Pharmacological Management In the Athletic Setting Asthma Pharmacological Management In the Athletic Setting

Exercise Induced Asthma (EIA) Transient bronchospasm resulting from vigorous physical activity EIA affects 10-15% of population 70-90% of asthmatics have EIA 40-50% of people with allergies have EIA 16-18% of Olympic Athletes have EIA

Clinical Symptoms EIA occurs after strenuous exercise near 80% maximum capacity for > 6 minutes Can also occur 4-8 hrs after exercise Repetitive attacks can cause  severity by strengthening bronchial muscle Common symptoms Shortness of breath Coughing Chest tightness Wheezing

Pulmonary Function 15-20% fall of forced expiratory volume (FEV1) > 10% fall of peak expiratory flow rate (PEFR) Bronchospasm is greatest 3-15 minutes post exercise Severity: mild, moderate, severe

Environmental conditions Influencing Factors Type of exercise Duration of exercise Intensity of exercise Environmental conditions Pulmonary disease Dietary salt

Type of Exercise Activities that cause EIA Running Cycling X-country skiing Activities less likely to cause EIA Swimming Dancing Gymnastics Rowing

Duration / Intensity of Exercise Occurs after 5-8 minutes of vigorous exercise Exercise for longer periods does not increase the chance of bronchospasm Strenuous defined a >80% maximal heart rate

Environmental Conditions Increased with cold, dry air, pollution, allergens Decreased with warm / humid air

Other Factors Pre-existing conditions such as asthma, bronchitis, emphysema Dietary salt High intake increases symptoms, occurrence Lower intake decreases symptoms, occurrence

Current Theories Increased ventilation results in water loss from bronchial tree This results in increased osmolarity of epithelial fluid that causes inflammatory mechanisms (mast cell degranulation) Inflammatory mediators are released when exposed to allergens Mouth breathing cools the airways and causes bronchial vascular bed dilation

Diagnosis Refer for testing in clinical situation Must abstain from medications before testing Beta agonists – 6 hrs. Leukotriene inhibitors, oral meds. Have medications to treat bronchospasm after testing

Nonpharmacological Rx Conditioning Warm up that includes strenuous bouts Diet (salt intake, 30 mg. lycopene) Run through Avoid hyperventilation Nasal breathing Cover mouth in cold weather Avoid strenuous exercise when allergens are high Choose indoor sports during winter

Pharmacological Treatment Beta agonists Cromolyn sodium & nedocromil Leukotriene inhibitors Theophylline Steroids Ipratropium Bromide Ca++ channel blockers

Beta 2 Agonists Taken 15 minutes prior to exercise Relax smooth bronchial muscle If more than 1/month is needed – other medications needed for better control Side effects: tachycardia, tremors, headache Inhaled forms more popular Prohibited by IOC without documented tests, Hx. of use

Albuterol / Salbutamol / Terbutaline Commonly prescribed Short acting Long duration Salmeterol Long acting, helps with latent phase EIA Commonly used with anti-inflammatories Metaproterenol Moderate duration

Cromolyn sodium / Nedocromil Better used as preventative if know exposure to allergens Inhibits response to cold, dry air Works in synergy with beta 2 agonists Safe Side effects : bad taste or smell

Leukotriene Inhibitors Long control medications Approved for use after 11 yrs. Old Convenience of pill vs. inhaler Zafirlukast (Accolate) Zileuton (Singulair)

Theophylline Dilate bronchial smooth muscle Increases diaphragm contractility Anti-inflammatory effects Long term control May help with nocturnal symptoms

Ipratropium Bromide Anticholergenic Causes bronchodilation Effective for quick relief of symptoms Not effective if underlying allergies, asthma Atrovent

Steroids Long term medications Taken to control persistent asthma, not EIA Inhaled used 1st - spacer makes delivery more effective Advair

Oral medications are reserved for severe cases of asthma that don’t respond to other therapy Long term use can suppress cortisol production

Banned Substances Check list frequently as it changes with new medications Generally Beta 2 agonists need documentation of testing, hx. of use for IOC, not for NCAA Clenbuterol is banned

Asthma

Asthma Etiology Sign and Symptoms Caused by viral respiratory tract infection, emotional upset, changes in barometric pressure or temperature, exercise, inhalation of noxious odor or exposure to specific allergen Sign and Symptoms Spasm of smooth bronchial musculature, edema, inflammation of mucus membrane Difficulty breathing, may cause hyperventilation resulting in dizziness, coughing, wheezing, shortness of breath and fatigue

Asthma - Characteristics Disease of the respiratory system Due to: spasm of bronchial smooth muscles, inflammation of bronchial wall, increase mucous secretion Stimuli - allergies, colds, viral infections, smoking, psych. stress, exercise Is not a progressive disease

Signs & Symptoms of Asthma Attack tight chest wheezing coughing rapid, shallow breathing anxiety tachycardia pale color lack of endurance

Exercise Induced Asthma Onset of S/S w/in 30 min. post exercise Prevention of symptoms know environmental conditions warm-up gradually & cool down use a bronchodilator

Exercise Induced Asthma 15% decrease in peak expiratory rate is diagnostic 10-20% of general population, 90% with asthma Episode usually occurs after 5-10 minutes May be caused by water and heat loss from airways from mouth breathing and increased respiration rate Also consider: Type of exercise Environmental factors Preexisting inflammation Intensity of exercise

Treatment for Asthma Attack Calm the patient Controlled breathing Drink water Medications Bronchodilators Corticosteroids Leukotriene Receptor Antagonists

Refractory Period Occurs after an asthmatic episode Time during which additional exercise doesn’t cause bronchospasm Lasts 1-4 hours In some individuals a refractory period can be induced with light exercise and no episode (ex) run 10 submaximal 100 yard sprints 30 minutes before competition

Preventive Measures Avoid cold, dry polluted air Increase nose breathing Change sports Decrease intensity Regular exercise, appropriate warm-up and cool down, w/ intensity graduated Exercise in warm, humid environment Exercise during refractory period

Monitoring Asthma Peak expiratory flow rate can be measured with a hand-held peak flow meter to allow self monitoring Take before and after bronchiodilator therapy to check effectiveness of Rx ATC may consider keeping one in kit with disposable mouth pieces

Medications 5-10% of asthma symptoms are worsened by NSAIDS Controller medications To prevent Sx (ex) Long acting beta agonist – Salmeterol Reliever medications 2-4 puffs just before exposure or as Sx present (ex) Short acting agonist – Albuterol Cause dilation of smooth muscles around lung and inhibits release of chemicals that cause inflammation Usually inhaled, but also oral (ex) Mast cell stabilizers Prevent release of contents of mast cells –therefore prevent inflammation and brochoconstriction

Medications - Bronchodilators Stimulate Beta2 receptors - causes dilation of bronchials Decrease smooth muscle spasm For an acute asthma attack **Long term / excessive use causes hyper- responsiveness

Bronchodilators - Examples Administration - Inhalation (Albuterol) Proventil (Piributerol) MaxAir (Salmeterol) Serevent (Epinephrine) Primatene Mist (Theophylline) TheoDur, SlowBid decrease release of prostaglandins Side effects - nausea, mental confusion, irritability, restlessness

Medications - Corticosteroids Use prophylactically before asthma attack to decrease release of prostaglandins, decrease responsiveness of smooth muscles in airways Has no effect on an acute attack

Corticosteroids - Examples Administration - Inhalation, Ingestion (Dexamethasone) Decadron (Cromolyn) Intal, NasalCrom Azmacort Tilade Vanceril Flonase – allergy corticosteroid

Medications - Leukotriene Receptor Antagonists Prevents spasm and swelling within the bronchial smooth muscles Leukotrienes cause constriction of airways & promote mucous secretions Examples Singulair Accolate

Role of the ATC Recognize decreased performance caused by EIA Measure peak flows and refer if indicated Monitor efficacy of Rx by tracking Sx and tracking peak flows Educate on proper inhaler use

Proper use of an inhaler

Diabetes

What is diabetes? A disease which involves the production or function of insulin Normal blood sugar level = 80-90mg/100 ml blood

Diabetes - Types Type II, Non-Insulin Dependent, Adult Onset 90% of all cases Predisposing factor – obesity, heredity Pancreas still produces insulin Symptoms usually controlled by diet & exercise Oral Antidiabetic Drugs - stimulates pancreas to produce insulin Amaryl Glimepiride Glucophage Avandia

Diabetes - Types Type I, Insulin Dependent, Juvenile Onset Onset before age 30 Pancreas does not produce insulin Must take insulin - type & dosage determined by severity & Dr. Administration Injection Implant pumps

Effects of exercise on diabetes Decreases need for insulin

Associated Conditions Diabetic Coma blood sugar elevated develops over days S/S - thirst, difficulty breathing, nausea, vomiting, mental confusion, loss of consciousness Ketoacidosis Rx. - call 911, insulin

Associated Conditions Insulin Shock (Hypoglycemia) blood sugar level too low develops rapidly S/S - physical weakness, moist pale skin, headache, tachycardia, fatigue, hunger, anxiety Rx. - eat sugar, candy, fruit juice, crackers, Prevention - eat before practice

Diabetes Mellitus 1997 report by The Expert Committee on Diagnostic and Classification of Diabetes Mellitus Defined diabetes, “a group of metabolic disorders characterized by hyperglycemia resulting from insulin secretion, insulin action or both and is associated with damage and failure of various organs, especially the eyes, kidney, nerves, heart, and blood vessels.”

Glucagon vs Insulin

Criteria for Diabetes 2 fasting blood glucose levels > 126mg/dL or 2 random draws > 200mg/dL Normal blood glucose level varies between 80-120mg/dL

Type I Diabetes “juvenile onset” or “insulin dependent” Results from destruction of pancreatic beta cells which make insulin; thus, insulin is not produced < 30 yo Sudden onset Frequent urination, constant thirst, weight loss, constant hunger, tiredness, weakness, itchy dry skin and blurred vision Insulin injections required to control If not controlled ketoacidosis occurs

Treatment for Type I Diabetes Complications are reduced by 76% if managed Recommendations for Treatment Self monitoring of blood glucose 4x/day Use insulin pump or shots 3x/day Adjust insulin dose based on glucose level Anticipate and plan dietary intake and exercise

Type II Diabetes “Adult-onset” or “Non-insulin dependent” Caused by insulin resistance Also may see a decrease in insulin production >40 yo Controlled with diet, exercise, weight loss, and/ or oral medication Not associated with ketoacidosis

Diabetic Coma Etiology Sign and Symptoms Management Loss of sodium, potassium and ketone bodies through excessive urination (ketoacidosis) Extreme hyperglycemia Sign and Symptoms Labored breathing, fruity smelling breath (due to acetone), nausea, vomiting, thirst, dry mucous membranes, flushed skin, mental confusion or unconsciousness followed by coma. Management Early detection is critical as this is a life-threatening condition Insulin injections may help to prevent coma

Insulin Shock Etiology Sign and Symptoms Management Occurs when the body has too much insulin and too little blood sugar Hypoglycemia Sign and Symptoms Tingling in mouth, hands, or other parts of the body, physical weakness, headaches, abdominal pain Normal or shallow respiration, rapid heart rate, tremors along with irritability and drowsiness Management Adhere to a carefully planned diet including snacks before exercise

Guidelines for Pre-exercise Caloric Intake Based on Blood Glucose Levels Eat when < 80mg/dL Eat a high complex CHO snack before exercise before exercise if < 100mg/dL Exercise if 100 – 250mg/dL Exercise > 1 hour, then eat 15g of CHO and drink 250 mL every 15-20 min >250mg/mL check urine for ketones If ketones present or if >300mg/dL, then cancel exercise and adjust insulin **Sports Drinks?