I occasionally get questions about athletes’ medications and the issue of doping, usually from amateur athletes who are simply concerned about breaking the rules of their sport. I’m certainly not an expert at all of the aspects of doping rules, detection and enforcement efforts, and participation of various events/sports in organized anti-doping efforts, but it’s worth discussing some important points that will be generally applicable.
Many competitive sports will be involved with the efforts of the World Anti-Doping Agency (WADA). So-called signatories to the WADA Anti-Doping Code agree to a set of policies, rules, and regulations that govern the conduct of their particular sports. Current signatories include all organizations related to the broad Olympic Movement (eg, USA Triathlon, USA Swimming, USA Track & Field); many national sport organizations (eg, U.S. Anti-Doping Agency [USADA]); and various miscellaneous sports organizations (eg, World Karate Organization, World Triathlon Corporation [WTC]). If you participate in activities of these organizations, the rules of the WADA Code apply to you and you should be familiar with these rules.
WADA periodically publishes a Prohibited List that outlines prohibited substances and methods. The most recent List was published in August, 2011 and went into effect on January 1, 2012. There are separate requirements for in- and out-of-competition settings and there are special rules that apply to certain sports.
With heart disease being so common in the American adult population, especially if we include hypertension, it’s worth drawing attention to several items on the Prohibited List:
1. Non-approved substances. Pharmacologic substances that are investigational (ie, not yet approved by a national regulatory agency) are prohibited at all times.
2. Peptide Hormones, Growth Factors, & Related Substances are prohibited at all times. Examples include erythropoeitin (EPO) and insulins.
3. Beta-2 Agonists are used to treat asthma and other pulmonary diseases. These medications are prohibited at all times EXCEPT for salbutamol (eg, Albuterol) or formoterol (eg, Symbicort) used at dosages in accordance with the manufacturer’s recommendations. Athletes who use salbutamol or formoterol are subject to urine testing where levels of >1000 ng/mL or >30 ng/mL, respectively, indicate usage in excess of the manufacturer’s recommendations.
4. Diuretics, in virtually every form, are prohibited at all times. These medications (eg, hydrochlorothiazide [HCTZ], spironolactone, metolazone, acetazolamide) are common and are used alone or in combination with other agents to treat patients with high blood pressure and also in patients with heart failure. They are on the Prohibited List because they can mask the detection of other agents on the List.
5. Stimulants, in all forms, are prohibited during competition EXCEPT for a small group of stimulants included in the 2012 Monitoring Program: caffeine, nicotine, phenylephrine, phenylpropanolamine, pipradol, and synephrine.
6. Narcotics are prohibited during competition.
7. Cannabinoids (ie, marijuana) are prohibited during competition.
8. Alcohol is prohibited during competition for the following sports: aeronautic, archery, automobile, karate, motorcycling, powerboating.
9. Beta-Blockers (eg, atenolol, carvedilol, metoprolol) are prohibited during competition for the following sports: aeronautic, archery (also, out-of-competition), automobile, billiards, boules, bridge, darts, golf, ninepin and tenpin bowling, powerboating, shooting (also, out-of-competition), and skiing/snowboarding.
I suspect that there are many amateur athletes participating in a sport governed by the WADA Code who are using one or more of these substances. Armed with some knowledge about the rules, one logical approach might be to have a discussion with your doctor about alternative(s) to the prohibited medications. Sometimes there might be a viable alternative. Other times, a particular agent may well be the most appropriate choice of medication for a given athlete with a specific medical problem. In that case, there is an oppotunity to obtain a Therapeutic Use Exemption (TUE)–permission to use a prohibited substance because of its medical necessity. Information about the TUE application process is available through WADA. Athletes will file applications with either their sport’s international federation or their country’s anti-doping agency.