Use of β₂agonists in sport: are the present criteria right?

Abstract

Background: The regulations for doping control prohibit the use of b 2 agonist bronchodilators (salbutamol, salmeterol, formoterol, and terbutaline) unless the subject follows the procedure known as abbreviated therapeutic use exemption (ATUE). Objective: To highlight how the interest in discovering possible cheats may result in damage to athletes who really need bronchodilator treatment. Methods: Thirty one high level athletes (18 men and 13 women) with a previous diagnosis of asthma were examined in our laboratory in order to obtain an ATUE for b 2 agonists. All the subjects underwent spirometry at rest. If the results were normal, the subjects underwent an effort test and, if negative, a methacholine test inhaling progressive doses of methacholine until a fall of 20% in forced expiratory volume in one second (FEV 1 ) was achieved. The international anti-doping regulations require that the fall in FEV 1 occurs with a concentration of methacholine (PC20) lower than 2 mg/ml (4 mg/ml for Torino 2006). In clinical practice, a test is positive if the response occurs with a PC20 lower than 8 mg/ml. Results: Only one subject met the criterion for the bronchodilation test at rest. The remaining 30 athletes underwent an effort test, which was positive in nine of them. In 21 cases (13 men and 8 women) the effort test was negative so a methacholine test was carried out. Seven (33%) were negative for ATUE with a PC20 higher than 8 mg/ml, seven (33%) were positive for ATUE with a PC20 less than 2 mg/ml, in four (19%) the PC20 was 2-4 mg/ml, and in three (14%) it was 4-8 mg/ml. Conclusions: Strict vigilance of fair play should be pursued, but excessive control can lead to situations of inequality for asthmatic athletes such that a third of athletes cannot be treated with b 2 agonists. Therefore under current regulations, asthmatic athletes are often denied the most effective therapeutic option.

Diagnosis of exercise-induced bronchoconstriction: eucapnic voluntary hyperpnoea challenges identify previously undiagnosed elite athletes with exercise-induced bronchoconstriction

“…Athletes can demonstrate EVH negative, but still experience EIB for a number of reasons, including being well-controlled with inhaled corticosteroids, being in a period of remission or the EIB being linked to specific allergens such as pollution or pollen. Furthermore, some studies have suggested that the cut-off criterion used to diagnose EIB following recognised bronchoprovocation is not suitable for elite athletes and may result in athletes with EIB being denied the most effective therapeutic treatment(s) 22–24. Therefore, an athlete who is EVH negative, but has either symptoms and/or a previous diagnosis of EIB, should not immediately be deemed EIB negative.…”

The rush to adrenaline: drugs in sport acting on the β‐adrenergic system

“…Overall, the acute use of the current inhaled β 2 ‐AR agonist anti‐asthma medications by non‐asthmatic or asthmatic athletes seems unlikely to provide any improvement in performance in addition to that provided by the control of their condition. Of more concern is the adequacy of the tests required to obtain a therapeutic use exemption, as they may be inappropriate for diagnosing exercise‐induced asthma under the conditions experienced in competition ( Naranjo Orellana et al ., 2006 ).…”

How to Diagnose Exercise Induced Asthma?

“…The test is considered positive if the decline in FEV 1 is greater than 20% from baseline value (FEV 1 measurements at rest). The fall in FEV 1 must be presented with a methacholine concentration of less than or equal to 8 mg/ml [ 6 , 7 ] . The test is useful in the clinic to diagnose chronic asthma, but has a low sensitivity for the screening of EIA.…”