Exercise-induced hypersensitivity syndromes in recreational and competitive athletes: a PRACTALL consensus report (what the general practitioner should know about sports and allergy).

Exercise-induced (EI) hypersensitivity disorders are significant problems for both recreational and competitive athletes. These include EI-asthma, EI-bronchoconstriction, EI-rhinitis, EI-anaphylaxis and EI-urticaria. A group of experts from the European Academy of Allergology and Clinical Immunology and the American Academy of Allergy Asthma and Immunology met to discuss the pathogenesis of these disorders and how to diagnose and treat them, and then to develop a consensus report. Key words (exercise with asthma, bronchoconstriction, rhinitis, urticaria or anaphylaxis) were used to search Medline, the Cochrane database and related websites through February 2008 to obtain pertinent information which, along with personal reference databases and institutional experience with these disorders, were used to develop this report. The goal is to provide physicians with guidance in the diagnosis, understanding and management of EI-hypersensitivity disorders to enable their patients to safely return to exercise-related activities.

A report of a rare immediate reaction after ingestion of acetaminophen.

BACKGROUND: Acetaminophen hypersensitivity is rare and, when seen, is usually in association with sensitivity to nonsteroidal anti-inflammatory drugs. METHODS: This is a case report of an immediate reaction to acetaminophen, confirmed by a drug challenge, in a subject who tolerated ibuprofen. RESULTS: After an oral challenge with 50 mg of acetaminophen, the subject had generalized pruritus, urticaria, and dyspnea. CONCLUSIONS: This patient demonstrates a rare but potentially severe reaction to acetaminophen that may occur in patients who are not otherwise sensitive to other nonsteroidal anti-inflammatory drugs.

Expression of C1 esterase inhibitor by the baculovirus expression vector system: preparation, purification, and characterization.

C1 esterase inhibitor (C1INH) is an important regulator of the classical complement pathway. Hereditary deficiency of C1INH causes angioedema of the skin, gut, and respiratory tissues that may be fatal. C1INH replacement therapy may be lifesaving for patients with this disorder. The objective of this study was to evaluate the use of the baculovirus expression vector system for mass producing biologically active human recombinant (rC1INH). A recombinant baculovirus was constructed coding the human native (nC1INH) sequence under control of the polyhedrin promoter. Spodoptera frugiperda Sf-9 insect cells were infected with this recombinant baculovirus in a medium-scale (10-L) bioreactor to produce rC1INH with a specific activity of 45 U/mg. Purification of rC1INH from the culture harvested at 60 h postinfection yielded 5.9 microg rC1INH/mL supernatant of a 75-kDa product with a specific activity of 31,000 U/mg purified rC1INH compared to 71,000 U/mg purified nC1INH from human serum using the same procedure. This rC1INH was about 25 kDa smaller than nC1INH, suggesting that Sf-9 cells express underglycosylated rC1INH. Glycan analysis showed that both N-glycan and O-glycan chains were present in rC1INH. The N-glycan chains, released using PNGaseF and fluorescently labeled, were analyzed using exoglycosidase treatment and capillary electrophoresis. Their high-mannose structure was consistent with the known failure of the insect cell glycosylation pathway to afford the fully elaborated biantennary structures found on human native nC1INH.

Certain high molecular weight heparin chains have high affinity for vitronectin.

Vitronectin is a 70-kDa protein that is found in both the extracellular matrix as well as serum. Vitronectin is one of the few proteins that regulates both the complement and the coagulation systems. Heparin is known to bind to vitronectin. Review of the literature reveals apparently conflicting outcomes of the interaction of heparin, vitronectin, and the complement system. Previous studies demonstrated that heparin diminishes vitronectin inhibition of complement activity. Numerous studies have also demonstrated that heparin exerts a net inhibitory effect on complement. We used two dimensional affinity resolution electrophoresis (2DARE) to examine this apparent paradox. 2DARE allowed simultaneous determination of binding affinity of heparin for vitronectin as well as the M(r) of the heparin species. In the 2DARE experiment, the interaction of heparin with vitronectin caused retardation of the movement of the heparin through the tube gel in the first dimension. The degree of the retardation of movement was used to calculate the approximate K(d) of that interaction. The heparin from the tube gel was then subjected to a second dimension electrophoresis to determine the M(r) of the heparin. 2DARE analysis of the interaction of heparin with vitronectin clearly demonstrated that a sub-population of heparin chains with M(r) > 8000 bound vitronectin with high affinity whereas most high M(r) chains and all lower M(r) chains showed little to no affinity for vitronectin. Our findings are consistent with the hypothesis that a unique binding domain exists in certain heparin chains for vitronectin.

A review of the reported defects in the human C1 esterase inhibitor gene producing hereditary angioedema including four new mutations.

C1 esterase inhibitor (C1INH) is an important regulatory protein of the classical pathway of complement. Mutations in the gene for this protein cause the autosomal dominant disorder hereditary angioedema (HAE). Approximately 85% of patients with HAE have a Type I defect, characterized by a diminished level of antigenic and functional C1INH. Patients with Type II defects have sufficient protein, but one allele produces dysfunctional protein. We have sequenced the DNA from HAE patients and have discovered four previously unreported mutations. The first mutation is a splice site error at nucleotide 8721, which changes the 3' acceptor splice site AG to GG at the end of intron 5 at nucleotide 8721-8722. The second mutation is a single base insertion in exon 3 between nucleotides 2467 and 2468. The third mutation is a missense error present in the eighth exon of the C1INH; at nucleotide 16867 (amino acid 470), a T to A mutation transforms a Met to a Lys. The fourth mutation closely resembles the third mutation in that it is a missense error occurring in exon 8 in the distal hinge region; a T16827C substitution changes the Phe at amino acid 457 to Leu. This report compiles a list of 97 distinct defects in the C1INH gene that cause hereditary angioedema.

Effect of IGFBP-derived peptides on incorporation of(35)SO(4)into proteoglycans.

18 amino acid peptides from the C-terminal region of IGFBP-3, -5 (P3, P5), increased the incorporation of(35)SO(4)into proteoglycans in endothelial cells with greater stimulation in large vessel than microvessel cells. The homologous region of IGFBP-6 (P6) also stimulated sulfate uptake, but less potently than P3 and P5. P6 variants were synthesized with one or two amino acids changed to the basic amino acid in the equivalent position of P3. The P6 variants with one additional basic amino acid behaved similarly to P6. The P6 mutant with two altered amino acids was equipotent to P3. P3F, a scrambled version of P3 was less effective than P3. P3, P5, P6, P3F and all P6 variants all stimulated glucose uptake, which occurred only in microvessel cells. P1, P2, P4, and equimolar intact IGFBP-3 stimulated neither glucose uptake nor sulfate incorporation. Thus, C-terminal basic portions of IGFBP-3, -5 and -6 alter two specific functions of endothelial cells with sufficient differences to suggest mediation by distinct mechanisms.

Asthma in United States olympic athletes who participated in the 1998 olympic winter games.

BACKGROUND: About one of every 5 athletes who participated in the 1996 Summer Olympic Games in Atlanta had a past history of asthma, had symptoms that suggested asthma, or took asthma medications. No previous study has determined the prevalence of asthma in all US athletes who participated in an Olympic Winter Games. OBJECTIVES: We sought to determine how many US athletes who participated in the 1998 Olympic Winter Games had a past history of asthma, had symptoms that suggested asthma, or indicated taking a medication used to treat asthma. METHODS: We evaluated responses to questions that asked about allergic and respiratory diseases in the United States Olympic Committee Medical History Questionnaire that was completed by all 196 athletes who represented the United States at the 1998 Olympic Winter Games in Nagano, Japan. RESULTS: Forty-three (21.9%) of the 196 athletes had a previous diagnosis of asthma, and 36 (18. 4%) recorded use of an asthma medication at some time in the past. Forty-four (22.4%) reported use of an asthma medication, a diagnosis of asthma, or both (our basis for the diagnosis of asthma). Thirty-four (17.4%) of the athletes were currently taking an asthma medication at the time that they completed the questionnaire or indicated that they took these medications on a permanent or semipermanent basis and were considered to have active asthma. Athletes who participated in Nordic combined, cross-country, and short track events had the highest prevalence of having been told that they had asthma or had taken an asthma medication in the past (60.7%) in contrast with only one (2.8%) of the 36 athletes who participated in bobsled, biathlon, luge, and ski jumping. Eighteen (24%) of 75 athletes who participated in alpine, long track, figure skating, snow boarding, and curling had a previous diagnosis of asthma or recorded use of an asthma medication. CONCLUSIONS: We conclude that asthma appeared to have been more common in athletes who participated in the 1998 Winter Games than in athletes who participated in either the 1996 or 1984 Summer Games. Clearly, asthma rates vary widely among sports. This suggests that the environment in which exercise is performed is important in leading to a decrease in the amount of exercise required to trigger asthma and perhaps in causing injury to the airways.

Effects of fexofenadine, diphenhydramine, and alcohol on driving performance. A randomized, placebo-controlled trial in the Iowa driving simulator.

BACKGROUND: Sedating antihistamines may impair driving performance as seriously as alcohol. OBJECTIVE: To compare the effects of fexofenadine, diphenhydramine, alcohol, and placebo on driving performance. DESIGN: Randomized, double-blind, double-dummy, four-treatment, four-period crossover trial. SETTING: The Iowa Driving Simulator. PARTICIPANTS: 40 licensed drivers with seasonal allergic rhinitis who were 25 to 44 years of age. INTERVENTION: One dose of fexofenadine (60 mg), diphenhydramine (50 mg), alcohol (approximately 0.1% blood alcohol concentration), or placebo, given at weekly intervals before participants drove for 1 hour in the Iowa Driving Simulator. MEASUREMENTS: The primary end point was coherence, a continuous measure of participants' ability to match the varying speed of a vehicle that they were following. Secondary end points were drowsiness and other driving measures, including lane keeping and response to a vehicle that unexpectedly blocked the lane ahead. RESULTS: Participants had significantly better coherence after taking alcohol or fexofenadine than after taking diphenhydramine. Lane keeping (steering instability and crossing the center line) was impaired after alcohol and diphenhydramine use compared with fexofenadine use. Mean response time to the blocking vehicle was slowest after alcohol use (2.21 seconds) compared with fexofenadine use (1.95 seconds). Self-reported drowsiness did not predict lack of coherence and was weakly associated with minimum following distance, steering instability, and leftlane excursion. CONCLUSIONS: Participants had similar performance when treated with fexofenadine or placebo. After alcohol use, participants performed the primary task well but not the secondary tasks; as a result, overall driving performance was poorer. After participants took diphenhydramine, driving performance was poorest, indicating that diphenhydramine had a greater impact on driving than alcohol did. Drowsiness ratings were not a good predictor of impairment, suggesting that drivers cannot use drowsiness to indicate when they should not drive.

Heparin binding and augmentation of C1 inhibitor activity.

Heparin and other glycosaminoglycans have profound activity in vitro on the regulation of complement activity. The studies reported here examined the mechanism whereby heparin enhances C1 esterase inhibitor (C1INH) activity on C1 esterase (C1). The interaction of heparin and heparan sulfate with C1INH was first examined using surface plasmon resonance. Heparin was immobilized on a biosensor chip in two orientations, at its reducing end and in midchain, and heparan sulfate was immobilized at its reducing end. Heparin immobilized at its reducing end interacted with C1INH, giving an association constant (Ka) value of 1.43 x 10(7) M-1, whereas heparin immobilized in midchain afforded a Ka value of 7 x 10(6) M-1. No interaction between C1INH and heparan sulfate could be observed. Next, the augmentation of C1INH by heparin (Mr (av) 13,000), low-molecular-weight (LMW) heparin (Mr (av) 5000), and heparan sulfate (Mr (av) 11,000) was determined. C1INH alone was at least 10, 000 times more active in inhibiting fluid phase C1 compared with erythrocyte-bound C1 (EAC1). When C1 was in the fluid phase, both heparin and LMW heparin were relatively ineffective at augmenting C1INH activity on C1. In contrast, when C1 was present as EAC1, heparin augmented C1INH activity at all C1INH concentrations examined and LMW heparin was up to 1.3 times more effective than heparin. This augmentation only occurred when both C1INH and heparin were present together with the EAC1. Hence, although surface plasmon resonance shows that heparin binds to C1INH, heparin augmentation of C1INH activity appears to require a terniary complex in which cell bound C1 interacts with both heparin and C1INH. This is the first report of LMW heparin augmenting C1INH activity. Heparan sulfate neither interacted with C1INH nor did it augment C1INH activity.

Asthma in United States Olympic athletes who participated in the 1996 Summer Games.

BACKGROUND: Asthma prevalence appears to be increasing in the general population. We sought to determine whether asthma prevalence has also increased in highly competitive athletes. OBJECTIVE: Our aim was to determine how many United States Olympic athletes who were chosen to participate in the 1996 Summer Olympic Games had a past history of asthma or symptoms that suggested asthma or took asthma medications. METHODS: We analyzed responses to questions that asked about allergic and respiratory diseases on the United States Olympic Committee (USOC) Medical History Questionnaire that was completed by all athletes who were chosen to represent the US at the 1996 Summer Olympic Games in Atlanta. RESULTS: Of the 699 athletes who completed the questionnaire, 107 (15.3%) had a previous diagnosis of asthma, and 97 (13.9%) recorded use of an asthma medication at some time in the past. One hundred seventeen (16.7%) reported use of an asthma medication, a diagnosis of asthma, or both (which was our basis for the diagnosis of asthma). Seventy-three (10. 4%) of the athletes were currently taking an asthma medication at the time that they were processed in Atlanta or noted that they took asthma medications on a permanent or semipermanent basis and were considered to have active asthma. Athletes who participated in cycling and mountain biking had the highest prevalence of having been told that they had asthma or had taken an asthma medication in the past (50%). Frequency of active asthma varied from 45% of cyclists and emountain bikers to none of the divers and weight lifters. Only about 11% of the athletes who participated in the 1984 Summer Olympic Games were reported to have had exercise-induced asthma on the basis of other criteria that may have been less restrictive. On the basis of these less restrictive criteria, more than 20% of the athletes who participated in the 1996 Olympic Games might have been considered to have had asthma. CONCLUSIONS: Asthma appeared to have been more prevalent in athletes who participated in the 1996 Summer Games than in the general population or in those who participated in the 1984 Summer Games. This study also suggests that asthma may influence the sport that an athlete chooses.

Glycosaminoglycan-protein interactions: definition of consensus sites in glycosaminoglycan binding proteins.

Although interactions of proteins with glycosaminoglycans (GAGs), such as heparin and heparan sulphate, are of great biological importance, structural requirements for protein-GAG binding have not been well-characterised. Ionic interactions are important in promoting protein-GAG binding. Polyelectrolyte theory suggests that much of the free energy of binding comes from entropically favourable release of cations from GAG chains. Despite their identical charges, arginine residues bind more tightly to GAGs than lysine residues. The spacing of these residues may determine protein-GAG affinity and specificity. Consensus sequences such as XBBBXXBX, XBBXBX and a critical 20 A spacing of basic residues are found in some protein sites that bind GAG. A new consensus sequence TXXBXXTBXXXTBB is described, where turns bring basic interacting amino acid residues into proximity. Clearly, protein-GAG interactions play a prominent role in cell-cell interaction and cell growth. Pathogens including virus particles might target GAG-binding sites in envelope proteins leading to infection.

Azelastine nasal spray as adjunctive therapy to azelastine tablets in the management of seasonal allergic rhinitis.

BACKGROUND: Azelastine rhinitis medications (nasal spray and tablets) have been shown to relieve the symptoms of allergic rhinitis. Nevertheless, many rhinitic subjects suffer from acute exacerbations of symptoms that sometimes require additional treatment. OBJECTIVE: To assess the efficacy and safety of azelastine nasal spray as adjunctive therapy to azelastine tablets in the management of symptomatic seasonal allergic rhinitis in subjects who remain symptomatic despite the oral medication. METHODS: A 2-day, randomized, multicenter, double-blind, placebo-controlled, parallel-group study. Two hundred thirty-three subjects with symptomatic allergic rhinitis received azelastine tablets (0.5 mg bid) for a minimum of seven days prior to receiving either azelastine nasal spray (2 sprays per nostril bid) or placebo nasal spray as adjunctive therapy. Efficacy was determined by improvement in rhinitis symptoms that were grouped according to total and major symptom complex severity scores. RESULTS: Mean percent improvements in the total symptom complex severity scores for azelastine were statistically significant (P < or = .05) or showed a trend toward statistical significance (.05 < or = P < .10) versus placebo from the second through the first ten hours after the initial dose and for each of the last five hours of the second day, demonstrating a rapid onset of action and sustained efficacy over the 2-day study period. Azelastine was well tolerated, and no subject discontinued therapy with azelastine due to an adverse experience. CONCLUSION: Azelastine nasal spray can be effectively administered as adjunctive therapy, in an outdoor environment in which subjects are exposed to pollen and other aeroallergens.

Interaction of fibroblast growth factor-1 and related peptides with heparan sulfate and its oligosaccharides.

Fibroblast growth factors (FGFs) are a family of angiogenic and mitogenic proteins that promote cell division. The binding of FGFs to the heparan sulfate of cell-surface-bound proteoglycans appears to be critical for their activity. The interaction of fibroblast growth factor-1 (FGF-1 or aFGF) using heparin lyase-derived oligosaccharides from heparan sulfate was investigated. FGF-1 was also shown to protect sequences in heparan sulfate from heparin lyase digestion and protected oligosaccharide products of octasaccharide and decasaccharide size were recovered by FGF-1 affinity chromatography, suggesting that the high-affinity binding of heparan sulfate to FGF-1 resides within an octasaccharide sequence. The FGF-1 binding affinity of heparan sulfate is reduced compared to heparin presumably due to the absence of 6-sulfate groups in heparan sulfate. Inspection of the FGF-1 heparan sulfate binding domain shows that the majority of interacting amino acids are contained within a 20-amino-acid sequence that folds back upon itself (because of three turns) forming a triangular shaped cup of positive charge. The importance of FGF-1 binding site topology was investigated using three synthetic peptide mimics of the FGF-1 glycosaminoglycan (GAG) binding site. Heparan sulfate affinity chromatography and isothermal titration calorimetry, used to measure binding thermodynamics, demonstrated that a synthetic peptide analogous to the GAG binding site in FGF-1 bound tightly to heparan sulfate. A peptide containing a D-proline in place of L-proline bound with considerably reduced affinity, presumably due to the altered structure of the second turn in the binding site. A cyclic peptide, expected to be topologically most similar to the triangular GAG binding site in FGF-1, bound with the highest affinity to heparan sulfate. These data suggest the triangular topology of the GAG binding site in FGF is critical for its interaction with heparan sulfate. Analysis of known GAG binding sites in 25 proteins using the Chou-Fasman algorithm show that these sites commonly contain turns.

Pattern and spacing of basic amino acids in heparin binding sites.

Glycosaminoglycan (GAG)-protein interactions regulate a myriad of physiologic and pathologic processes, yet an understanding of how these molecules interact is lacking. The role of the pattern and spacing of basic amino acids (arginine (R) and lysine (K)) in heparin binding sites was investigated using peptide analogs as well as by examining known heparin binding sites. Peptides having the general structure R(n)W (n = 3-9, where tyrosine (W) was added for peptide detection) were synthesized and their interaction with heparin was determined by isothermal titration calorimetry. Binding affinity increased with increasing number of R residues. A 9-mer of R (R9W) bound as tightly to heparin as acidic fibroblast growth factor under physiologic conditions. Despite their high affinity for heparin, long stretches of basic amino acids are uncommon in heparin binding proteins. Known heparin binding sites most commonly contain single isolated basic amino acids separated by one nonbasic amino acid. Peptides having the structure, H3CCONH-GRRG(m)RRG(5-m)-CONH2 (denoted as the RRG(m)RR peptide series) and H3CCONH-GRRRG(m)RG(5-m)-CONH2 (denoted as the RRRG(m)R peptide series), where m = 0-5, were synthesized to test the hypothesis that the spacing of basic amino acids in heparin binding sites is optimally arranged to interact with different GAGs. The peptides, in both the -RRG(m)RR- and -RRRG(m)R- peptide series, when m = 0, bound most tightly with heparin, as measured by affinity chromatography. In contrast, the -RRG(m)RR-peptide series interacted most tightly with heparan sulfate when m = 0 or 1, whereas the -RRRG(m)R- peptide series bound tightest when m = 3. These results are consistent with our understanding of heparin and heparan sulfate structure. A highly sulfated GAG, such as heparin, interacts most tightly with peptides (or peptide sequences within proteins) containing a complementary binding site of high positive charge density. Heparan sulfate, having fewer and more highly spaced negatively charged groups, interacts most tightly with a complementary site on a peptide (or peptide sequences with proteins) that has more widely spaced cationic residues.

Heparin detection by the activated coagulation time: a comparison of the sensitivity of coagulation tests and heparin assays.

OBJECTIVE: Laboratory and point-of-care coagulation tests are frequently obtained to determine the presence of heparin after surgical procedures. The objective of this study was (1) to compare the sensitivity of the activated coagulation time (ACT), activated partial thromboplastin time (aPTT), protamine titration (Hepcon; HMS Medtronic, Hemotec, Englewood, CO), and thromboelastography (TEG) with heparin anticoagulation and (2) to determine how frequently residual heparin is present in the 24-hour period after heparin neutralization in cardiopulmonary bypass (CPB) patients. DESIGN: A prospective study. SETTING: A tertiary care university teaching center that performs more than 15,000 surgical procedures per year. PARTICIPANTS: Vascular surgical (n = 17) and CPB (n = 29). INTERVENTIONS: In vascular surgical patients, coagulation tests (ACT, protamine titration [Hepcon], and TEG) were obtained before and 90 minutes after heparin (50 to 60 U/kg IV) and compared with heparin concentration determined by factor Xa inhibition assay. In cardiac surgical patients, ACT and heparin concentrations were measured after anesthesia induction, during CPB, after protamine neutralization, and 3 as well as 6 hours after CPB. In addition to heparin concentrations and ACT measures, platelet counts, fibrinogen levels, and bleeding times were determined before and 3 and 24 hours after CPB. MEASUREMENTS AND MAIN RESULTS: Ninety minutes after heparin, significant heparin concentrations were present in all vascular surgical patients, but ACT was elevated in only 4 of 17 patients. Protamine titration (Hepcon) correlated with the factor Xa inhibitory assay for heparin (r2 = 0.76). All 17 patients had an abnormal TEG (mean "R" time = 81 +/- 39 minutes) and a marked elevation of aPTT (135 +/- 35 sec [normal 22 to 33 seconds]) 90 minutes after heparin. In CPB patients, ACT did not correlate with heparin assays. After protamine neutralization of heparin in CPB patients, ACT returned to baseline despite the presence of heparin in 3 of 29 patients (0.22, 0.18, and 0.33 U/mL). CONCLUSIONS: ACT was less sensitive to residual heparin anticoagulation than aPTT, TEG, and whole blood heparin assay. The whole blood heparin assay (Hepcon) provided sensitive and specific data about the presence of residual heparin. Despite the limitation of ACT in detecting heparin, the investigators found that residual heparin was not common in the period after uncomplicated CPB.

Structure-function relationships in the heparin-binding C-terminal region of insulin-like growth factor binding protein-3.

IGFBP-3 contains a carboxyterminal basic region which, when present as an isolated 18 amino acid peptide (P3), binds heparin, associates with cultured endothelial cells and stimulates glucose uptake. The P3 molecule has now been modified relative to charge, amino acid sequence and size to determine structure-function relationships relative to four properties of P3: affinity for heparin; inhibition of IGFBP-3 binding; stimulation of glucose uptake; and displacement of bFGF from the extracellular matrix of endothelial cells. Results indicate: (1) the presence or absence of heparin binding was concordant with the presence/absence of the other three properties; (2) the number of basic amino acids was an important, if not limiting, factor for each property; (3) the order of potency of the basic amino acids was arginine = lysine > > histidine; (4) the unrelated, basic protein, protamine, mimics all properties of P3; and (5) the putative consensus heparin-binding sequence of P3 was not essential for any of the P3 activities.

Exercise-induced asthma: a practical guide to definitions, diagnosis, prevalence, and treatment.

Exercise-induced asthma is defined as an intermittent narrowing of the airways, demonstrated by a decrease in some measure of flow, that the patient experiences as wheezing, chest tightness, coughing, and difficulty breathing that is triggered by exercise. Exercise will trigger asthma in most individuals who have chronic asthma, as well as in some who do not otherwise have asthma. Definitive diagnosis requires demonstration of a drop in flow rate, typically > or = 13-15% for forced expiratory volume in one second (FEV1) and > or = 15-20% for peak expiratory flow rate (PEFR), after exercise, associated with symptoms. Prevalence data indicate that this disorder is very common in those who participate in recreational sports as well as in highly competitive athletes, with at least 12-15% of unselected athletes having positive exercise challenges. Treatment of exercise induced asthma involves use of nonpharmacological measures (such as the use of the refractory period after exercise and prewarming air) as well as use of medications (beta-agonists, cromolyn, and nedocromil). With treatment, those who suffer from exercise-induced asthma may be able to participate and compete at the highest levels of performance.