Leukotriene antagonists have been recommended on a trial basis with follow-up to evaluate the treatment response.4 Although there are several long-term studies of leukotriene antagonists for adults, few have studied children. A recent study assessed the effects of montelukast (Singulair) on 64 children with exercise-induced bronchoconstriction. After 8 weeks of treatment, the montelukast group showed significant improvements (compared with placebo) in asthma symptom scores (24.3±8.2 before vs 17.8±6.8 after 8 weeks of montelukast treatment, P<.05; vs 17.7±6.7 8 weeks after stopping treatment, P<.05), maximum percent fall in FEV1 after exercise (36.5±10.2% before vs 27.6±14.4% after 8 wks of treatment, P<.01; vs 26.7±19.4% 8 weeks after stopping treatment, P<.01), and time to recovery (41.8±8.1 min before vs 25.3±23.3 min after 8 weeks of treatment, P<.01; vs 27.7±26.5 min 8 weeks after stopping, P<.05).5
Therapies awaiting further study include a combination of budesonide (Pulmicort) and formoterol (Foradil), which is similar to the currently available preparation of fluticasone and salmeterol (Advair Diskus) but contains a long-acting beta-agonist with quicker onset. The phosphodiesterase-4 inhibitors roflumilast (Daxas) and cilomilast (Ariflo)—neither of which have been FDA-approved—and inhaled low-molecular-weight heparin have potential efficacy.6 Other options suggested for this problem—including inhaled furosemide, vitamin C, antihistamines, calcium channel blockers, and reduced dietary salt intake—need further study.7
Recommendations from others
Review articles on this topic suggest the following to prevent exercise-induced bronchoconstriction: controlling baseline asthma, avoiding known allergens, choosing appropriate sports with short bursts of activity, and selecting warm, humid environments for the activities.6-8 Some authorities recommend warm-up before athletic events to take advantage of a 30- to 90-minute refractory period. This can help prevent exercise-induced bronchoconstriction; however, effects vary considerably from person to person.7,8
The National Asthma Education and Prevention Program recommends prevention of exercise-induced bronchoconstriction by optimally controlling underlying asthma. If a patient remains symptomatic during exercise, you should review medication usage, understanding of dosage instructions, and administration technique before any changes in the treatment regimen.9