What medication is used to treat exercise-induced asthma?

Medications for Exercise-Induced Asthma

Short-acting beta-agonists (SABAs) like albuterol are the first-line medication for exercise-induced asthma, administered 15 minutes before exercise. 1

First-Line Treatment

Short-Acting Beta-Agonists (SABAs)

• SABAs are the single most effective agents for prevention of exercise-induced bronchoconstriction (EIB)
• Provide approximately 80% protection against EIB for 2-4 hours 2
• Should be administered 15 minutes before exercise
• Examples: albuterol (most commonly used), levalbuterol, pirbuterol
• Mechanism: Stimulate beta2-receptors on airway smooth muscle causing relaxation and bronchodilation
• Usage should be less than daily on average to prevent tolerance 1

Second-Line/Add-On Treatments

For patients who continue to have symptoms despite using a SABA before exercise, or who require SABA daily or more frequently:

Inhaled Corticosteroids (ICS)

• Recommended for daily administration (not just before exercise) 1
• Takes 2-4 weeks to reach maximal effectiveness
• Reduces underlying airway inflammation
• Strong recommendation with moderate-quality evidence 1

Leukotriene Receptor Antagonists (LTRAs)

• Example: montelukast (Singulair)
• Provides 50-60% protection for up to 24 hours 2
• Does not induce tolerance with regular use
• Can be used daily or before exercise
• FDA-approved for prevention of exercise-induced asthma in patients 15 years and older 3
• Strong recommendation with moderate-quality evidence 1

Mast Cell Stabilizers

• Examples: cromolyn sodium, nedocromil (not currently available in the US)
• Provide 50-60% protection for 1-2 hours 2
• Less effective than beta2-agonists but do not induce tolerance
• Can be used shortly before exercise
• Strong recommendation with high-quality evidence 1

Treatment Algorithm

1. Initial therapy: SABA 15 minutes before exercise

   • If effective and used less than daily → continue this regimen

2. If SABA alone is insufficient or needed daily:

   • Add daily ICS as controller medication, OR
   • Add daily LTRA (especially if patient has allergies), OR
   • Add mast cell stabilizer before exercise

3. For breakthrough symptoms despite above treatments:

   • Consider inhaled anticholinergic agent before exercise (weak recommendation) 1

Important Clinical Considerations

• Tolerance development: Daily use of beta2-agonists (both short and long-acting) can lead to tolerance, reducing their effectiveness 1
• LABA caution: Long-acting beta-agonists should not be used as monotherapy for EIB and are not recommended as first-line treatment 1
• Monitoring: Schedule regular office visits as medication effectiveness may vary over time due to changes in airway responsiveness, environmental conditions, and tachyphylaxis 1
• Combination therapy: The recent TYREE study showed that albuterol/budesonide combination was significantly more effective than placebo in preventing EIB 4

Non-Pharmacologic Approaches

• Warm-up period before exercise may reduce EIB severity
• Wearing a mask or scarf over mouth may attenuate cold-induced EIB 1
• Improving physical conditioning
• Weight loss if obese

Remember that frequent or severe EIB may indicate poorly controlled persistent asthma that requires adjustment of controller medications rather than just pre-exercise treatment 1.