TUEs, pushing the boundaries of WADA

Asthma inhalerOne of the many issues and discussion points in doping is the use of Therapeutic Use Exemptions (TUE) by athletes. It’s been more of a talking point after the Fancy Bears’ leaks though so we thought it would be a good time to take a look at the topic and discuss its impact on canoeing / kayaking.

What are TUEs?

If an athlete needs to take a medicine for an illness, but the medicine is prohibited by the World Anti Doping Agency, WADA, (the agency that sets and monitors anti doping policy around the world) then they can apply to get permission to use the medicine. Generally the application is done through their National Governing Body. A doctor has to say they are genuinely in need of the medication and sign off on it, and they must fulfil all four of the below criteria [1]:

  • The athlete would experience significant health problems without taking the prohibited substance or method
  • The therapeutic use of the substance would not produce significant enhancement of performance
  • There is no reasonable therapeutic alternative to the use of the otherwise prohibited substance or method
  • The requirement to use that substance or method is not due to the prior use of the substance or method without a TUE which was prohibited at the time of use.

If you need emergency treatment then you can receive it and then apply for a retroactive TUE after the treatment (to make sure athletes aren’t going to start turning down necessary treatments or anything crazy). This is all in place to try and make sure that the TUEs are used to keep athletes healthy but not provide any advantage to those receiving them. However, the world of sport has shown again and again that people will try and push boundaries and take advantages where they can find them.

Can TUEs be abused?

If you’re allowed to apply to take drugs that are normally banned because they can be performance enhancing then there’s an obvious follow on that maybe you can take them for precisely those performance benefits… but is that possible within the system? There is plenty of anecdotal evidence from ex athletes that they did precisely this. Corticosteroids have been used by dopers for years (Armstrong was one of them) and Michael Rasmussen (who was kicked out of the Tour de France in 2007 and has admitted to doping throughout his career) has said that he used to get the team doctor to apply for a TUE for Triamcinolone acetonide for a made up illness before big races [2].

Other ex pro cyclists such as Joerg Jaksche have said things like “You would apply for a TUE, telling WADA that you had hay fever. Your team doctor would tell them you were having certain problems like [watering] eyes, blah blah blah … So you would get your cortisone injection in order to be competitive at the Tour or to lose weight or whatever“ [3].

So we have evidence that people used to game the system, add that to evidence that athletes are still taking corticosteroids and it’s not hard to be cynical. Prednisone (a corticosteroid) and prednisolone (its active metabolite) have been coming up again and again as information on TUEs has come out, Serena and Venus Williams have had TUEs for them [4] Alberto Salazar has said that Galen Rupp has taken it [5] and prednisolone was one of the two treatments slalom paddler Jess Fox had a TUE for. There are obviously good medical reasons to take them, they are used to treat asthma, autoimmune diseases and allergic reactions amongst lots of other uses but on the flip side there’s both anecdotal evidence and published studies that they can boost performance [6, 7] .

As it stands, if you can get a doctor to sign off on it then you can take prednisolone and hope for some of the gains. Clearly not everyone is taking it cynically without a medical need, maybe very few are, but the possibility and potential is still there.

Asthma meds

Another good example of the struggle to strike a balance is Salbutamol. It is a common treatment for asthma and is a β2 agonist that relaxes muscles in the lungs and airways. It was previously banned by WADA but allowed from 2010 onwards. They changed their position and now you are allowed to use it (along with the similar medicines formoterol and salmeterol) as long as you make a “declaration of use”, and don’t have way more in you blood than would be expected from a normal dose.

It’s an interesting case, WADA decided to “un ban” it because there wasn’t evidence that it was performance enhancing, and there are meta analyses that support that, for example:
β2-Agonists and Physical Performance: A Systematic Review and Meta-Analysis of Randomized Controlled Trials, which reported “no significant effects for inhaled β2-agonists on endurance, strength or sprint performance in healthy athletes” and although “there is some evidence indicating that systemic β2-agonists may have a positive effect on physical performance in healthy subjects, the evidence base is weak.” Also, Inhaled beta2 agonists and performance in competitive athletes which looked at twenty randomised, placebo controlled studies but only three reported a performance enhancing effect of inhaled beta2 agonists. “However, methodological shortcomings were most likely responsible for these findings (for example, non-elite athletes, inconsistent results in different tests, subgroups with above-average responsiveness)” and they concluded that “inclusion of inhaled beta2 agonists on the list of prohibited substances should be reconsidered.” (the study is from 2006 when salbutamol was still banned).

However, all of the studies tend to be small, many have under 20 participants, some used trained athletes and other don’t, and what they actually measure varies depending on what the investigators want to look at. If you want to cherry pick then there are studies that make salbutamol look like a promising candidate for improving performance [8, 9, 10, 11, 12, 13].

If there’s a possibility it seems inevitable that athletes will try taking it in the hopes that they get an extra edge. Maybe if you have 100% perfect lung function then you won’t get any help but if you have a low level of allergies, are affected by pollution or have reduced lung function for some reason that wouldn’t bother you much in your normal life and then take some salbutamol then you might get a bit of an athletic boost. Is it cheating to take an inhaler “just in case”?

So where do we draw the line?

There are studies that show taking paracetamol (acetaminophen) can make you time trial faster [14], possibly because you don’t notice the pain as much. But is that much different to taking creatine, or caffeine, or coffee or concentrated beetroot for the nitrates … it’s not always easy to know where to draw a line.

Just because you can get away with something it doesn’t mean you should or that it is ethical. As fans and competitors it’s an area that can’t be ignored even if the questions don’t always have easy answers. Perhaps the simplest way is just to say athletes can do ”whatever WADA will let them do” but that’s really just trying to shy away from making any hard calls about what you think is ethical. For example, when meldonium was still allowed, should people have taken it without a medical need? Probably not …

Additional links:
WADA prohibited list 2017

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