Medical perspective on Therapeutic Use Exemptions: TUEs
As described in part 1 of this series of blogs I was on the international medical research team investigating the development of a test for identifying athletes doping with growth hormone. This experience helped form my view on the interaction of medicine and sport performance.
Over the next few days the results of anti-doping study will be presented at the International Federation Forum, with one of the discussions being “Medication Abuse in Elite Sport: the Epidemic!”
As doctors, our primary objective is to treat medical conditions in the most effective manner. It would not be ethical to withhold treatment to certain groups of patients, such as elite athletes. Therefore, where the prescribed medication for the treatment of a legitimate medical condition is on the prohibited list issued by the World Anti-Doping Agency (WADA), a TUE should be sought. After all elite athletes are just as likely to become ill as the general population, if not more so with functional immunosuppression due to training loads and possible energy deficient states.
In my opinion, the use of TUEs in the case of preventative treatment appears to be where the main discussion is centred. The athlete might not be acutely unwell, but may have a chronic condition, which can flare in an acute manner especially where there are known triggers. For example in the general population it is better medical practice to offer prophylactic treatment to a known asthmatic in order to decrease the risk of having an acute asthma attack, rather than waiting to treat an acute attack. Following on this argument, there is a case for offering elite athletes preventative treatment, rather than running the risk of an acute exacerbation requiring urgent treatment in difficult circumstances, for example in the middle of a race where access to required urgent treatment might be problematic. A view has been expressed that athletes with severe asthma have no place in performance sport and the paralympics would be more appropriate. Maybe this view is too extreme, after all exercise is recommended as a supportive strategy for asthma. Successful swimmers such as Thorpedo (Ian Thorpe) overcame both asthma and a reported allergy to chlorine to win Olympic and World titles.
In my opinion, the concept of TUEs for prevention of acute exacerbations of documented chronic conditions is valid. However, the issue seems to be the exact nature of such prophylatic treatment. Ideally the minimum dose of a medcation with the least potential performance enhancing qualities should be preferred. This has to be balanced against the most effective treatment for the specific documented medical condition of the individual athlete. Ultimately the athlete should be at neither disadvantage nor advantage due to a chronic, treatable medical condition.
Canadian law professor and sports lawyer Dr Richard Mc Laren (who conducted investigation into Russian state-sponsored doping) suggested that to investigate potential abuse of TUE system, frequency of certain medications being used in specific sports would need to be quantified.
In the meantime this vexed issued is being discussed at the Association of Summer Olympic International Federations (ASOIF) 9-11 November.
For further discussion on Endocrine and Metabolic aspects of SEM come to the BASEM annual conference 22/3/18: Health, Hormones and Human Performance
Enhancing sport performance: part 1 Dr N. Keay, British Association of Sport and Exercise Medicine
Relative Energy Deficiency in Sport Dr N. Keay, British Association of Sport and Exercise Medicine
WADA World Anti-Doping Agency
UKAD UK Anti-Doping