The correct answer is:

aspirin

Educational Objective:

Recognize aspirin-exacerbated respiratory disease.

Key Point:

The Samter’s triad, or aspirin-exacerbated respiratory disease, manifests with asthma, nasal polyps, and an allergy to aspirin.

Explanation:

Exercise-induced asthma (EIA) is triggered by the release of histamines during aerobic exercise.

Patients with EIA usually present with complaints of exercise-related respiratory symptoms, which are much more common among children and younger athletes but can be seen in people of any age.

In patients with exercise-induced bronchospasm, the primary aim of therapy is prophylaxis to prevent acute episodes.

Managing exercise-induced bronchoconstriction includes:

• the administration of an inhaled short acting beta agonist (SABA) about 15 minutes before exercise,
• use of a daily inhaled corticosteroid,
• a daily leukotriene receptor antagonist,
• or a mast-cell stabilizing agent before exercise for patients who continue to exhibit symptoms despite SABA therapy or those who require daily or more frequent SABA use

A warm-up period of 15 minutes is recommended prior to a scheduled exercise event and has been shown to have a duration of effect as long as 40 minutes.

This approach is not helpful for unscheduled events, prolonged exercise, or elite athletes.

Daily use of an inhaled long-acting beta agonist or an inhaled corticosteroid is not recommended as monotherapy in patients with symptoms.

Medical conditions, environmental factors, and asthmogenic agents are all common etiologies for EIA. Cold air, histamines, pollen, insecticides, nonsteroidal anti-inflammatory drugs are all well-known triggers for EIA and therefore should be avoided.

The Samter's triad is seen in some persons with asthma, such as the patient in this case, and includes asthma, nasal polyps, and an allergy to aspirin.

All cyclooxygenase 1–inhibiting nonsteroidal anti-inflammatory drugs, including aspirin, induce bronchospasm, rhinorrhea, and nasal obstruction in these patients and should therefore be avoided.

References:

Parsons JP, Hallstrand TS, Mastronarde JG, et al. An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. Am J Respir Crit Care Med. 2013;187(9):1016-1027.

Drazen, JM. Asthma. Goldman-Cecil Medicine. 2016; 87: 548-555