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  #1  
Old 09-25-17, 01:18 PM
orangechik00 orangechik00 is offline
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Inhalers

It has been my experience with my athletes using inhalers for asthma or sports induced asthma, that they use their inhalers 30 minutes before a race or practice. I have an athlete who was prescribed and inhaler last week and the doctor told her to take it only 5 minutes before she races or practices. Doesn't seem to be giving her much help using it only 5 minutes prior to her run. Any insights on this?
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  #2  
Old 09-25-17, 02:56 PM
said_aouita said_aouita is offline
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It may depend what they've been prescribed.
Short-acting beta-2 agonists (Albuterol) is taken 5-10 minutes before.
Inhaled cromolyn sodium, (Intal or Tilade) is 15 to 20 minutes before exercise.
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Old 09-25-17, 04:52 PM
SOTT SOTT is offline
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I have an athlete that takes Albuterol about 10 minutes before.
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Old 09-25-17, 05:11 PM
mathking mathking is offline
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It also depends on exactly what they inhaler has been prescribed for. It can be asthma generally, exercise induced asthma, vocal chord disfunction or other ailments. I have kids who take a puff five minutes before, some who take it just before the warm up run starts (32 minutes before start time) and a few who carry for use during the race. (As a coach make sure you have your permission to carry documentation in that case.)
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Old 09-25-17, 05:38 PM
orangechik00 orangechik00 is offline
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Thanks all. I should have shared some more details. I have 3 athletes on Albuterol, all for sports-induced asthma and all have the same dosage. Two were told to take it 30 minutes before a race or practice and one was told to take it 5 minutes before a race or practice because it would make her jittery. Doctor didn't give much reasoning after that. Just wanted to pick some brains.
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Old 09-25-17, 06:45 PM
ccrunner609 ccrunner609 is offline
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i had a doctor tell me many years ago that a runner should only take an inhaler after they have induced a response from exercise.

They recommended that a runner jogs a warmup every day and then takes the inhaler. Only taking it after the bronchial cells have been triggered.

Also once an inhaler is taken, the inhaler doesnt need taken again for quite awhile.
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Old 09-27-17, 08:52 AM
Rohbino Rohbino is offline
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This is long so I apologize in advance. I am not a doctor but have done some research on asthma thorough my training in biomedical engineering. I've also worked on various medication delivery systems. As always, get medication advice from a doctor or pharmacist (but hopefully one that know what he or she is talking about).

Exercise induced asthma or, more correctly, EIB (exercise-induced bronchoconstriction), is treated in a variety of ways depending on the severity of the condition. It is worth noting here, and you are probably already aware of this, exercise does not cause asthma in an of itself, but it is frequently an asthma trigger.

First of all, you are correct in believing that your athletes should be using their inhalers at least 30 minutes prior to exercise. The onset of action is about 5 to 10 minutes for a short acting beta-2 agonist. That does not mean that peak effect is achieved. Ideally your runners will be racing when peak effect has been achieved. Peak effect isn't achieved until around 50 minutes. Even though albuterol is a short acting beta-2 agonist, it still has a half-life of 6 hours in some pediatric patients. If your athletes follow said aouita's advice, and use their inhaler 5 to 10 minutes prior to racing, the race will be over before the drug has reached peak effect. While using the medication 30 minutes prior to exercise is "OK", one hour is even better.

Another point that I would like to make is that most that use inhalers, particularly inhaled short acting beta-2 agonists, use them incorrectly. Ideally a user will take a puff and wait about 5 minutes before taking the next one. This will allow the medication to begin to have an effect on the smooth muscle and begin dilation of the bronchial passages. Subsequent inhalations will then be more effective. Many users also do not hold the medication in the lungs for as long as they should. Also, as much air as possible should be expelled from the lungs prior to taking the medication and, when the medication is expelled, it should be done so against the resistance of pursed lips. Lastly, for even better medication effect, it should be taken with a chamber.

said aouita also commented on cromyln sodium. The medications that he commented on, Intal (cromyln sodium) and Tilade (nedocromil sodium), are no longer available in inhaled form. Hence, those medications don't merit discussion here.

If your athletes are, indeed, also using a combination inhaler for their asthma regimen, it should not be being used prior to racing. Those combination medications I am referring to contain a long-term beta-2 agonist such as salmeterol, vilanterol, etc, AND a corticosteroid such as fluticasone, budesonide, etc. Brand name examples of these medications are Symbicort, Dulera, Advair, and Breo. These medications have no place at a XC meet and should be used at home. Unless your athletes have more severe issues with their asthma, they may not be using these medications.

I am wiling to bet that the doctor that advised your athlete to use the inhaler 5 minutes prior to exercise is a GP. Alarmingly many GPs are not well trained in issues surrounding EIB or, even more alarming, asthma in general. If your athletes are having issues getting their EIB under control, they should be seeing a physician that specializes in asthma and allergies. Any or those specialists would be advising your athletes to use their inhaler about an hour prior to exercise. The doctor that advised one of your athletes "to take it 5 minutes before a race or practice because it would make her jittery" is totally off base. It's called a side effect. Yes, the "jittery" aspect might be avoided prior to racing but the drug will not be having its desired effect. That athlete should find a new doc.

One other point I would like to mention here is the use of a medication known as montelukast. The brand name of this is Singulair. Singulair is cysteinyl leukotriene receptor antagonist so it blocks the actions of leukotriene which, in turn, should reduce bronchoconstriction. A lot of the current literature supports the use of Singulair for EIB and, indeed, some athletes are able to only use that medication for control and without inhaler usage. Some use a both. You need to be careful, orangechik, in dispensing medical advice so you probably should not mention the drug. It doesn't sound as if your athletes are getting good medical advice and are seeing docs that are not current in the literature so they probably wouldn't be prescribed Singulair. If Singulair works it is nice. It is taken by mouth once per day, is relatively inexpensive, and negates the use of using an inhaler. Many, though, still like to have an inhaler on hand.

EIB and asthma issues are a lot more complicated than most realize. There are many aspects to managing it. Allergies can also play a significant role as a trigger. There is a lot to look at. Some GPs know what they're doing and are able to effectively help the athlete control EIB. Others should be seeing a specialist. Good luck.

Last edited by Rohbino; 09-27-17 at 09:33 AM..
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Old 09-27-17, 09:33 AM
mathking mathking is offline
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Rohbino has some good advice. Particularly about making sure that doctors know what they are doing. Many pediatricians/family practice doctors don't have a lot expertise in this field. I have found a similar issue when diagnosing iron deficiency. The information about taking the inhaler correctly is also vital. Holding the meds in the lungs is important. Using a spacer generally helps a lot, even though a lot of athletes don't have a spacer with their inhaler.

But you need to be really careful in how you handle this. You are not a doctor, and as far as I know no one here is a doctor. I am a long time coach and have a wife and children with asthma, and there is a ton I don't know. And you can get yourself in trouble by giving medical advice that contradicts what a doctor has said. In other words you should not tell athletes to change when they take a puff of their inhaler if a doctor told them when to do it. You are opening yourself up to liability and you might not understand exactly what is wrong with a particular athlete and what medication they are actually taking. (I have a child of my own that has an albuterol inhaler and an inhaled anti-allergy medication that only has a peak efficiency for 20-40 minutes. Those have to be used at very different times.) If you think the instructions are wrong talk to the athlete's parents about it and have them ask their doctor or ask for second opinion. You can also talk to your athletic trainer. There are a number of different kinds of medications, and some inhalers mix types of medications. There are also a lot of different ailments that can require an inhaler, and some kids have more than one, such as asthma and vocal chord disfunction or enlarged lymph nodes. I have athletes this year who think/thought they had asthma when their diagnosis was something different.

When our athletes start using an inhaler we have them track when they took a dose and how many doses and compare that to their race and practice performances. That helps them when they talk to their doctor.
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Old 09-27-17, 11:42 AM
SOTT SOTT is offline
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Quote:
Originally Posted by mathking View Post
I have found a similar issue when diagnosing iron deficiency.
Gosh, isn't that the truth!

"Their ferritin levels are 14ng/mL. That's in the normal range. They are fine."

Great, thanks doc!
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Old 09-27-17, 11:50 AM
orangechik00 orangechik00 is offline
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Thanks so much Rohbino and mathking! To be clear, I'm not giving any medical advice, just haven't experienced someone using their inhaler only 5 minutes before a race, and I've been coaching for 25 years with at least 1-2 athletes using an inhaler each season. Rohbino, you were spot on when you asked if the doctor is a GP. I know the majority of my athletes who have been prescribed inhalers over the years did see an allergy specialist. Always good to be informed. I appreciate everyone taking the time to share his/her knowledge.
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Old 09-27-17, 01:16 PM
SOTT SOTT is offline
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Rohbino, that is some good information. Do you have any particular literature or studies you can point me to for my reading pleasure?

Thanks.
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  #12  
Old 09-27-17, 02:24 PM
Rohbino Rohbino is offline
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I'm glad to hear that you are not giving medical advice, orangechik. mathking emphasized that point and I can not emphasize it enough. That is why I stated, "You need to be careful, orangechik, in dispensing medical advice so you probably should not mention the drug" when I mentioned Singulair. For you to give medical advice would be akin to a teacher telling a parents that their easily distracted children should be put on Ritalin or Adderall. Talking to parents and letting them know that they might want to consult with a specialist is about all you can do.

Quote:
Originally Posted by SOTT View Post
Rohbino, that is some good information. Do you have any particular literature or studies you can point me to for my reading pleasure?

Thanks.
I'll post some links to info here when I have time. I'm getting ready to catch a flight tonight. The literature is probably about as interesting as reading a quarterly report but there is some good info out there.
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Old 10-02-17, 12:39 PM
Rohbino Rohbino is offline
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This is in followup to the discussion here on exercise-induced bronchoconstriction (EIB)/exercise-induced asthma and inhalers/medications. I prefer the term of EIB because I feel that it is more descriptive of the health issue. Too many people believe that exercise-induced asthma is a type of asthma. Exercise is merely the trigger for the bronchoconstriction. Allergens can also be triggers. If an athlete experiences EIB, he or she has asthma - period.

In my experience, those that don't contend with EIB or don't have severe issues with it, have no idea how difficult it is to manage for those that have more severe problems. Some coaches are clueless about the issue and, unfortunately, couldn't care less about their athletes that have the problem. It is a multi-faceted problem that can be very difficult to overcome. Those that can overcome it, though, or finally land on the right treatment, can become elite athletes. Finding the right treatment can be very difficult and excruciating, though. A lot of it can be trial and error.

Several people have PM'd me and ask that I share some literature on the subject. Rather than answer those folks individually, I'll post links here.

Exercise-induced bronchoconstriction: The effects of montelukast, a leukotriene receptor antagonist

This is an older study (2009) but still has information that is pertinent. It is technical in nature so some of the terminology will not be well understood by everyone. Also, this was written at a time that both cromolyn & nedocromil were available as inhalers. Both of those drugs (trade names Intal & Tilade respectively) are now available in nebulizer form only. The study has an excellent list of references.

Full disclosure: I am a big fan of the use of montelukast (Singulair) for EIB. I believe that for many athletes it can be nearly 100% preventative. Additionally, montelukast does not have the issue of "tolerance" of down-regulation of receptors that short-acting β2 adrenergic receptor agonists (SABAs) like albuterol does. There is more on that later. Also, my biomed/biotech firm, in which I am a partner, has done work in conjunction with Merck - the developer and primary marketer of montelukast. Merck markets the drug under the name of Singulair. it is available in generic form.

Package insert for Singulair
This stuff is as exciting to read as it is watching paint dry.

Montelukast versus salmeterol in patients with asthma and exercise-induced bronchoconstriction

Salmeterol is a long-acting β2 adrenergic receptor agonist (LABA) that is known as Servent. The study could more than likely be extrapolated out to include other LABAs such as Symbiocort, Advair, Breo, etc. Many think that Breo is now the most effective of these LABAs, though, and it offers once a day dosing. The LABAs are the medications/inhlaers that I mentioned earlier as not having a place at a XC meet. If you have an athlete using these types of medications they should be using them at home.

An Official American Thoracic Society Clinical Practice Guideline: Exercise-induced Bronchoconstriction

Although the above journal article is scholarly, I think that it is more interesting than the studies and can read like a non-scholarly article. Of note in this article is a recommendation of the use of a short-acting β2 adrenergic receptor agonist (SABA) to be used 15 minutes prior to exercise. I pointed out in an earlier post that the onset of the medication is between 5 and 10 minutes. That is true and I feel that even the 15 minutes referenced here is not adequate. The article is very good so I wanted to include it here. It should be noted that I believe the article is not written by an allergist or asthma specialist. I am fairly certain that a specialist would tend to want a SABA used more than 15 minutes prior to exercise. If it were me I would err on the side of caution and used it so that it was at peak effect prior to racing.

For those really interested in this subject, the article also points out "tolerance" issues of albuterol. Really what this is is a phenomena known as down-regulation. In simple terms, the receptors are not as sensitive to the medication. It's another reason that I advocate that those with more severe EIB seeing a specialist and not relying on a GP for treatment. This is what I referenced above when mentioning that down-regulation is a non-issue with montelukast.

Exercise-Induced Asthma - This article is really not that scholarly and should be well-understood by most lay people. There may be a required password for some sections of the article.

I though that the following was an interesting read on an "alternative" preventive measure. The data in the study suggests that dietary fish oil supplementation does have a markedly protective effect in suppressing EIB in elite athletes.

Fish Oil Supplementation Reduces Severity of Exercise-induced Bronchoconstriction in Elite Athletes

Another point that I would like to make has to do with seasonal allergies. I think that many athletes do not treat seasonal allergies with an antihistamine and/or a coticosteroid such as Nasacort and Flonase. This alone can sometimes be enough to eliminate problems with asthma that are exacerbated even more with exercise. If the allergic response trigger for the asthma is lessened or eliminated, the exercise trigger may not be a factor.

As always, coaches should not be advising athletes of courses of treatment. I merely am posting all of this for information that some may find useful in understanding the disease process. If a coach does talk to a parent, some of this may be made known to the parent but, again, not presented in a way that could be construed as making recommendations of advising for treatment. All advice and treatment should come from a physician.
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