WADA Cracks Down on the Abuse of Asthma Drugs by Athletes in 2017

The World Anti-Doping Agency (WADA) published its 2017 Prohibited List (of performance-enhancing drugs) on September 29, 2016. Perhaps the most notable change to the list was WADA’s apparent crack down on the abuse of asthma drugs by athletes.

The new 2017 Prohibited List made it clear that ALL long- and short-acting, selective and non-selective beta-2 adrenoreceptor agonists are strictly prohibited both in- and out-of-competition. WADA specifically listed fenoterol (Berotec), formoterol (Foradil), higenamine (Jack3d Micro), indacaterol (Onbrez), olodaterol (Respimat), procaterol (Meptin), reproterol, salbutamol (Ventolin), salmeterol (Serevent), terbutaline (Bronclyn) and vilanterol (Breo Ellipta). It also included clenbuterol but listed it as an “anabolic agent” instead of an asthma drug.

WADA made exceptions for three specific beta-2 adrenoreceptor agonists used in specific delivery methods with strict dosage restrictions.

Inhaled salbutamol: maximum 1600 micrograms over 24 hours, not to exceed 800 micrograms every 12 hours;

Inhaled formoterol: maximum delivered dose of 54 micrograms over 24 hours;

Inhaled salmeterol: maximum 200 micrograms over 24 hours.

“Dosing parameters of salbutamol were refined to make it clear that the full 24 hour dose should not be administered at one time.”

Salbutamol, also known as albuterol, is one of the most widely-used long-acting β2 adrenergic receptor agonist for asthma in the general population as well as the athlete population. The inhalers are sold under the tradenames of Ventolin and Proventil in the United States and most of the rest of the world.

Athletes do not need explicit permission to use Ventolin, Serevent or Foradil inhalers. There is no requirement for athletes to apply for a therapeutic use exemption (TUE) even though the three drugs are prohibited as long as the amount of salbutamol in a urine test never exceeds 1000 ng/mL and/or the amount of formoterol never exceeds 40 ng/mL.

If the salbutamol or formoterol levels exceed this threshold, then the burden rests on the athlete to prove “through a controlled pharmacokinetic study, that the abnormal result was the consequence of the use of the therapeutic dose [by inhalation] up to the maximum dose” indicated in the WADA 2017 Prohibited List.

Some athletes have apparently been simultaneously using multiple asthma drugs at therapeutic levels for performance-enhancing purposes. While respecting the thresholds established by WADA, the athletes could use salbutamol, formoterol AND salmeterol inhalers at the same time and still legally follow WADA’s rules.

The alleged practice of concurrent use of multiple beta-2 agonists has caused WADA to add this pattern of use to its 2017 Monitoring Program. The practice remains legal throughout 2017. However, WADA will specifically investigate how widespread this practice may be. It will target athletes who engage in this practice. The athletes will not be penalized but if it turns out to be a major problem, then WADA may add it to the 2018 Prohibited List.