Asthma inhalers and their anti-doping status in sport

Preventer inhalers used on a regular and ongoing basis are the foundation of treatment for asthma. They help to stop or prevent symptoms by reducing the inflammation in your airways. In the UK, there are two types of preventer inhalers, those which contain an inhaled glucocorticoid and those which contain a combination of an inhaled glucocorticoid and a long-acting beta-2-agonist.

Inhaled glucocorticoids
Glucocorticoids are permitted in sport when administered via inhalation. A TUE is not required for a medication which is permitted in sport. NB. Your doctor may refer to these medications as inhaled corticosteroids. 

Inhaled long-acting beta-2-agonists
Combination inhalers typically contain one of the long-acting beta-2-agonists below. Each of these medications has a conditional status depending on the dose - this means they are permitted in sport when used up to a maximum threshold which is defined in the Prohibited List, as follows:

• Inhaled formoterol: maximum delivered dose of 54 micrograms (mcg) over 24 hours in divided doses not to exceed 36 mcg over 12 hours starting from any dose
• Inhaled salmeterol: maximum delivered dose of 200 mcg over 24 hours
• Inhaled vilanterol: maximum delivered dose of 25 mcg over 24 hours

A TUE is only required if an athlete’s prescribed dose exceeds the maximum permitted threshold for the specific long-acting beta-2-agonist contained within their inhaler (as described above). The athlete will need to know how many puffs of their inhaler they take a day and how much medication is delivered in each puff, in order to work out if their daily use is below or above the prohibited threshold.

Reliever inhalers contain a short-acting beta-2-agonist medication and they are used when needed to relieve breakthrough symptoms, like wheezing and difficulty breathing (and in some cases they can be used before exercise). In the UK, reliever inhalers typically contain salbutamol or terbutaline.

If an athlete is using their reliever inhaler regularly, they should speak to their healthcare professional to have their asthma control reviewed.

Inhaled salbutamol
Inhaled salbutamol has a conditional status depending on the dose – it is permitted in sport when up to a maximum of 600 micrograms (mcg) is inhaled over any 8-hour period, and total use does not exceed 1600 mcg over 24 hours. A TUE is only required if an athlete exceeds this maximum permitted threshold – for example, during an asthma attack. In this scenario, the athlete would apply for a retroactive TUE as soon as possible after the attack.

It is important that athletes pay close attention to how much they use their salbutamol inhaler to make sure they do not exceed the maximum threshold unless there is an urgent medical need to do so, otherwise their TUE application may get rejected. 

Inhaled terbutaline 
Terbutaline is prohibited in sport at all times regardless of the dose. Athletes who are prescribed a terbutaline inhaler must therefore obtain a TUE in advance of using it (unless exceptional circumstances apply).

It is important that athletes who are prescribed a terbutaline inhaler check with their doctor whether they could instead be prescribed with any alternative beta-2 agonist medications which are permitted in sport (such as salbutamol at doses lower than the prohibited threshold) - otherwise their TUE application may get rejected.

When to apply for a TUE
Athletes who are prescribed a terbutaline inhaler, or who have used their salbutamol inhaler in excess of the permitted threshold, should use UKAD’s TUE Wizard to find out when they need to apply for a TUE, who they need to submit their application to, and how to apply. 

Athletes with asthma should follow these six top tips to help them manage their symptoms and reduce the likelihood of an asthma attack and potential need for medications which are prohibited in sport:

1. Get your asthma formally diagnosed
2. Tell your doctor you have anti-doping obligations as an athlete
3. Use your inhaler in accordance with your prescribed treatment plan and stick to a good routine of taking your preventer inhaler every day
4. Go for an asthma review at least once per year
5. Ask your doctor or pharmacist to check your inhaler technique regularly (for example, when you start or change medication and at your annual review)
6. Know what your asthma triggers are so you can manage the ones you can control

Athletes who experience breakthrough symptoms (such as breathlessness, wheeziness or feeling tight-chested), and who need to use their salbutamol inhaler to relieve their symptoms, should follow the five steps below to make sure they adhere to the anti-doping regulations:

1. Follow the asthma action plan given to you by your doctor
2. Record your symptoms and use of your inhaler(s)
3. If you use your salbutamol inhaler above the maximum permitted threshold, inform your doctor as soon as possible
4. Tell your doctor you have anti-doping obligations as an athlete
5. Submit a retroactive TUE application - use UKAD’s TUE Wizard to find out when you need to apply and who to submit your application to

It is really important that athletes pay close attention to how much they use their salbutamol inhaler so that they do not exceed the maximum threshold unless there is an urgent medical need to do so - otherwise their TUE application may get rejected.

For more information: Athletes who receive treatment with nebulised salbutamol and/or are prescribed a short course of oral glucocorticoids should refer to the Exacerbation of Asthma TUE Guidelines and Infographic found in the special topics section for more information on when a TUE is required and the medical evidence required to support a retroactive TUE application.

Remember: Emergency treatment should never be withheld due to anti-doping considerations. An athlete’s health is the first and foremost priority and their return to play should be considered carefully by their doctor.