Background Asthma is highly prevalent among elite endurance athletes, but long-term natural history data beyond 5 years are lacking. Understanding disease trajectory and sport-specific risks are important for clinical management. Methods We conducted a 10-year prospective postal survey of Swedish elite endurance athletes in biathlon, cross-country skiing, ski orienteering, and orienteering. Baseline questionnaires were collected 2011-2015, with follow-up 10 years later. We calculated 10-year cumulative incidence of physician-diagnosed asthma, remission (no medication use during last 12 months at follow-up), and relapse (medication use at follow-up after none at baseline). Factors associated with incident asthma were analyzed using logistic regression. Results Of 591 eligible athletes, 290 (49.1%) responded at 10-year follow-up. Among 220 athletes without baseline asthma, 50 developed asthma (cumulative incidence 22.7%, 95% CI 17.7-28.7%). Among 45 athletes with asthma and asthma medication use at baseline, 19 achieved remission (42.2%, 95% CI 29.0-56.7%). Among 16 athletes with physician-diagnosed asthma but no medication at baseline, 3 relapsed (18.8%, 95% CI 6.6-43.0%). Cross-country skiers had more than twice the cumulative incidence (30.2%) compared to orienteers (13.2%). Multivariate logistic regression adjusting for age, sex, training volume, allergic rhinitis, and family history did not identify statistically significant independent associations. Conclusions One in four elite endurance athletes developed asthma over 10 years, with cross-country skiers showing more than twice the cumulative incidence of orienteers, while over 40% with active asthma achieved remission. No statistically significant factors associated with incident asthma were identified. Asthma remains a dynamic condition throughout athletic careers and warrants continuing reassessment.
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