Exercise-Induced Bronchoconstriction: The New Guidelines

Treatment: Start With a Short-Acting Bronchodilator

Medscape: Let's talk about treatment. The guidelines list many different agents for the treatment of EIB. Do you suggest that clinicians use them in the order they are listed in the guidelines?

Dr. Parsons: Yes. The first step after you have made a formal diagnosis objectively of EIB, typically, is to start with a short-acting bronchodilator, such as albuterol -- usually 2 puffs 15-20 minutes before exercise. If a person really has EIB, that will be sufficient to control the symptoms of EIB in about 80% of the cases, so that in and of itself is an easy fix for this diagnosis in the vast majority of cases. Now, if an athlete continues to be symptomatic despite using the albuterol properly, that may indicate that he or she actually has underlying asthma that is inadequately controlled.

If that is the case, that patient may need an additional controller agent. There are multiple choices for that, as we outlined in the guidelines. You can go with an inhaled steroid or a leukotriene receptor antagonist. It depends on what the patient is comfortable with, what their insurance will cover, and the physician preference or caretaker preference as well. Typically, we start with the albuterol. If that's not doing the job, then we will go to a second-line agent of the patient's and prescriber's choice at that point.

I will also say that if you treated EIB with albuterol without making a formal diagnosis, on the basis of symptoms alone, and the patient continues to be symptomatic despite using the albuterol properly, that is the point in time when you need to start looking for an alternative diagnosis, because maybe this wasn't EIB after all.

Medscape: Does the severity of EIB enter into how you would treat the patient?

Dr. Parsons: I would still start with an albuterol inhaler and then go from there. Some patients who exercise every day, or multiple times a day or who are on a competitive sports team, and who have significant EIB might need a controller agent as well.

Typically, I would use an inhaled corticosteroid as a maintenance medicine, and then I would have the patient continue to use their albuterol before exercise. I don't think it would be wrong, if the patient had very severe EIB, to go ahead and give them an inhaled corticosteroid along with the albuterol. That's not necessarily in our guidelines, but in practice that would be a reasonable thing to do.

Medscape: Let's talk about the issue of performance-enhancing drugs and the treatment of EIB. Are any of the agents used to treat EIB banned, and whose responsibility is it to know?

Dr. Parsons: It will always be the responsibility of the athlete to be aware of the rules and regulations of the governing body under which they exercise. Most of these athletes are going to clinicians who have good experience with what these rules are, but it's not going to be an acceptable excuse to a governing body to say, "I didn't know what the rules are" if they take something that is banned. That is pretty cut and dried. It's always the athlete's responsibility to know what they can and cannot put in their body, even if it's prescribed to them.

The good news is that the guidelines have changed quite a bit over the past 4-5 years. In the past, there was quite a bit of regulation with the inhaled asthma medications. Now, the vast majority of these medicines, if they are taken in therapeutic doses, do not need any kind of waiver or therapeutic use exemption.

Patients don't need to get a waiver anymore for inhaled steroids, leukotriene modifiers, or albuterol. All of those are okay now. The oral steroids, however, are not permitted. It is very uncommon to use oral bronchodilators, such as oral albuterol, anymore (although they are still available), and they are banned. The inhaled medications are fine, however.

Medscape: Just to summarize, are any of the agents that you might prescribe for the treatment of EIB banned?

Dr. Parsons: No. The long-acting bronchodilators, such as formoterol and salmeterol, which are the long-acting beta agonists, do have regulations based on dosing. They could potentially test the dose in the urine of an athlete to see if they are abusing it. But in therapeutic doses, if used as prescribed, those are totally fine. So there aren't any major regulations anymore for these medications except if for some other reason, the patient was taking oral prednisone, which can't be done without a waiver.

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