Asthma and Exercise: Elite Athletes with Asthma: Anti-Doping and Fair Play

Asthma doesn’t have to stop you from competing in sports at an elite level. While statistics are variable within sports, and competition years (and seasons!), in 2004, 4.6% of athletes competing in the Summer Olympics in Athens were identified as having asthma via their applications to anti-doping authorities to use inhaled bronchodilators (fast-acting rescue medication to open the airways) during the Games—at the Winter Olympics two years later, 8.3% of athletes applied, indicating a higher rate of asthma treated via bronchodilators.¹ Research has indicated that competitions taking place in cold, dry air, as well as in high-altitude conditions, like skiing and snowboarding, tend to be a more common precursor to developing exercise-induced asthma symptoms.²

Exercise induced asthma symptoms are the same of those as classic asthma, but they can often be less predictable than typical asthma symptoms—for instance, while someone with asthma will experience a fairly predictable response to exercise, someone with only EIA may only occasionally exhibit symptoms of asthma with exercise—for instance, at extremely high altitudes, high humidity, or very cold temperatures.² However, elite competitors are often found to not experience wheezing, while still presenting with dyspnea (shortness of breath), chest tightness, or coughing after a competition². While for most people with asthma, the treatment for EIA is fairly straightforward—using a bronchodilator medication before exercise as prescribed, but also when symptoms occur—elite athletes, as noted, experience the added step of having to declare any medication or substance that they put into their bodies to their national anti-doping or doping control authority.

What does this mean if you have asthma and are competing in sport at a high level? Or, what does it mean for athletes you may know who have asthma—such as NFL football player Jerome Bettis, NBA basketball player (among his other claims to fame!) Dennis Rodman, and British marathon runner Paula Radcliffe… Just to name a few!³ Despite their name, most people with asthma are aware that corticosteroids—that can either be taken as an inhaler, or may be taken as a pill, prednisone, in more severe situations—are not the same as the “steroids” that athletes use for enhancing performance—known as anabolic steroids. Corticosteroids taken by those with asthma simply reduce inflammation in the body, while anabolic steroids have a host of effects that can be performance enhancing. While there are medical uses for anabolic steroids—a synthetic version of male sex hormones—they are often used in sport to enhance performance by facilitating rapid muscle growth, improve strength and stamina… alongside a host of other negative effects³.

So, don’t worry: there are no connections between your asthma meds and the illegal anabolic steroids that are often used illegally in competition—most notably in, but certainly not limited to the sports of cycling and bodybuilding. However, that doesn’t mean athletes with asthma are in the clear when competing.

Here’s a synopsis of the process athletes with medical conditions, like asthma, should consider when competing—even if you’re not at an elite level (yet), your local sport organization may—and should—have anti-doping regulations in place, that keep sport fair and fun for everyone: learn what they are. At an elite level, the protocol is as follows:

• Athletes receive education on anti-doping regulations, protocols, and their rights and responsibilities
• Athletes are responsible for what they put into their bodies—food, medications prescribed by a doctor, over the counter meds, supplements, and illegal drugs. Substances banned for use in performance by the World Anti-Doping Agency [WADA] are either demonstrated to be harmful to the athlete, or to violate the spirit of sport when used improperly. Note as well that supplements are always taken at the risk of the athlete, as their manufacturing is not regulated⁴
• The Global DRO (Drug Reference Online) is a tool available to athletes, coaches, support staff, and those curious, to check their medications for their allowed use in sport. There are different regulations for some medications for in-competition vs. out-of-competition use.
• If an athlete finds they are taking a substance that is prohibited, they should speak with their medical team, or discontinue use of non-medically necessary drugs (not prescribed by a doctor). If the substance is prescribed from a doctor, the athlete may proceed with a Therapeutic Use Exemption (TUE).
• A TUE is an application from the athlete’s physician explaining the requirement for the athlete to be on the prohibited substance. The Therapeutic Use Exemption allows an athlete to continue taking his or her prescribed medication, and participate in sport.

While everyone’s asthma treatment plan is different, and it’s best to investigate for yourself, here are where a few of the most common asthma medications stand in terms of anti-doping, accessed via the United States portion of the Global DRO. Note that each sport may have different anti-doping regulations, so check for your individual sport every time!

Albuterol/Salbutamol/Levalbuterol/Levosalbutamol [inhaled only!]⁵
No more than 1600 micrograms [mcg] per 24 hours (about 8 puffs)
Note that if an athlete is using this medication via a nebulizer, the dosing formats are different. The Global DRO recommends athletes contact the drug manufacturer to determine their need for a TUE, since each nebulizer (and patient) will receive a different amount of the drug to their lungs vs. what is lost to the air.⁴

Inhaled Steroids [including Mometasone/Fluticasone/Beclametasone, etc.]
Not prohibited. ⁵

Inhaled Long Acting Beta-2 Agonist Bronchodilators [including Formoterol/Salmeterol]
Formoterol, no more than 54 mcg per day
Salmeterol is not prohibited when taken in accordance with the manufacturer’s recommendations ⁵

Leukotriene Receptor Antagonists [LTRA, ie. montelukast]
Not prohibited.

Though I don’t currently work with any elite athletes, as a provincial team coach and kinesology grad, I am fairly well versed in anti-doping strategies: organizations like the United States Anti-Doping Authority, Canadian Centre for Ethics in Sport, and the World Anti-Doping Authority exist to keep sport clean and fair by not only enforcing doping control (yes—elite athletes DO have to repot their whereabouts to anti-doping authorities at all times, AND they can be visited at absolutely any time to produce a sample (blood or urine) to be tested for substances associated with doping. Currently in Canada, all athletes competing in National games (therefore, provincial team athletes), must complete an anti-doping education course, informing them of banned substances, the fact that an athlete is 100% responsible for anything they put into their body and that is found in their sample, the procedures for sample collection, and how positive doping tests are handled: information is readily available for athletes to be well-informed about their responsibilities when it comes to doping. The Therapeutic Use Exemption procedure is straightforward by contacting your state, province, or national sport organization to get you started.

The consequences of being caught doping are severe—you can be banned from all participation in your sport, even simply training or going to events if not competing, for varying lengths of time. Names of those caught doping are often released to the media, and can affect your ability to get a job and participate in other sport opportunities. If you’re competing with asthma, you have rights when it comes to your normal medication that helps you preform your best—but, make sure you know the regulations… and play clean!