How Allergies Can Be Managed in Exercise and Sport

Heidi Splete

August 04, 2022

For people who exercise for health and well-being or athletes who compete at an elite level, early assessment of allergy and respiratory conditions will allow individuals to maintain their physical activity routines, according to a new position paper from the European Association of Allergy and Clinical Immunology.

The prevalence of allergy and respiratory disorders in young, athletic individuals is as high as 40% and 20%, respectively, but the reason for an increased risk remains unclear, write Oliver J. Price, MD, of the University of Leeds, Leeds, United Kingdom, and colleagues.

“Physical inactivity is now recognized as a potential cause of chronic disease, and thus, the importance of controlling allergic and respiratory symptoms and optimizing disease management to help reduce barriers to exercise and physical activity engagement, within the wider general population, should not be overlooked,” the authors noted.

Dr Oliver Price

The European Academy of Allergy and Clinical Immunology (EAACI) commissioned the paper as an update to previously published articles in a series on exercise-induced hypersensitivity in athletes.

The complete paper, published in the journal Allergy, provides details on the clinical presentation, diagnostic methods, and treatment strategies for the most common allergic and respiratory conditions related to exercise.

For exercise-related allergic conditions in particular, the update focuses on allergic rhinitis, exercise-induced anaphylaxis (EIAn), and exercise-induced urticaria (EIU).

Allergic Rhinitis

For allergic rhinitis, patients may present with nasal obstruction, rhinorrhea, itchy nose, and sneezing. A diagnostic assessment should include a clinical history of correlation between nasal symptoms and allergy sensitization, as well as nasal endoscopy or anterior rhinoscopy, and a nasal cytology to confirm inflammation, the authors write.

Management of these patients can include both nonpharmacological and pharmacological strategies. Individuals can use saline nasal douchings for relief, and swimmers may benefit from nose clips. Avoidance of triggers is advised if possible.

Nose surgeries, mainly turbinoplasty, can be considered in cases of medically resistant, reversible nasal obstruction caused by inflammation or swelling of the turbinates (small structures inside the nose), according to the authors.

Exercise-Induced Anaphylaxis

Individuals suffering from EIAn present with fatigue, pruritus, warmth, flushing, and urticaria. These symptoms may progress to include angioedema, wheezing, rhinitis, gastrointestinal discomfort, and even cardiovascular collapse. Diagnostic tools include an incremental exercise test, and identification of foods consumed in the 24 hours before a reaction.

Acute treatment for EIAn is the Trendelenburg position and administration of adrenaline. When emergency medical personnel become involved, anaphylaxis management should follow current established guidelines, according to the authors.

Individuals with EIAn should be educated to recognize their earliest symptoms and stop exercising immediately, the authors emphasized.

Management strategies for athletes with EIAn include exercising with someone else who can use an adrenaline autoinjector, carrying a cell phone, exercising near emergency medical facilities, and wearing a medical alert bracelet or other identification that explains their condition.

Exercise-Induced Urticaria

For individuals with EIU, pruritic wheals, or hives greater than 5 mm in diameter may develop during or after exercise. A positive diagnosis can be made using an incremental exercise test, with wheals present for 10 minutes after testing. The update also recommends a passive warming test 24 hours after exercise to rule out cholinergic urticaria.

Advise athletic individuals with EIU to recognize their symptoms and to develop a treatment plan, the authors write. In cases of food-dependent EIU, individuals should be aware of their condition and avoid the specific food in advance of activity. Treatment with nonsedative antihistamines is an option, up to four times daily for nonresponders.

In general, management of allergic disorders in athletic individuals should follow current guidelines for the general population, according to the authors, “yet at the same time, interventions should be tailored according to the individual patient,” they write.

“Simple management strategies include avoidance of triggering allergens by following the four Ps concept (predictive, preventive, personalized, participative) of personalized medicine,” they write.

Overcoming Diagnostic Dilemmas

“The diagnosis of allergy and respiratory disorders in association with sport can be difficult and confounded by the poor precision of a standard clinical approach to diagnosis,” Price told Medscape Medical News. “Therefore, objective testing is required to confirm a diagnosis prior to initiating treatment.”

Barriers to prompt diagnosis and management of allergic disease in athletic individuals include limited availability of several of the optimal diagnostic tests, Price noted.

“To overcome this issue, we provide pragmatic recommendations to aid clinical decision making and inform diagnostic referral pathways,” Price told Medscape. “For example, attending a specific training session and environment where symptoms typically present, or requesting a ‘selfie-type’ video, recorded on a smartphone or tablet, is a simple yet effective first step.”

Price said he envisions the new paper as “a catalyst for future studies.” Looking ahead, “Key research priorities in this area include evaluating global prevalence estimates and identifying relevant risk factors and high-risk athletic groups who are at heightened susceptibility to the development of allergy and respiratory disorders,” he explained.

Detecting and classifying individuals according to disease subtype and severity “will also permit future work exploring mechanisms of disease and efficacy of preventative strategies and novel therapeutic interventions,” he said.

Athletes Need Better Prognostics for Better Protection

“During the COVID-19 pandemic and the curtailing on international and professional competitions, athlete welfare and readiness to return to competition has been a key topic of conversation,” among coaches and sport-governing bodies, said Mark Faghy, MD, associate professor of respiratory physiology at the University of Derby, Derby, United Kingdom, in an interview with Medscape.

“In light of the challenges that were exacerbated by the pandemic, the development and publication of this task force paper is extremely timely, and will serve as a great resource to stimulate research and positively influence applied practice for many years to come,” said Faghy, who was not involved in the task force report.

The message is clear, “research is needed to improve quality and sensitivity of diagnostic/prognostic tools that can be used to mitigate the impact of allergies for athletes,” Faghy said.

Barriers to following the recommendations persist, including lack of funding for respiratory-related issues in sports medicine, Faghy noted. Although the study authors provide strong recommendations, “the brevity of the issue needs to be acknowledged and campaigned for by sport’s governing bodies and international agencies,” he said.

“The article offers a detailed overview of the current understanding and position within sports performance, but there is a need for the stated recommendations to be taken forward and established into a detailed blueprint that includes the relevant stakeholders to put the suggestions into practice,” he added.

The study was supported by the European Academy of Allergy and Clinical Immunology. The researchers report no relevant financial conflicts. Faghy disclosed no financial conflicts, but has worked with some of the study authors outside the scope of the current study.

Allergy. Published July 9, 2022. Full text.

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