Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Exercise-Induced Asthma Medication

  • Author: Joseph P Garry, MD, FACSM, FAAFP; Chief Editor: Craig C Young, MD  more...
 
Updated: Sep 29, 2015
 

Medication Summary

Traditional asthma medications (eg, corticosteroids, theophylline) have less of a role in the treatment of pure exercise-induced asthma (EIA). There is ongoing investigation regarding other agents (eg, heparin, calcium-channel blockers, diuretics).

As discussed earlier, the optimal treatment for exercise-induced asthma (EIA) is to prevent the onset of symptoms. The basis of treatment is with preexercise short-acting β2-agonist administration.[1] Long-acting β2-agonists, mast cell stabilizers, and antileukotriene drugs also have a role.[9, 10]

Go to Use of Metered Dose Inhalers, Spacers, and Nebulizers for complete information on this topic.

Special Patient Considerations

Although most of the commonly used drugs to treat EIA are in pregnancy category C, these agents are often used for asthma, which is a common condition of pregnancy. Another issue to consider is that many of the agents used for asthma are not indicated for children younger than 2 years; other agents are not indicated for children younger than 6 years. However, these medications have been used successfully for decades in the management of childhood asthma.

Next

Beta2-Adrenergic Agonists, Short-Acting

Class Summary

These agents are used for prophylactic bronchodilation to prevent the onset of symptoms with exercise and have been shown to have a 90% efficacy.

Albuterol (AccuNeb, Proventil HFA, Ventolin HFA, Proair HFA, ProAir RespiClick)

 

Albuterol is the drug of choice and first-line agent in the treatment of EIA. It is a β2-agonist used to treat bronchospasm that is refractory to epinephrine by relaxing bronchial smooth muscle via action on β2-receptors. This agent has little effect on cardiac muscle contractility.

Pirbuterol (Maxair Autohaler)

 

Pirbuterol acts directly on β2 receptors to relax bronchial smooth muscle, relieving bronchospasm and reducing airway resistance.

Levalbuterol (Xopenex, Xopenex HFA)

 

Levalbuterol is a β-agonist for bronchospasm. It relaxes bronchial smooth muscles by action on β2 receptors, with little effect on cardiac muscle contractility.

Previous
Next

Beta2-Adrenergic Agonists, Long-Acting

Class Summary

Long-acting β-agonists have a greater selectivity for the β2 adrenoreceptors than the short-acting agents. These agents cause bronchial smooth muscle relaxation with little effect on cardiac muscle contractility.

Salmeterol (Serevent Diskus)

 

Salmeterol is FDA approved for the prevention of exercise-induced bronchospasms. This agent can relieve bronchospasms by relaxing the smooth muscles of the bronchioles in conditions that are associated with bronchitis, emphysema, asthma, or bronchiectasis. The effect may also facilitate expectoration. Adverse effects are more likely to occur when this agent is administered at high or more frequent doses than recommended; the incidence of side effects is then higher.

Previous
Next

Mast Cell Stabilizers

Class Summary

These agents are 70-80% effective in preventing bronchospasm during exercise. An additive effect is noted when used in combination with albuterol.

Cromolyn sodium (NasalCrom)

 

Cromolyn sodium is a first- or second-line agent in the prevention of EIA but should not be used as rescue therapy for acute bronchospasm. In addition, avoid use of cromolyn sodium with isoproterenol during pregnancy.

Previous
Next

Inhaled Corticosteroids

Class Summary

These agents provide no bronchodilatory effect but are useful in controlling the underlying inflammation of allergic asthma.

Flunisolide (AeroBid, AeroBid-M)

 

Flunisolide is considered a third-line agent that decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. It does not depress the hypothalamus.

Beclomethasone dipropionate (Beconase AQ, QVAR)

 

Beclomethasone dipropionate inhibits bronchoconstriction mechanisms and produces direct smooth muscle relaxation. It may decrease number and activity of inflammatory cells, in turn decreasing airway hyperresponsiveness. As with other agents in this class, beclomethasone dipropionate is also considered a third-line agent.

Ciclesonide (Alvesco)

 

Ciclesonide is an aerosol inhaled corticosteroid indicated for maintenance treatment of asthma as prophylactic therapy. It is not indicated for relief of acute bronchospasm. Corticosteroids have wide range of effects on multiple cell types (eg, mast cells, eosinophils, neutrophils, macrophages, lymphocytes) and mediators (eg, histamines, eicosanoids, leukotrienes, cytokines) involved in inflammation. Individual patients experience a variable time to onset and degree of symptom relief.

Fluticasone (Flovent HFA, Flovent Diskus)

 

Fluticasone inhibits bronchoconstriction mechanisms, produces direct smooth muscle relaxation, and decreases the number and activity of inflammatory cells, in turn decreasing airway hyper-responsiveness. It also has vasoconstrictive activity.

Budesonide (Pulmicort Flexhaler)

 

Budesonide inhibits bronchoconstriction mechanisms, produces direct smooth muscle relaxation, and decreases the number and activity of inflammatory cells, in turn decreasing airway hyperresponsiveness. It has extremely potent vasoconstrictive and anti-inflammatory activity. It alters level of inflammation in airways by inhibiting multiple types of inflammatory cells and decreasing the production of cytokines and other mediators. It also decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.

Previous
Next

Xanthine Derivatives

Class Summary

Xanthine derivatives have been used in allergic asthma for their bronchodilatory and anti-inflammatory properties; however, these agents have multiple side effects. Therefore, monitoring for nontoxic levels is necessary. Traditional asthma medications such as theophylline have less of a role in the treatment of pure exercise-induced asthma.

Theophylline (Aminophylline, Theo-24, Theolair)

 

Theophylline potentiates exogenous catecholamines and stimulates endogenous catecholamine release and diaphragmatic muscular relaxation, which in turn stimulates bronchodilation. However, near-toxic levels (>20 mg/dL) are usually required.

Previous
Next

Leukotriene Receptor Antagonist

Class Summary

Leukotriene receptor antagonists can be used as adjuncts in cases of incompletely controlled EIA with the use of other agents; however, leukotriene receptor antagonists should be reserved for more frequent and persistent cases of EIA rather than for intermittent cases. Leukotriene receptor antagonists should not to be used alone for the treatment of EIA.

Zafirlukast (Accolate)

 

Zafirlukast is a third-line agent that is used only as an adjunct. This agent inhibits effects by the leukotriene receptor, which has been associated with asthma, including airway edema, smooth muscle contraction, and cellular activity associated with the symptoms.

Montelukast (Singulair)

 

Like zafirlukast, montelukast is a third-line agent and is used only as an adjunct. This agent inhibits the leukotriene receptor effects associated with asthma, including airway edema, smooth muscle contraction, and cellular activity associated with the symptoms. In addition, European studies have suggested an improvement in gas exchange versus β2-agonist medication.

Previous
Next

5-lipoxygenase Inhibitor

Class Summary

5-Lipoxygenase inhibitors such as zileuton are indicated for the prophylaxis and long-term treatment of asthma in children and adults.

Zileuton (Zyflo CR)

 

Zileuton selectively inhibits 5-lipoxygenase and inhibits leukotriene formation, which, in turn, decreases neutrophil and eosinophil migration, neutrophil and monocyte aggregation, leukocyte adhesion, capillary permeability, and smooth muscle contractions. Zileuton is a third-line agent and is used only as an adjunct.

Previous
Next

Adrenergic Agents

Class Summary

Adrenergic agonists are used in the emergency treatment of life-threatening situations, when β-agonists are unavailable, or treatment with β-agonists has failed.

Epinephrine (Adrenalin, EpiPen, Primatene Mist)

 

Epinephrine is indicated in the emergency treatment of bronchospasm. This medication has α-agonist effects that include increased peripheral vascular resistance, reversed peripheral vasodilatation, systemic hypotension, and vascular permeability. β-agonist effects of epinephrine include bronchodilation, chronotropic cardiac activity, and positive inotropic effects.

Previous
 
Contributor Information and Disclosures
Author

Joseph P Garry, MD, FACSM, FAAFP Associate Professor, Department of Family Medicine and Community Health, University of Minnesota Medical School

Joseph P Garry, MD, FACSM, FAAFP is a member of the following medical societies: American Academy of Family Physicians, American Medical Society for Sports Medicine, Minnesota Medical Association, American College of Sports Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Anthony J Saglimbeni, MD President, South Bay Sports and Preventive Medicine Associates; Private Practice; Team Internist, San Francisco Giants; Team Internist, West Valley College; Team Physician, Bellarmine College Prep; Team Physician, Presentation High School; Team Physician, Santa Clara University; Consultant, University of San Francisco, Academy of Art University, Skyline College, Foothill College, De Anza College

Anthony J Saglimbeni, MD is a member of the following medical societies: California Medical Association, Santa Clara County Medical Association, Monterey County Medical Society

Disclosure: Received ownership interest from South Bay Sports and Preventive Medicine Associates, Inc for board membership.

References
  1. National Heart, Lung,and Blood Institute, National Asthma Education and Prevention Program. Expert Panel Report 3:Guidelines for the Diagnosis and Management of Asthma: Full Report 2007. Bethesda, Md: NHLBI; August 2007. Publication no. 07-4051:

  2. Anderson SD. How does exercise cause asthma attacks?. Curr Opin Allergy Clin Immunol. 2006 Feb. 6(1):37-42. [Medline].

  3. Hough DO, Dec KL. Exercise-induced asthma and anaphylaxis. Sports Med. 1994 Sep. 18(3):162-72. [Medline].

  4. Smith BW, MacKnight JM. Pulmonary. Safran MR, McKeag DB, Van Camp SP, eds. Manual of Sports Medicine. Philadelphia, Pa: Lippincott-Raven; 1998. Vol 1.: 244-9.

  5. Parsons JP, Hallstrand TS, Mastronarde JG, Kaminsky DA, Rundell KW, Hull JH, et al. An Official American Thoracic Society Clinical Practice Guideline: Exercise-induced Bronchoconstriction. Am J Respir Crit Care Med. 2013 May 1. 187(9):1016-27. [Medline].

  6. Kaplan TA. Exercise challenge for exercise-induced bronchospasm: confirming presence, evaluating control. Phys Sports Med. 1995. 23(8):47-57.

  7. Dickinson JW, Whyte GP, McConnell AK, Harries MG. Screening elite winter athletes for exercise induced asthma: a comparison of three challenge methods. Br J Sports Med. 2006 Feb. 40(2):179-82; discussion 179-82. [Medline]. [Full Text].

  8. Rundell KW, Anderson SD, Spiering BA, Judelson DA. Field exercise vs laboratory eucapnic voluntary hyperventilation to identify airway hyperresponsiveness in elite cold weather athletes. Chest. 2004 Mar. 125(3):909-15. [Medline].

  9. Storms W. Update on montelukast and its role in the treatment of asthma, allergic rhinitis and exercise-induced bronchoconstriction. Expert Opin Pharmacother. 2007 Sep. 8(13):2173-87. [Medline].

  10. Steinshamn S, Sandsund M, Sue-Chu M, Bjermer L. Effects of montelukast and salmeterol on physical performance and exercise economy in adult asthmatics with exercise-induced bronchoconstriction. Chest. 2004 Oct. 126(4):1154-60. [Medline].

  11. Wilson JJ, Wilson EM. Practical management: vocal cord dysfunction in athletes. Clin J Sport Med. 2006 Jul. 16(4):357-60. [Medline].

  12. Kenn K. [Vocal Cord Dysfunction--what do we really know? A review]. Pneumologie. 2007 Jul. 61(7):431-9. [Medline].

  13. Stensrud T, Berntsen S, Carlsen KH. Exercise capacity and exercise-induced bronchoconstriction (EIB) in a cold environment. Respir Med. 2007 Jul. 101(7):1529-36. [Medline].

  14. Butcher JD. Exercise-induced asthma in the competitive cold weather athlete. Curr Sports Med Rep. 2006 Dec. 5(6):284-8. [Medline].

  15. Weiler JM, Hallstrand TS, Parsons JP, Randolph C, Silvers WS, Storms WW, et al. Improving screening and diagnosis of exercise-induced bronchoconstriction: a call to action. J Allergy Clin Immunol Pract. 2014 May-Jun. 2(3):275-80.e7. [Medline].

  16. Beaudouin E, Renaudin JM, Morisset M, Codreanu F, Kanny G, Moneret-Vautrin DA. Food-dependent exercise-induced anaphylaxis--update and current data. Eur Ann Allergy Clin Immunol. 2006 Feb. 38(2):45-51. [Medline].

  17. Sánchez-García S, Rodríguez del Río P, Escudero C, García-Fernández C, Ibáñez MD. Exercise-induced bronchospasm diagnosis in children. Utility of combined lung function tests. Pediatr Allergy Immunol. 2015 Feb. 26 (1):73-9. [Medline].

  18. Weiler JM, Hallstrand TS, Parsons JP, Randolph C, Silvers WS, Storms WW, et al. Improving screening and diagnosis of exercise-induced bronchoconstriction: a call to action. J Allergy Clin Immunol Pract. 2014 May-Jun. 2(3):275-80.e7. [Medline].

 
Previous
Next
 
Pathogenesis of asthma. Antigen presentation by the dendritic cell with the lymphocyte and cytokine response leading to airway inflammation and asthma symptoms.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.