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December 2, 2013

Role for LABAs before Sports


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.

From the Editors: Have you ever been faced with the question of whether to prescribe a LABA to prevent exercise-induced asthma? Our world-wide experts weigh on this quandary. They even give you a short literature update on this topic. You will want to download and file this article!

By Prof. Sandra Anderson:

I assume that the subject has objective evidence of EIB as the diagnosis is often incorrectly made on the basis of symptoms.  I also assume that there is a reason that the patient does not wish to have a 12 week trial of inhaled corticosteroid such as Ciclesonide. This ICS treatment has shown to be very effective in reducing severity of EIB even over a short time.  I also assume the subject has normal spirometry. 

If these assumptions are correct then I think it would be useful to use LABA as a single agent in the clinically recommended dose of two inhalations prior to exercise. Providing the LABA use is limited to 3-4 times a week tolerance should not be a problem.   The role of the LABA will be in preventing the mast cell release of mediators in addition to protecting against smooth muscle contraction. Theoretically the LABA will be present in the airways for a longer period of time compared with the sodium cromoglycate or nedocromil. Whilst anti leukotrienes are likely to have some effect many mediators are involved in EIB so blocking just one is unlikely to completely prevent EIB.

Sandra Anderson, PhD, DSc
Department of Respiratory Medicine
Royal Price Alfred Hospital - Camperdown, Australia

By Dr. Matteo Bonini:

Both short- and long-acting beta-2 agonists (SABA and LABA), administered in standard doses immediately before exercise, have been shown to reduce the fall in FEV1 by 70% to 80% in the majority of people with exercise-induced bronchoconstriction (EIB) with or without asthma1.

The mechanism of this protection is mainly related to the beta-2 receptor induced relaxation of bronchial smooth muscle which opposes the contractile effects of the various mediators of bronchoconstriction. Protection from EIB may be also afforded by the beta-2 receptor induced inhibition of mediator release from mast cells.

The choice of the most appropriate beta-2 agonist molecule to be administered should take into consideration sport discipline duration and features (i.e. LABA are often preferred for endurance physical activities).

At present, however, there is no consensus about the efficacy and safety of beta-2 agonists in the pre-treatment of EIB. The role of these molecules in preventing EIB was questioned when patients taking beta-2 agonists daily, reported breakthrough EIB within a dosing period. There are, in fact, several negative findings regarding the efficacy of a daily treatment with beta-2 agonists in controlling the severity of bronchoconstriction and the recovery from EIB. Read the entire answer

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