What is the treatment for exercise-induced asthma?

Treatment of Exercise-Induced Asthma

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

First-Line Treatment

• Inhaled SABA (e.g., albuterol) should be administered 15 minutes before exercise for all patients with EIB (strong recommendation, high-quality evidence) 1
• SABA use should be less than daily on average (ideally <4 times per week) to prevent tolerance development 1
• SABAs are the single most effective agents for prevention of EIB, providing approximately 80% protection for 2-4 hours 2

Second-Line Options for Persistent Symptoms

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

• 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 (strong recommendation) 1

• Daily leukotriene receptor antagonist (LTRA) such as montelukast (strong recommendation, moderate-quality evidence) 1

  • Montelukast can provide protection against EIB for up to 24 hours 3
  • Does not induce tolerance with regular use 2

• Mast cell stabilizing agent before exercise (strong recommendation, high-quality evidence) 1

  • Examples include cromolyn sodium and nedocromil
  • Provide 50-60% protection for 1-2 hours 2
  • No tolerance development with regular use 2

• Inhaled anticholinergic agent before exercise (weak recommendation, low-quality evidence) 1

Important Cautions and Considerations

• AVOID daily use of an inhaled long-acting β2-agonist (LABA) as monotherapy (strong recommendation, moderate-quality evidence) due to serious side effect concerns 1

• Tolerance can develop with regular use of β2-agonists (both SABA and LABA), manifested as:

  • Reduced duration of protection 1
  • Reduced magnitude of protection 1
  • Prolonged recovery time after exercise 1
  • Tolerance can develop within 12-24 hours of first dose 1

• Schedule regular follow-up visits as medication effectiveness can vary over time due to:

  • Changes in airway responsiveness 1
  • Environmental conditions 1
  • Exercise intensity 1
  • Development of tolerance 1

Clinical Decision-Making Algorithm

1. Initial treatment: Prescribe SABA to be used 15 minutes before exercise 1

2. If symptoms persist or SABA is needed daily:

   • Add daily ICS or daily LTRA (choice based on patient preference and baseline lung function) 1
   • Consider mast cell stabilizing agent before exercise as an alternative 1
   • Consider inhaled anticholinergic before exercise as a secondary option 1

3. For patients with allergies and persistent EIB symptoms:

   • Consider additional allergy management strategies 1

Non-Pharmacologic Approaches

• Warm-up period before exercise to induce a refractory period 1
• Mask or scarf over the mouth during cold weather exercise 1
• Improve general physical conditioning 1
• Weight loss if obese 1

Remember that EIB can occur in patients with known asthma or in individuals without asthma diagnosis, and proper treatment is essential to maintain quality of life and enable continued participation in physical activities 4.