Asthma and exercise‐induced bronchoconstriction in athletes: Diagnosis, treatment, and anti‐doping challenges

Abstract

Athletes often experience lower airway dysfunction, such as asthma and exercise‐induced bronchoconstriction (EIB), which affects more than half the athletes in some sports, not least in endurance sports. Symptoms include coughing, wheezing, and breathlessness, alongside airway narrowing, hyperresponsiveness, and inflammation. Early diagnosis and management are essential. Not only because untreated or poorly managed asthma and EIB potentially affects competition performance and training, but also because untreated airway inflammation can result in airway epithelial damage, remodeling, and fibrosis. Asthma and EIB do not hinder performance, as advancements in treatment strategies have made it possible for affected athletes to compete at the highest level. However, practitioners and athletes must ensure that the treatment complies with general guidelines and anti‐doping regulations to prevent the risk of a doping sanction because of inadvertently exceeding specified dosing limits. In this review, we describe considerations and challenges in diagnosing and managing athletes with asthma and EIB. We also discuss challenges facing athletes with asthma and EIB, while also being subject to anti‐doping regulations.

Beyond bronchodilation: Illuminating the performance benefits of inhaled beta2‐agonists in sports

“…11 In athletes relying too heavily on inhaled beta 2agonists, the practitioner must consider additional treatment options, 130,131 including management with inhaled corticosteroids, leukotriene antagonists, and anticholinergics. [132][133][134] If symptoms become so severe that a high-dose inhaled beta 2 -agonist is needed, then one may also ask whether the athlete should compete.…”

“…Conversely, complete liberation likely leads to blatant doping, as reported in bodybuilding 11 and could jeopardize athletes' health as overuse of beta 2 ‐agonists induces tachyphylaxis and increases the risk of exacerbation and death 11 . In athletes relying too heavily on inhaled beta 2 ‐agonists, the practitioner must consider additional treatment options, 130,131 including management with inhaled corticosteroids, leukotriene antagonists, and anticholinergics 132–134 . If symptoms become so severe that a high‐dose inhaled beta 2 ‐agonist is needed, then one may also ask whether the athlete should compete.…”

Inhaled beta2‐agonist, formoterol, enhances intense exercise performance, and sprint ability in elite cyclists

“…As of 2023, WADA permits athletes to inhale formoterol at daily doses up to 54 μg. And while such a dose is rarely recommended in asthma treatment, 3 the current regulations do not specifically restrict 54 μg as a one‐off dose. Given its performance enhancing potential on sprint performance and short intense exercise performance, it could be argued that the dosing limits of formoterol should be set such only split doses are allowed (for example a maximum of 27 μg in every 12 h period).…”

Annual banned‐substance review 16th edition—Analytical approaches in human sports drug testing 2022/2023

“…Asthma and exercise‐induced bronchoconstriction reportedly affect 15–30% of the elite athlete population, and the use of β 2 ‐agonists in the context of appropriate medication necessitates thorough education and awareness of permissive and prohibited therapies 144 . Concise regulations were deemed inevitable and established in the light of a growing body of evidence demonstrating the potential of β 2 ‐agonists to positively affect athletic performance when used at dosages considered prohibited by WADA.…”