Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions
Exercise-Induced Bronchoconstriction Update
J Allergy Clin Immunol; 2016 Nov; Weiler, et al
The Joint Task Force on Practice Parameters (JTFPP), representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology; (ACAAI); and the Joint Council of Allergy, Asthma & Immunology, has issued an updated practice parameter on exercise-induced bronchoconstriction (EIB). The following are among the key statements and recommendations:
- In asthmatic patients, EIB can indicate lack of control of the underlying asthma. Treat the uncontrolled asthma to get control of EIB.
- A diagnosis of EIB should be confirmed by demonstration of airways reversibility or challenge in association with a history consistent with EIB because self-reported symptoms do not highly correlate with EIB testing.
- Evaluate EIB in elite athletes by using objective testing.
- Prescribe inhaled short-acting β2-adrenergic receptor agonists for protection against EIB and for accelerating recovery of pulmonary function when there is a decrease in pulmonary function after exercise.
- Prescribe a single dose of SABA, LABA, or both on an intermittent basis before exercise.
- Consider prescribing daily therapy with leukotriene inhibitors because this does not lead to tolerance and has been shown to attenuate EIB in 50% of patients.
- Do not prescribe daily LABAs with ICS therapy to treat EIB unless needed to treat moderate-to-severe persistent asthma. The ICS might not prevent the occurrence of tolerance from daily β2-agonist use.
Weiler JM, Brannan JD, Randolph CC, et al. Exercise-induced bronchoconstriction update – 2016. J Allergy Clin Immunol. 2016;138(5):1292-1295. doi:10.1016/j.jaci.2016.05.029.
This Week's Must Reads
Must Reads in Clinical Guidelines
USPSTF: Interventions to Avert Perinatal Depression, JAMA; 2019 Feb 12; US Preventive Services Task Force
ACIP Updates Adult Immunization Schedule, Ann Intern Med; 2019 Feb 5; Kim, Hunter, et al
USPSTF: Interventions to Prevent Child Maltreatment, JAMA; 2018 Nov 27; US Preventive Services Task Force
Cholesterol Guidelines Stress Lifetime Approach, Circulation; ePub 2018 Nov 10; Grundy, et al
USPSTF: Screen Adults for Unhealthy Alcohol Use, JAMA; 2018 Nov 13; Curry, et al
EIB is common, with 10-20% of exercising adults having EIB.1 The guideline states the recommendations for exercise testing differently in 2 different parts of the guidelines. In one part it states, “In a subject who has no history of current clinical asthma, normal PFT results, and no response to bronchodilator, an exercise challenge with a treadmill or cycle or in the sport venue or a surrogate challenge, such as EVH, can be indicated.” In another part of the guidelines, the recommendation is more forceful and states that exercise testing to make the diagnosis should always be done to make the diagnosis of EIB. Often in clinical practice, an EIB diagnosis is made based on symptoms and the response to treatment. The guidelines are clear on the efficacy of beta-agonist therapy, given before participation in exercise, to both prevent and decrease the severity of EIB. If beta-agonists alone are not sufficient, or they are being used frequently, then leukotriene inhibitors or inhaled corticosteroids should be used. In addition to pharmacologic therapy, pre-exercise warm-up is recommended to prevent EIB, and face masks might promote humidification and prevent water loss, which can attenuate EIB. —Neil Skolnik, MD