What is the recommended treatment for exercise-induced bronchoconstriction according to GINA (Global Initiative for Asthma) guidelines?

Treatment of Exercise-Induced Bronchoconstriction According to GINA Guidelines

The first-line treatment for exercise-induced bronchoconstriction (EIB) is administration of an inhaled short-acting β2-agonist (SABA) 15 minutes before exercise. 1, 2

First-Line Therapy

• Inhaled SABA (e.g., albuterol/salbutamol) should be administered approximately 15 minutes before exercise as preventive therapy 1, 2
• SABA use should be limited to less than 4 times per week to prevent development of tolerance 2, 3
• When properly administered, SABAs provide high-quality protection against EIB with strong evidence supporting their efficacy 1

Second-Line Options for Persistent Symptoms

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

• Daily inhaled corticosteroid (ICS) is recommended as the preferred controller medication 1, 2

  • It may take 2-4 weeks to see maximal improvement after initiating ICS therapy 1
  • ICS should NOT be used only before exercise (pre-exercise use alone is not recommended) 1

• Daily leukotriene receptor antagonist (LTRA) such as montelukast is recommended as an alternative controller 1, 2

  • LTRAs do not lead to tolerance and have been shown to attenuate EIB in approximately 50% of patients 1
  • LTRAs can be used for both intermittent and maintenance prophylaxis 1

• Mast cell stabilizing agents (e.g., cromolyn sodium) before exercise are recommended for patients with persistent symptoms 1

  • These agents have a short duration of action and no bronchodilator activity 1
  • They can be effective alone or as added therapy with other medications 1

• Inhaled anticholinergic agents before exercise may be considered, though evidence is weaker 1

Important Cautions and Considerations

• AVOID daily use of an inhaled long-acting β2-agonist (LABA) as monotherapy due to serious safety concerns 1, 2
• Regular use of β2-agonists can lead to tolerance, manifested as:
  • Reduced duration of protection against EIB 1, 3, 4
  • Reduced magnitude of protection 1, 3
  • Prolonged recovery time after exercise 1, 3
• Tolerance to β2-agonists can develop rapidly, sometimes within 12-24 hours after the first dose 3, 4

Non-Pharmacologic Approaches

• Interval or combination warm-up exercise before planned exercise is recommended 1, 2
• For cold weather exercise, wearing a mask or device that warms and humidifies inspired air is suggested 1, 2
• Dietary modifications that may help include:
  • Low-salt diet 1
  • Fish oil supplementation 1
  • Ascorbic acid (vitamin C) supplementation 1
  • Lycopene supplementation is NOT recommended 1

Combination Therapy Considerations

• For patients with inadequate control on single agents, combination therapy may be beneficial 5
• Recent research suggests that albuterol/budesonide combination therapy taken approximately 30 minutes before exercise can be effective in preventing EIB 6
• The choice between daily ICS or daily LTRA should be made based on patient preferences and baseline lung function 1
• For patients with EIB and allergies who have persistent symptoms, antihistamines may be considered; however, they are not recommended for patients with EIB without allergies 1