The use of anti-asthmatic drugs. Do they affect sports performance?

Exercise-Induced Asthma Symptoms and Nighttime Asthma: Are They Similar to AHR?

Background. Asthma experienced during exercise and during the night is based on the presence of airway hyperresponsiveness (AHR). The aim of the present study was to examine whether AHR is a predictor of exercise-induced asthma (EIA) and nighttime symptoms. Material. We included 793 asthmatics subjects with symptoms and a positive asthma test. Results. Mean (SD) FEV1 was 93% (15), 71% had rhinitis, and 62% had atopy. Both EIA and nighttime symptoms were associated with AHR; however, when including other factors of importance in a multivariate analysis, logRDR was eliminated, whereas FEV1% pred (P < .001), smoking (P < .05), atopy (P < .001), sex (P < .001), and treatment (P < .01) were associated with having EIA while dyspnoea (P < .001), cough (P < .001), and eosinophils (P < .01) were associated with frequent night symptoms. The risk of having nighttime awakenings due to asthma was more than twofold higher among those with EIA symptoms than among those without symptoms (OR (CI95%) 2.77 (2.0–3.8) (P < .001)). In Conclusion. EIA and night symptoms are associated with AHR, but other factors of importance eliminated this close association. Night asthma is more closely associated with airway inflammation than AHR.

No variation of physical performance and perceived exertion after adrenal gland stimulation by synthetic ACTH (Synacthen) in cyclists

There is anecdotal evidence that athletes use the banned substance Synacthen because of its perceived benefit with its associated rise in cortisol. To test the performance-enhancing effects of Synacthen, eight trained cyclists completed two, 2-day exercise sessions separated by 7-10 days. On the first day of each 2-day exercise session, subjects received either Synacthen (0.25 mg, TX) or placebo (PLA) injection. Performance was assessed by a 20-km time trial (TT) after a 90-min fatigue period on day 1 and without the fatiguing protocol on day 2. Plasma androgens and ACTH concentrations were measured during the exercise bouts as well as the rate of perceived exertion (RPE). Spot urines were analyzed for androgens and glucocorticoids quantification. Basal plasma hormones did not differ significantly between PLA and TX groups before and 24 h after the IM injection (P > 0.05). After TX injection, ACTH peaked at 30 min and hormone profiles were significantly different compared to the PLA trial (P < 0.001). RPE increased significantly in both groups as the exercise sessions progressed (P < 0.001) but was not influenced by treatment. The time to completion of the TT was not affected on both days by Synacthen treatment. In the present study, a single IM injection of synthetic ACTH did not improve either acute or subsequent cycling performance and did not influence perceived exertion. The investigated urinary hormones did not vary after treatment, reinforcing the difficulty for ACTH abuse detection.

Pharmaceutical treatment of asthma symptoms in elite athletes - doping or therapy?

Asthma, exercise-induced bronchoconstriction, and airway hyper-responsiveness are often found in elite athletes, perhaps as a consequence of their sport or maybe because asthma is a common disorder in young adults. Inhaled beta2-agonists (IBA) are frequently used in elite athletes, but due to regulations introduced by the International Olympic Committee, the use of anti-asthmatic therapy might change. Drugs that make ergogenic effect persist are prohibited in all athletes, whether or not they take part in competitions and systemic steroids and beta2-agonists are among such drugs. On the other hand, opinion is more divided about the use of inhaled corticosteroids (ICS) and IBA. In humans, no effect has been found on the oxygen uptake, performance or distance run with therapeutic doses of IBA, either in asthmatics or non-asthmatics, whereas others report an ergogenic effect and better lung function of high doses of a beta2-agonist in non-asthmatics. Anti-asthmatic treatment is necessary for asthmatics, but should not be used by non-asthmatic elite athletes due to both possible systemic effects and furthermore, side effects of both ICS and IBA.

beta2-Agonists at the Olympic Games

The different approaches that the International Olympic Committee (IOC) had adopted to beta2-agonists and the implications for athletes are reviewed by a former Olympic team physician who later became a member of the Medical Commission of the IOC (IOC-MC). Steadily increasing knowledge of the effects of inhaled beta2-agonists on health, is concerned with the fact that oral beta2-agonists may be anabolic, and rapid increased use of inhaled beta2-agonists by elite athletes has contributed to the changes to the IOC rules. Since 2001, the necessity for athletes to meet IOC criteria (i.e., that they have asthma and/or exercise-induced asthma [EIA]) has resulted in improved management of athletes. The prevalence of beta2-agonist use by athletes mirrors the known prevalence of asthma symptoms in each country, although athletes in endurance events have the highest prevalence. The age-of-onset of asthma/EIA in elite winter athletes may be atypical. Of the 193 athletes at the 2006 Winter Olympics who met th IOC's criteria, only 32.1% had childhood asthma and 48.7% of athletes reported onset at age 20 yr or older. These findings lead to speculation that years of intense endurance training may be a causative factor in bronchial hyperreactivity. The distinction between oral (prohibited in sports) and inhaled salbutamol is possible, but athletes must be warned that excessive use of inhaled salbutamol can lead to urinary concentrations similar to those observed after oral administration. This article provides justification that athletes should provide evidence of asthma or EIA before being permitted to use inhaled beta2-agonists.

Effects of acute salbutamol intake during supramaximal exercise in women

OBJECTIVE

To study the effects of an acute therapeutic oral intake of beta(2) agonist on performance and substrate response during supramaximal exercise in women.

METHODS

12 healthy moderately trained female volunteers performed a Wingate test after ingestion of placebo (Pla) and salbutamol (Sal; 4 mg) according to a double-blind randomised crossover study. Blood samples were collected at rest, at the end of exercise and after 5 (r5), 10 (r10) and 15 (r15) min of passive recovery for adrenocorticotropic hormone (ACTH), growth hormone (GH), insulin, blood glucose and lactate measurements.

RESULTS

Peak power (PP) and mean power (MP) significantly increased whereas time to peak power was significantly shorter with Sal than with Pla (p<0.05). No change was observed in the fatigue index. ACTH was not significantly modified but r15 growth hormone significantly decreased (p<0.05) after the intake of Sal. Both blood INS and blood glucose were significantly increased by the intake of Sal during all the experiments (p<0.01). Blood lactate was significantly increased by the intake of Sal compared with that of Pla (p<0.05) after 10 and 15 min of passive recovery.

CONCLUSION

From these data, acute therapeutic oral intake of Sal seems to induce, irrespective of the subjects' gender, an improvement in performance during a supramaximal exercise--that is, increase in PP and MP. Further studies are necessary to clarify whether the mechanisms involved in the response to intake of Sal are linked to central and/or peripheral pathways.

The cardiorespiratory response to submaximal exercise in subjects with asthma following pretreatment with controlled release oral salbutamol and high-dose inhaled salmeterol

Treatment for exercise induced asthma (EIA) in sporting competition is controlled to prevent the use of agents which might enhance physical performance. There is little information concerning the effects of the long-acting inhaled, and oral, sustained release type bronchodilators on the cardiorespiratory effects of submaximal exercise. The aim of this study was to compare the cardiorespiratory effects of submaximal exercise in patients with EIA before and after pretreatment with high-dose inhaled salmeterol xinafoate (SX) and controlled release oral salbutamol (CR). Patients were treated with SX (100 micrograms b.d.) and CR (8 mg b.d.) for > or = 3 days in a double-blind randomized cross-over design, with a 5-14 day washout period between treatments. A submaximal exercise test (total exercise time 6 min, final 3 min at 60% of VEpeak) was performed prior to each treatment period, and repeated at 1, 6, and 12 h postdose at the end of the treatment period. Two subjects were withdrawn from the study. Three subjects required relief medication after 1 h (CR) and one subject after 6 h (SX) and they did not perform further exercise tests. Both treatments increased baseline FEV1, with SX producing significantly greater pre-exercise bronchodilation than CR (P = 0.04). Following CR, there were no significant differences from the pretreatment values for VO2, VE, respiratory exchange ratio, heart rate, ventilatory equivalents for VO2, and oxygen pulse during the submaximal exercise challenge. Following SX, there were no significant differences for any of the exercise variables except for VE at 6 and 12 h (mean increase 4.27 l min-1 at 6 h, P < 0.01 and 4.69 l min-1 at 12 h, P = 0.05). The changes in ventilation following SX did not have an effect on oxygen consumption, and the ventilatory efficiency (VE/VO2) remained unchanged. The findings from this study demonstrate that, despite exercising from a higher baseline FEV1, short pretreatment periods with controlled release oral salbutamol and with inhaled salmeterol do not confer any cardiorespiratory advantage during submaximal exercise in subjects with EIA.

Asthmatic drugs and competitive sport. An update

Almost all asthmatics are prone to asthma triggered by moderate to severe exercise. Fortunately there are a number of pharmaceutical agents now available which can prevent and/or reverse exercise-induced asthma (EIA) and allow many asthmatics to participate in vigorous physical activities with minimum respiratory disadvantage. Regular exercise is an accepted part of the management of asthma and EIA can now be controlled so successfully that a number of elite sportspersons, in almost all types of sporting events, are asthmatic. This control of EIA, which is essential if asthmatics are to participate safely, requires that the patient and his/her doctor initiate a strategy to manage the disease during sport and other physical activities. In recent years the mortality and morbidity from asthma have been increasing and this has indicated the need to improve patient care. One of the most important innovations aiming to improve the control and treatment of asthma has been the recent development of the 6 point asthma management plan which is a strategy to simplify and optimise the long term management of asthma. It aims to improve the quality of life of most asthmatics and more importantly, prevent deaths due to asthma. Because antidoping controls operate in many high performance sports it is essential that the EIA management plan rely on those medications which are permitted. The list of allowable drugs is in continual flux as new ones are added and others are challenged on the grounds of possible ergogenicity. All aerosol beta 2-agonists except fenoterol, the khellin derivatives, theophylline, ipratropium bromide and the aerosol corticosteroids are currently permitted. Some nonasthmatic athletes who are aware of the improved performance of asthmatic athletes when using pre-exercise medication have been known to take antiasthma medication in the hope that it might improve their performance. Current evidence indicates, however, that the permitted medications are not ergogenic and do not give the asthmatic any advantage over the nonasthmatic athlete but merely removes the respiratory disadvantage under which he/she competes.

The effect of ipratropium bromide on maximal exercise capacity in asthmatic and non-asthmatic men

The effect of 0.5 mg nebulized ipratropium bromide (IB) on the cardio-respiratory responses to a progressive maximal cycle exercise test was compared with a matched placebo (P) in eight mild asthmatic and eight non-asthmatic men. The forced expiratory volume in l s (FEV1) in the asthmatic group was higher after ipratropium bromide both at rest [IB, mean 4.07 (SD 1.18) l versus P, 3.83 (1.29) l, P less than 0.05] and after exercise [IB, 3.64 (1.31) l versus P, 3.30 (1.40) l, P less than 0.02]. Since the percentage fall in the FEV1 after exercise was not significantly changed by ipratropium bromide [IB, -12 (11)% versus P, -16 (14)%], the improvement in the post-exercise FEV1 in the asthmatic group is attributable to the pre-exercise bronchodilatation. The resting and post-exercise FEV1 in the non-asthmatic group were also significantly higher after ipratropium bromide. However, neither group showed any differences in the cardio-respiratory, haemodynamic or subjective responses to the progressive maximum exercise test when ipratropium bromide was compared with placebo. These results demonstrate the absence of significant cardio-respiratory effects during exercise with this relatively high dose of ipratropium bromide, in patients with mild asthma and in non-asthmatic subjects. No ergogenic effect on maximal exercise performance was shown to question its use by asthmatic athletes engaged in high level competition.

Inhaled albuterol does not protect against ozone toxicity in nonasthmatic athletes

We evaluated the acute prophylactic efficacy of albuterol aerosol in protecting nonasthmatic athletes from the untoward effects of 0.21 ppm ozone (O3) on symptoms, pulmonary function, exercise performance, and post-exposure histamine bronchoprovocation. Fifteen trained competitive cyclists participated in a randomized crossover study consisting of double-blinded inhalations of albuterol (180 micrograms) and placebo approximately 30 min prior to heavy continuous exercise (minute ventilation, [VE] greater than or equal to 80 L/min) for 60 min, followed by a maximal sprint (peak VE greater than 140 L/min) until exhaustion. Each subject was exposed randomly to either 0.21 ppm O3 or filtered air (FA) during the four single-blinded exposure sessions. Albuterol pretreatment resulted in modest but significant bronchodilation as compared to placebo. However, albuterol did not prevent O3-induced respiratory symptoms, decrements in forced vital capacity (FVC), forced expired volume in one second (FEV1.0), and maximum midexpiratory flow rate (FEF25-75%), and positive histamine challenges as compared to that with placebo/O3. There were no statistically significant differences in the metabolic data or ride times across all drugs and exposures, although the peak VE was significantly lower with O3 than FA (142.3 vs. 150.7 L/min, respectively) regardless of drug. The results indicate that acute pretreatment with inhaled albuterol is unable to prevent or ameliorate O3-induced symptoms and alterations in pulmonary function and exercise performance. The contribution of beta-adrenergic mechanisms in the acute airway responses to O3 appears to be minimal.