What treatment options are available for a patient with exercise-induced asthma who is already on Trelegy (fluticasone furoate, umeclidinium, vilanterol) therapy?

Treatment for Exercise-Induced Asthma Despite Trelegy Therapy

For a patient on Trelegy (which already contains an inhaled corticosteroid and long-acting beta-agonist) who continues to experience exercise-induced bronchoconstriction, add a short-acting beta-agonist (SABA) 15 minutes before exercise as first-line therapy. 1, 2

Primary Treatment Approach

Since Trelegy already provides daily inhaled corticosteroid (fluticasone furoate) and long-acting beta-agonist (vilanterol) therapy, the patient's controller medication is optimized. The breakthrough exercise symptoms require pre-exercise prophylaxis:

• Administer an inhaled SABA (such as albuterol) 15 minutes before exercise 1, 2
• This provides 80-95% protection for up to 2 hours in the majority of patients 3, 4
• SABAs are the most effective single-dose agents for preventing exercise-induced bronchoconstriction 1, 5

Critical caveat: Because the patient is already on daily LABA therapy (vilanterol in Trelegy), do not add additional daily LABA doses, as this increases tolerance risk 1. The SABA should be used intermittently (less than 4 times per week) before exercise only 1.

Second-Line Options if SABA Alone is Insufficient

If pre-exercise SABA provides inadequate protection, consider adding:

Leukotriene Receptor Antagonist (Preferred Second-Line)

• Add daily montelukast 10 mg once daily 1, 2
• Provides 50-60% protection for up to 24 hours 1, 4
• Does not cause tolerance with regular use 1, 4
• Can be used in combination with pre-exercise SABA 6
• Note: Monitor for neuropsychiatric side effects (agitation, depression, suicidal thoughts) 6

Mast Cell Stabilizers (Alternative Second-Line)

• Cromolyn sodium inhaled 10-20 minutes before exercise 1, 2
• Provides 50-60% protection for 1-2 hours 1, 7
• Does not induce tolerance 4, 7
• Can be combined with SABA for additive effect 7
• Multiple daily doses are safe if needed 4

Non-Pharmacologic Strategies (Always Recommend)

These should be implemented alongside pharmacologic therapy:

• Perform interval or combination warm-up exercise for 10-15 minutes before planned activity 1, 2

• This induces a refractory period that can reduce bronchoconstriction 1, 3

• Use a face mask or scarf during cold weather exercise 1, 2

• Warming and humidifying inspired air reduces the osmotic trigger 1, 3

Important Clinical Pitfalls to Avoid

Do not add additional LABA doses: The patient is already receiving daily vilanterol in Trelegy. Adding more LABA (either daily or pre-exercise) increases the risk of tolerance, which manifests as reduced protection duration and magnitude 1, 5. Daily beta-agonist use can also prolong recovery time after exercise 1, 4.

Do not use ICS only before exercise: The patient already receives daily ICS in Trelegy, which is the correct approach 1. Spot ICS dosing before exercise is ineffective and not recommended 1.

Monitor SABA frequency: If the patient requires SABA daily or more than 4 times per week, this indicates inadequate asthma control despite Trelegy, and the treatment plan needs reassessment 1, 2.

Treatment Algorithm Summary

1. Start with pre-exercise SABA (albuterol 15 minutes before exercise) 1, 2
2. If inadequate response after 2-4 weeks, add daily montelukast 1, 2
3. If still inadequate, consider adding pre-exercise cromolyn sodium to the SABA 1, 2
4. Always implement warm-up exercises and cold air protection measures 1, 2
5. Reassess asthma control if SABA needed daily or more frequently 1, 2

The combination of optimized controller therapy (already provided by Trelegy), pre-exercise SABA, and potential addition of montelukast addresses the pathophysiology through multiple mechanisms: reducing baseline inflammation, preventing mast cell degranulation, blocking leukotriene pathways, and providing acute bronchodilation 3, 4.