What is the treatment for exercise-induced asthma?

Treatment for Exercise-Induced Asthma

The first-line treatment for exercise-induced asthma (EIA) is administration of an inhaled short-acting β2-agonist (SABA) 15 minutes before exercise. 1

First-Line Treatment

Short-Acting β2-Agonists (SABAs)

• SABAs are the single most effective agents for preventing EIA
• Administer 15 minutes before exercise
• Provides approximately 80% protection for up to 2-4 hours 1, 2
• Strong recommendation based on high-quality evidence 1
• Should be used on an intermittent basis (less than 4 times per week) 1

Treatment Algorithm for Persistent Symptoms

If symptoms persist despite pre-exercise SABA or if SABA is needed daily or more frequently:

1. Add daily inhaled corticosteroid (ICS)

   • Strong recommendation, moderate-quality evidence 1
   • May take 2-4 weeks to see maximal improvement 1
   • ICS should NOT be used only before exercise 1

2. Alternative or additional options:

   • Daily leukotriene receptor antagonist (LTRA)

     • Strong recommendation, moderate-quality evidence 1
     • Provides 50-60% protection for up to 24 hours 2
     • Does not induce tolerance with regular use 2

   • Mast cell stabilizing agent before exercise

     • Strong recommendation, high-quality evidence 1
     • Examples include cromolyn sodium
     • Provides 50-60% protection for 1-2 hours 2
     • Can be used as add-on therapy to supplement SABAs 1

3. For breakthrough symptoms:

   • Inhaled anticholinergic agent before exercise
     • Weak recommendation, low-quality evidence 1

Important Cautions and Considerations

Tolerance Development

• Daily use of β2-agonists (especially LABAs) can lead to tolerance 1
• Tolerance manifests as:
  • Reduced duration and magnitude of protection against EIA
  • Prolonged recovery in response to SABAs after exercise 1
  • May lead to increased exercise-induced bronchoconstriction 3

LABA Warning

• Do not use long-acting β2-agonists (LABAs) as single therapy
• Strong recommendation against LABA monotherapy due to serious side effect concerns 1

Controller Medication

• A controller agent should be added whenever SABA therapy is used daily or more frequently 1
• For patients with underlying asthma, addressing overall asthma control is essential

Non-Pharmacological Approaches

• Warm-up exercises to induce refractory period
• Breathing through a face mask or scarf to prewarm and humidify air
• Improve general physical conditioning
• Weight loss if obese
• Avoid known triggers (cold air, allergens, pollutants) 4, 5

Monitoring and Follow-Up

• Schedule regular office visits as medication effectiveness can vary over time due to:
  • Changes in airway responsiveness
  • Environmental conditions
  • Exercise intensity
  • Development of tachyphylaxis 1

By following this treatment approach, most patients with exercise-induced asthma can participate in physical activities with minimal respiratory symptoms, significantly improving their quality of life and reducing feelings of fearfulness, frustration, and isolation associated with untreated EIA 6.