The prevalence of exercise-induced asthma ranges from 9% to 50%, depending on the sport cited.21 The acute release of bron-choconstricting agents and the chronic inflammatory airway changes, both of which are complexly intertwined, suggest two pathways to target for prevention of exercise-induced asthma attacks. A recent Cochrane review confirms that albuterol, a short-acting beta agonist, is the number one treatment for exercise-induced asthma episodes. The bronchodilating effects of albuterol are superior in the acute setting to the anti-inflammatory effects of cromolyn (a mast cell stabilizer) or the anticholinergic effects of ipratropium.22 Appropriate use of albuterol must consider tolerance, timing of use, and ergogenic effects.
Daily use of short-acting beta agonists has been linked with increased frequency of bronchoconstriction during exercise and suboptimal efficacy of rescue.23 While no ergogenic effects of short-acting beta agonists have been demonstrated at therapeutic doses, increased use among Olympic athletes has been documented.24 Long-acting beta agonists are equally effective, can have similarly quick time to onset, and often result in longer periods of protection.25,26 Long-acting beta agonists have also not been shown to possess ergogenic benefits.27
Inhaled corticosteroids are standard therapy for patients with persistent asthma. While not well studied in exercise, the pulmonary delivery of inhaled corticosteroids has not shown any evidence of ergogenic or anabolic effects, and they are approved by the International Olympic Committee (IOC) via medical waiver for athletes with asthma.21 Leukotriene inhibitors are a new class of oral anti-inflammatory medications for asthmatics. While considered to be less effective than inhaled cortico-steroids, the oral delivery of leukotriene inhibitors may provide better compliance for some asthmatics. They can prevent acute episodes of exercise-induced asthma,28-30 but optimal protection requires them to be used 12 hours prior to exercise.28 Studies in children and adults have shown protective benefits after a brief period of 5 to 7 days of use.29,30 Minimal studies in adults have shown no change in time to anaerobic threshold with leukotriene inhibitor use, but there was a decrease in ratings of perceived exertion.30 Further studies of potential ergogenic effects of leukotriene inhibitors would be helpful.
Psychiatric Conditions Antidepressants and Anxiolytics
Primary care physicians commonly treat patients with depression and anxiety, and athletes with these conditions compete at all skill levels. However, very little research exists studying the interaction of medications for these conditions and exercise. In a study of patients with major depressive disorder, decreases in isokinetic quadriceps and hamstring strength were shown to improve significantly after 3 months of treatment with a selective serotonin reuptake inhibitor.31 However, selective serotonin reuptake inhibitors have also been linked with significant weight gain after 6 to 12 months of use32 and possible episodes of heat-related illness and hyponatremia.33,34 In a small trial of patients, use of loprazolam, a benzodiazepine that can be used for anxiety, did not affect hand-eye coordination, 30-m sprint time, VO2max, or time to exhaustion. However, use of loprazolam was associated with prolonged reaction time and a significant hangover effect.35 In a smaller study with midazolam, subjects experienced significant changes in heart rate variability and had significant orthostatic changes in blood pressure.36 No large, double-blind, randomized, controlled trials exist for either class of medication. Accordingly, no contraindications exist for the appropriate treatment of depression or anxiety. The only performance concerns might relate to a possible advantage from the anxiolytic effects of these medications (especially benzodi-azepines) in shooting events such as the biathlon.
Attention-deficit disorder (ADD) affects an estimated 5% of the school-age population,37 with a growing trend toward the identification of impairment due to ADD among adults. Methylphenidate is the standard treatment for ADD with either hyperactive, inattentive, or mixed predominance of symptoms. Methylphenidate is also a stimulant with properties and side effects similar to those of other drugs in the amphetamine class, including an ergogenic effect mediated by delayed fatigue. Methylphenidate is banned by the IOC and the National Collegiate Athletic Association. However, the National Collegiate Athletic Association has recognized the utility of methylphe-nidate in helping student athletes with ADD to succeed academically. Therefore, a therapeutic use exemption exists for National Collegiate Athletic Association athletes with documented ADD and appropriate methylphenidate therapy.38
ADD is known to affect athletic participation in a number of ways, including lessened motivation to participate, impaired motor skills, and decreased performance success.39,40 Methylphenidate has been shown to improve the attention of youths with ADD during baseball games, as reflected in higher rates of on-task behavior while on the field and better knowledge of their current game-specific situation.41 Methylphenidate has also been demonstrated to improve visual tracking by athletes with ADD during table tennis by maintaining their gaze on the ball in flight for significantly longer periods of time.42 Athletes with ADD who use methylphenidate should be aware of a possible increased risk of heat-related illness due to the stimulant's cardiovascular properties. However, methylphe-nidate may not only help athletes with ADD to succeed at work or school, but it may help them to more fully participate in athletics, thereby receiving a boost in self-esteem that many patients with ADD need.
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