What medication is most effective for a 12-year-old soccer player with partial relief from albuterol (bronchodilator) for exercise-induced bronchospasm?

From the Guidelines

For a 12-year-old soccer player with exercise-induced bronchospasm who has partial relief from albuterol, a montelukast (Singulair) 5mg tablet taken daily is likely the most effective next step medication. This recommendation is based on the expert panel report 3 (EPR-3) guidelines for the diagnosis and management of asthma, which suggests that leukotriene modifiers, such as montelukast, can attenuate exercise-induced bronchospasm (EIB) 1. The child should continue using albuterol (2 puffs 15-30 minutes before exercise) as needed, but adding daily montelukast often provides superior protection against exercise-induced symptoms.

Some key points to consider when using montelukast for EIB include:

• Montelukast works by blocking inflammatory mediators that cause airway constriction during exercise 1
• The recommended dose for children 12 years of age is 5mg daily 1
• Montelukast can be used as adjunctive therapy with inhaled corticosteroids (ICSs), but for exercise-specific symptoms, it is typically preferred due to its targeted mechanism and once-daily dosing convenience 1
• Proper inhaler technique should be verified, and the child should perform a gradual warm-up before intense activity

It's also important to note that long-acting beta2-agonists (LABAs) may be used before exercise to prevent EIB, but frequent or chronic use before exercise is discouraged, as it may disguise poorly controlled persistent asthma 1. Inhaled corticosteroids, such as fluticasone, may also be considered if the combination of albuterol and montelukast proves insufficient, but montelukast is typically preferred for exercise-specific symptoms due to its targeted mechanism and once-daily dosing convenience.

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. In pediatric patients 6 to 14 years of age, using the 5-mg chewable tablet, a 2-day crossover study demonstrated effects similar to those observed in adults when exercise challenge was conducted at the end of the dosing interval (i.e., 20 to 24 hours after the preceding dose).

Montelukast has been shown to be effective for use before exercise in patients with exercise-induced bronchospasm, including pediatric patients.

• The recommended dose for pediatric patients 6 to 14 years of age is 5 mg, and for patients 15 years and older is 10 mg.
• The medication can be given as a single dose 2 hours before exercise or as a daily dose for chronic treatment of asthma.
• However, it is essential to note that montelukast did not prevent clinically significant deterioration in maximal percent fall in FEV1 after exercise in 52% of patients studied 2.

From the Research

Medication Options for Exercise-Induced Bronchospasm

• For a 12-year-old soccer player with partial relief from albuterol, several medication options have been studied for exercise-induced bronchospasm.

Montelukast as a Potential Solution

• Montelukast, a leukotriene-receptor antagonist, has been shown to be effective in treating exercise-induced bronchoconstriction (EIB) in patients with mild asthma 3, 4, 5.
• Studies have demonstrated that montelukast provides significant protection against EIB, with improvements in lung function and reduction in symptoms 3, 6.
• Montelukast has also been shown to be effective in preventing EIB in children, with no evidence of tolerance or rebound worsening of lung function after discontinuation of treatment 4.

Comparison with Other Medications

• Montelukast has been compared to salmeterol, a long-acting beta(2)-receptor agonist, in the treatment of EIB, with montelukast providing superior protection at weeks 4 and 8 6.
• Additionally, montelukast has been shown to prevent salbutamol-induced tolerance in airway smooth muscle, suggesting a potential beneficial interaction between montelukast and beta(2)-adrenoceptor agonists 7.

Considerations for the 12-year-old Soccer Player

• While the studies mentioned above did not specifically focus on 12-year-old patients, montelukast has been approved for use in patients as young as 12 months of age for allergic asthma and 6 months of age for allergic rhinitis 5.
• However, the US approval for prevention of exercise-induced bronchoconstriction is for patients 15 years of age or older 5, so the use of montelukast in a 12-year-old patient would be off-label.