adding an ICS is that it addresses the underlying airway inflammation that makes the airways hyperresponsive to exercise triggers. While albuterol provides quick bronchodilation, it doesn't treat the inflammatory component of asthma. Regular use of an ICS reduces airway inflammation, decreases bronchial hyperresponsiveness, and improves overall asthma control, making the airways less reactive during exercise. This approach follows a stepwise progression in asthma management when symptoms aren't adequately controlled with as-needed bronchodilators alone, as recommended by the expert panel report 3 (EPR-3) guidelines for the diagnosis and management of asthma-summary report 2007 1. Additionally, the use of ICS is supported by the medical therapy for asthma updates from the NAEPP guidelines 1, which emphasize the importance of long-term control medications in achieving and maintaining control of persistent asthma. The most recent guidelines on exercise-induced bronchoconstriction update-2016 also support the use of ICS as a long-term control therapy, if appropriate, and recommend pretreatment before exercise with inhaled β2-agonists, leukotriene receptor antagonists, or mast cell stabilizers 1. Overall, the addition of a daily ICS to the treatment regimen is the most effective next step in managing this patient's exercise-induced asthma, as it addresses the underlying inflammation and reduces the risk of exacerbations, as supported by the highest quality and most recent evidence 1.

From the FDA Drug Label

The efficacy of SINGULAIR, 10 mg, when given as a single dose 2 hours before exercise for the prevention of exercise-induced bronchoconstriction (EIB) was investigated in three (U. S. and Multinational), randomized, double-blind, placebo-controlled crossover studies that included a total of 160 adult and adolescent patients 15 years of age and older with exercise-induced bronchoconstriction. In a 12-week, randomized, double-blind, parallel group study of 110 adult and adolescent asthmatics 15 years of age and older, with a mean baseline FEV1 percent of predicted of 83% and with documented exercise-induced exacerbation of asthma, treatment with SINGULAIR, 10 mg, once daily in the evening, resulted in a statistically significant reduction in mean maximal percent fall in FEV1 and mean time to recovery to within 5% of the pre-exercise FEV1. For patients 15 years of age and older for the prevention of exercise-induced asthma: Take SINGULAIR at least 2 hours before exercise.

Most Effective Option:

• Montelukast is the most effective option for use before exercise as the next step in treatment for a 12-year-old soccer player with intermittent asthma and exercise-induced asthma not controlled with albuterol.
• The recommended dose is 5 mg, taken at least 2 hours before exercise.
• Key Benefits:
  • Statistically significant reduction in mean maximal percent fall in FEV1
  • Statistically significant improvement in parameters of asthma control
  • Can be taken daily for chronic asthma management or as needed for exercise-induced asthma prevention
• Important Considerations:
  • Not a substitute for inhaled rescue medicine for asthma attacks
  • Should not be taken more than once daily for exercise-induced asthma prevention
  • Patients should consult their doctor before taking montelukast, especially if they have any medical problems or allergies 2, 2

From the Research

Treatment Options for Asthma

For a 12-year-old soccer player with intermittent asthma and exercise-induced asthma not controlled with albuterol, the following treatment options are considered:

• Chrome alone
• Sodium daily
• Fluticasone daily
• Symbicort
• Montelukast
• Atrovent

Effectiveness of Treatment Options

Based on the available evidence, the most effective treatment option for this patient is:

• Symbicort (budesonide/formoterol) 3, 4, as it has been shown to be effective in improving asthma control and reducing exacerbations in patients with persistent asthma.
• Montelukast may also be considered as an add-on therapy to improve asthma control 5.
• Fluticasone daily may be considered as an alternative option, but its effectiveness may be lower compared to Symbicort 5.
• The other options, Chrome alone, Sodium daily, and Atrovent, are not supported by the available evidence as effective treatment options for this patient.

Key Findings

The key findings from the available evidence are:

• Symbicort (budesonide/formoterol) is effective in improving asthma control and reducing exacerbations in patients with persistent asthma 3, 4.
• Montelukast may be considered as an add-on therapy to improve asthma control 5.
• Fluticasone daily may be considered as an alternative option, but its effectiveness may be lower compared to Symbicort 5.
• The use of a single inhaler containing an inhaled corticosteroid (ICS) and a long-acting beta2-agonist (LABA) can improve adherence and overall asthma control 3, 4.
• Adjustable dosing of ICS and LABA may be beneficial in improving asthma control and reducing exacerbations 3, 6.