New South Wales Institute of Sports Medicine, Concord Hospital, Sydney, Australia and 1 Department of Otolaryngology, Charing Cross Hospital, London, UK.
Correspondence to: L. Barnsley, New South Wales Institute of Sports Medicine and Department of Rheumatology, Concord Hospital, NSW 2139, Australia. E-mail: les.barnsley{at}email.cs.nsw.gov.au
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
KEY WORDS: Rheumatology, WADA (World Anti-Doping Agency), IOC (International Olympic Committee), Doping
![]() |
Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The results of a positive doping testing can be devastating to an athlete's career and the reputation of their club or country. A positive doping test results from the ingestion or administration of a banned substance either intentionally or accidentally. To avoid the potentially tragic error of accidental prescribing of banned drugs, it is vital that physicians caring for athletes of all backgrounds are fully educated. In light of the heightened interest in sport in this Olympic year and the recent revision of the World Anti-Doping Agency/International Olympic Committee (WADA/IOC) guidelines [2], this article aims to serve as a review of this important topic.
![]() |
Drugs in sport |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Testing of human athletes for performance-enhancing drugs did not begin until 1965 (over half a century after testing was introduced in racehorses). The first IOC banned substances list was produced in 1968, subsequently the WADA was created in November 1999 through a collective initiative of sporting organizations and government led by the IOC. WADA aims to educate athletes about the harmful effects of doping, reinforce the principles of fair play and detect those who cheat. In 2003 all major sporting federations and 73 governments approved a resolution accepting the WADA Code as the basis for the fight against doping.
A number of athletes who have tested positive for banned substances have used the defence that the substance was taken unknowingly as a nutritional substance or a prescribed or over-the-counter medicine. High-profile cases have included Alain Baxter, the British downhill skier who, in 2002, was stripped of his Olympic bronze medal after testing positive for methamphetamine from the US version of a Vicks nasal inhaler. Only the non-performance-enhancing L isomer of methamphetamine was detected; however, the IOC does not distinguish between the two isomers and despite appeal he received a 2-yr ban.
![]() |
Testing |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
Rheumatology and drugs in sport |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
|
Non-steroidal anti-inflammatory drugs (NSAIDs)
All NSAIDs and the newer selective cyclo-oxygenase 2 inhibitors are permitted orally, intramuscularly or topically.
Disease-modifying anti-rheumatic drugs (DMARDs)
These drugs act via mechanisms that neither enhance or detract from performance and are therefore freely permitted. New treatments for inflammatory diseases classified as biologicals such as etanercept, adalimumab and infliximab do not appear on the WADA prohibited list and are therefore freely permitted.
Drugs used for crystal arthritis
Colchicine is permitted for the treatment of acute gout. Allopurinol is also permitted for gout prophylaxis; however, probenecid may be used as a masking agent and is therefore banned.
Local anaesthetics and adrenaline
Local anaesthetics are permitted when administered by local or intra-articular injection. Adrenaline is banned in competition; however, it may be used in emergency settings (haemorrhage or anaphylactic shock). If a medical team has to administer adrenaline during a competition, the completion of a TUE will be required.
Anabolic steroids
Anabolic steroids are occasionally used for management of osteoporosis in hypogonadal males (e.g. sustanon) and stanazol is occasionally indicated for vascular manifestations of Behçet's disease and hereditary angioedema. All anabolic steroids are prohibited.
Agents with anti-oestrogenic activity may be illegally used to counteract undesirable side-effects associated with anabolic steroid use, such as gynaecomastia (development of breast tissue). Therefore agents such as aromatase inhibitors and tamoxifen are banned in males, but not females.
Drugs used for management of osteoporosis
As stated above, anabolic steroids and drugs masking their side-effects are banned in males. Bisphosphonates, calcitonin, recombinant parathyroid hormone, strontium, fluoride, calcium and vitamin D are all permitted.
Narcotics
Dextromoramide, morphine, buprenorphine, methadone, diamorphine, oxycodone oxymorphone, hydromorphone, pentazocine and pethidine are all prohibited. However, codeine, dihydrocodeine and dextropropoxyphene are allowed but the risk of adverse effects on performance must be considered.
Vasodilators and other antihypertensive agents
All diuretics including frusemide and thiazides are considered masking agents and prohibited unless a TUE is accepted. A TUE for diuretics is invalidated if found in association with a prohibited substance. Vasodilators such as calcium channel blockers and ACE inhibitors are permitted, although care must be made when prescribing some compound antihypertensives which may contain banned diuretics; examples include irbesartanhydrochlorothiazide and perindoprilindapamide combinations.
In certain weight-classified sports and sports where weight loss can enhance performance a TUE for diuretics will not be granted. This includes ski jumping, weight lifting, rowing and judo, amongst others.
Decongestants
Imidazole preparations such as oxymetazoline, xylometazoline (Otrivine, Vicks Sinex, Dristan) and tramazoline (Dexa-rhinaspray Duo) are likely to be found in over-the-counter combination remedies which athletes may not consider to be drugs. They may also be prescribed in the short term for exacerbations of rhinitis and rhinosinusitis, otitis media and prior to flying. These and other substances with similar chemical structure or pharmacological effects are, however, considered stimulants and permitted only for topical use. Even with topical use a test is considered positive for ephedrine and methylephedrine if urinary concentrations greater than 10 µg/ml are detected. Phenylephrine and pseudoephedrine (Sudafed) have recently been removed from the banned list and transferred to the 2004 monitoring programme (a programme where a samples are tested for the substance to monitor and detect potential misuse in sport) and are therefore permitted at present.
Antihistamines
Antihistamines are not prohibited; however, an important principle of prescribing to athletes is that no medication should adversely affect the athlete's performance. First-generation antihistamines may have undesirable sedating and anticholinergic side-effects, such as decreased sweating, if taken orally. Intra-nasal azelastine (Rhinolast), however, has been shown to have no adverse affect on performance [10] and may be used to manage seasonal allergic rhinitis.
Antimicrobial drugs
All antibiotics are freely permitted, as is acyclovir; however, some antifungal agents are banned. Miconazole (Daktarin Oral Gel) is an imidazole and therefore a potential stimulant. It is prohibited unless used solely as a topical agent. There is obviously potential for systemic absorption across the buccal mucosa and by ingestion and a TUE should be applied for. Non-imidazole antifungals are permitted.
Peptide hormones
Erythropoeitin, insulin, growth hormone, insulin growth factor (IGF1), corticotrophins and gonadotrophins are all prohibited unless elevated levels can be proved to be due to pathological or physiological condition.
Asthma medications
ß2 agonists are prohibited in and out of competition except formoterol, salbutamol, salmeterol and terbutaline which may be used in conjunction with an abbreviated TUE. A urinary salbutamol concentration greater than 1000 ng/ml is considered an adverse finding. The inhaled medications ipratropium bromide and sodium chromoglycate, often used for exercise-induced asthma, are all permitted.
Other considerations
Certain substances are prohibited in competition only in particular sports. Beta-blockers and alcohol are banned in any sport where their systemic effects may convey benefit. These include archery, billiards, football, skiing and automobile/aeronautic sports amongst others.
Caffeine, a common component of over-the-counter coryzal remedies, was removed from the prohibited list in 2003 and transferred to the 2004 monitoring programme.
To facilitate compliance with the WADA guidelines prescribers should ensure that adequate supplies of medications of known composition are available. This is particularly important for athletes training or competing abroad where locally available drugs may differ from similarly named medications from the athlete's home country.
![]() |
Summary |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The authors have declared no conflicts of interest.
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
|