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July 12, 2021

Role for LABAs before Sports

Question

Is there any role for long-acting beta-agonists given before sport if that is the only intervention that has helped? The patient is a teenager and has no interval asthma, and is not on an inhaled corticosteroid, and trials of short-acting beta-agonists, cromolyn, and anti-leukotriene have failed. The only effective prevention is salmeterol 2 puffs given in the morning of the sports activity, 3 or 4 times a week. We are warned about using LABA alone with inhaled corticosteroids.

Answer

Asthma produces dyspnea during exercise because of airway obstruction from bronchospasm, and that airway obstruction can be prevented by the bronchoprotective effect of inhaled β2-adrenergic agonists. Both types of beta-2-agonists (SABA and LABA) have shown to be effective in the reduction of exercise - induced bronchoconstriction.

Nevertheless, there are some studies that show that initial doses of both salmeterol and formoterol have similar but more sustained bronchoprotective effects for exercise-induced bronchospasm than shorter-acting bronchodilators, such as albuterol. However, an examination of 20 adults given salmeterol twice daily for 4 weeks showed that although a bronchodilator effect was maintained, a decrease in bronchoprotective effect for exercise-induced bronchospasm at 14 and 29 days of administration that was most prominent 9 hours after the dose was demonstrated.

This loss of bronchoprotective effect has also been reported to occur even with use of inhaled corticosteroids. In a study of sixteen 12- to 16-year-old children receiving an inhaled corticosteroid, Simons et al showed an initial protective effect of a 50-μg morning dose of salmeterol against exercise-induced asthma. Although the degree of protective effect in the morning 1 hour after the dose was greater than that at an afternoon exercise study 9 hours after the first morning dose, the protective effect was still significantly greater than that seen during placebo administration. After 28 days, although bronchodilatation persisted, the bronchoprotective effect was reported as having waned based on presenting the data as a maximum percentage decrease in FEV1. However, although the magnitude of decrease in exercise-induced bronchospasm was not significantly different from that with placebo at 9 hours, the actual FEV1 at 9 hours after salmeterol was still better than the 9-hour postexercise value after placebo.

These data suggest the loss of bronchoprotective effect to exercise is, on average, small and likely to be of little importance for most patients.

According to GINA guidelines 2020, in patients with mild asthma one study showed that the use of low dose budesonide/formoterol taken as needed and before exercise had similar benefit in reducing exercise-induced bronchoconstriction as daily low dose ICS with SABA as needed and pre-exercise.

In conclusion, more studies are needed, but evidence suggests that patients who are prescribed as needed ICS /formoterol to prevent exacerbations and control symptoms can use the same medication prior to exercise.

References

  1. Global Strategy for Asthma Management and Prevention (2020 update)
  2. Weinberger Miles, Long acting B-agonists and exercise The Journal ot allergy and CLinical Immunology VOLUME 122, ISSUE 2 P251 - 253 AUGUST 01 2008
  3. Eckerström F, Rex CE, Maagaard M, et al. Exercise performance after salbutamol inhalation in non-asthmatic, non-athlete individuals: a randomised, controlled, cross-over trial. BMJ Open Sport & Exercise Medicine 2018;4:e000397. doi:10.1136/ bmjsem-2018-000397

Reviewer

Gabriela Pérez, MD
Allergy and Immunology
Lima, Peru


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