The elite athlete: yes, with allergy we can.

On August 8, 2008, Beijing will welcome the XXIX Olympic Games, and a fourth to a third of the elite athletes from many of the national delegations in the multinational crowd taking part in the Opening Ceremony will have allergic or respiratory disease according to data published for several national delegations at previous Games. Mechanisms for the high prevalence of allergic diseases, including exercise-induced bronchospasm, in elite athletes— even higher than in the general population—still wait for further research. Although moderate physical activity is suggested and appears beneficial in allergic subjects to avoid risks associated with overweight and a sedentary lifestyle, intense and prolonged physical activity has been shown to induce marked changes in several parameters of innate and adaptive immunity. These include a TH2 shift and a transient immunodeficiency that have been related to the higher prevalence of allergy and upper respiratory diseases in athletes. Certainly, hyperventilation and exposure to allergens and pollutants may cause bronchial hyperreactivity even in subjects with no clinical asthma and/or allergy. In this issue of the Journal, Anderson and Kippelen have written an outstanding manuscript reviewing exercise-induced asthma and exercise-induced bronchoconstriction and the varied presentations depending on the type of sport and the athlete. Along with the discussion of pathophysiology is an explanation of why and how therapies are successful andwhy at times the contrary occurs. Surprisingly, however, in spite of the high prevalence of allergic diseases in elite athletes, allergy tests are often not part of the routine medical examination in sports medicine. This is even more questionable when considering that the treatment of allergic athletes implies several important issues such as environmental control, use of drugs that may affect vigilance and performance, or therapeutic use exemption of antiallergic and antiasthmatic drugs included in the list of substances prohibited by the World Anti-Doping Agency in and out of competition. Therefore, we strongly recommend that standardized practice parameters are set to include allergy assessment among clinical investigations to be performed in athletes and nonprofessional exercisers when indicated. In 2002, before the Salt Lake City Winter Games, the International Olympic Committee was extremely concerned about the wide and increasing use of b2-adrenergic agents by athletes and in response set strict criteria that required documentation of asthma in an attempt to limit the use of these drugs. Certainly, the use of b2-agonists in the context of exercise implies not only their potential, and controversial, effects on performance but also safety issues when considering the US Food and Drug Administration black box and the additional safety concerns that these drugs may have in elite athletes because of the intense cardiovascular and respiratory stress they undergo during competition. Weinberger’s article in this issue discusses the roleb-agonists in exercise, and he calls special attention to the potential tolerance induced over timewith routine use of b-agonists. In fact, the role of long-actingb-agonists in exercise is challenged by the evidence of the loss of a bronchoprotective effect by albuterol when using either formoterol or salmeterol on a routine basis. Criteria for diagnosing asthma in athletes have been an object of wide scientific debate and have been recently revised by the International Olympic Committee, as summarized in the Workshop Summary. In the article by Fitch, the author reports that the International Olympic Committee requests a positive bronchial challenge for the confirmation of exercise-induced asthma or exercise-induced bronchoconstriction in athletes to obtain permission for the use of b-agonists. Because the International Olympic Committee requires objective evidence of asthma, exercise-induced asthma, or exercise-induced bronchoconstriction to be approved for using b-agonists, one of the major questions that arises when screening athletes for asthma is which test to use. This issue of the Journal reviews exercise challenge tests and their surrogates that may be useful to evaluate bronchial hyperreactivity in athletes. These challenge tests can be used to diagnose asthma, help exclude diseases that mimic asthma, allow an assessment of the effectiveness of medical therapy for asthma, and can be used to confirm control of the asthma before participating in activities known to trigger exercise-induced bronchoconstriction—for example, scuba diving. Rundell and Slee also address the difference between direct and indirect challenges, pros and cons of the different challenges, how to interpret the data generated from the test, and standardized procedures to be used to assess the athlete. From the Second University of Naples, Rome; and Pennsylvania State University, Allergy, Asthma and Immunology, Hershey. Supported by the Italian Ministry of Health, Commission for Vigilance and Control of Doping (S.B.). Disclosure of potential conflict of interest: S. Bonini has a research appointment at the Institute of Neurobiology and Molecular Medicine, Italian National Research Council; is a member of the Research and Development Commission of the Italian Drug Agency; and has received research grants, consultancies, and honoraria from participation in speakers’ bureaus for Alcon, Allergopharma, Allergy Therapeutics, ALK, Almirall, Aventis, AstraZeneca, Bioallergy, Bioxell, GlaxoSmithKline, Lofarma, Merch Sharp and Dohme, Novartis, Pfizer, Sanofi-Synthelabo, Schering-Plough, Stallaergens, UCB, and Zambon. T. Craig has declared that he has no conflict of interest. Received for publication May 23, 2008; revised June 14, 2008; accepted for publication June 17, 2008. Available online July 11, 2008. Reprint requests: Sergio Bonini, MD, Second University of Naples, Via Ugo de Carolis 59, Rome 00136, Italy. E-mail: [email protected]. J Allergy Clin Immunol 2008;122:249-50. 0091-6749/$34.00 Ó 2008 American Academy of Allergy, Asthma & Immunology doi:10.1016/j.jaci.2008.06.020