A 19-year-old woman comes to the office for a routine health maintenance examination. She has coughing, wheezing, and breathlessness following her twice-weekly workout sessions, but no symptoms at other times. Her medical history is otherwise significant for allergic rhinitis and acne, for which she uses topical benzoyl peroxide and erythromycin cream. The patient does not use tobacco, alcohol, or illicit drugs. On physical examination, her vital signs are within normal limits and chest auscultation is unremarkable. Which of the following is the most appropriate pharmacotherapy in management of this patient?

Question

A 19-year-old woman comes to the office for a routine health maintenance examination.  She has coughing, wheezing, and breathlessness following her twice-weekly workout sessions, but no symptoms at other times.  Her medical history is otherwise significant for allergic rhinitis and acne, for which she uses topical benzoyl peroxide and erythromycin cream.  The patient does not use tobacco, alcohol, or illicit drugs.  On physical examination, her vital signs are within normal limits and chest auscultation is unremarkable.  Which of the following is the most appropriate pharmacotherapy in management of this patient?

Quizplus · Accepted Answer

This patient's symptoms are likely caused by exercise-induced bronchoconstriction (EIB). Bronchoconstriction occurs in response to mast cell degranulation triggered by the passage of high volumes of dry, cold air. EIB can occur in asthmatic patients but may also cause bronchospasm in those without a pre-existing diagnosis of asthma. Beta agonists and mast cell stabilizers are important in the management of EIB. Short-acting beta-adrenergic agonists such as albuterol, used 10-20 minutes prior to exercise, are typically sufficient to prevent symptoms. They are considered first-line therapy if used only intermittently (less than daily), as in this patient. An antileukotriene agent can be used 15-20 minutes prior to exercise for those unable to tolerate beta agonists. A combination of beta agonists and antileukotriene agents may also be used in high-performance athletes. (Choice B) Steroid inhalers may be appropriate for athletes who exercise daily and would require daily pre-treatment with albuterol. These are also the preferred treatment for persistent asthma. (Choice C) Ipratropium inhalers are often combined with beta-adrenergic agonists for an additive bronchodilator effect, usually to treat acute exacerbations. Ipratropium is more effective in patients with chronic obstructive pulmonary disease than in those with asthma. (Choice D) Long-acting beta agonists used as monotherapy have been shown to increase asthma-related mortality. They should not be used in patients with EIB or asthma. (Choice E) Montelukast can be used as an alternative to daily inhaled corticosteroids in patients who exercise daily and require daily albuterol pre-treatment. Educational objective: Short-acting beta-adrenergic agonists administered 10-20 minutes before exercise are the first-line treatment for exercise-induced bronchoconstriction if required only a few times a week (less than daily). Inhaled corticosteroids or antileukotriene agents can be used in patients who exercise daily. References: An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. (http://www.ncbi.nlm.nih.gov/pubmed/23634861) Asthma and exercise-induced bronchoconstriction in athletes. (http://www.ncbi.nlm.nih.gov/pubmed/25671256)

A 19-Year-Old Woman Comes to the Office for a Routine