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  • MadBlack

    Great article. But c’mon ‘the team doctor forgot to apply for a TUE???’ Seriously??? If I’m an elite athlete it is solely my responsibility to ensure that I’m compliant with anti doping regulations not my team doctor’s. It’s time cyclists own up to their responsibilities.

    • Warren J

      I’m a Dr studied sports medicine, and while it is the athlete’s career on the line, most doctors would feel medically responsible to advise their athlete patient correctly on the wada status of anything they prescribe, and the doctor needs to sign the TUE I believe.

      • jway18

        Hey Warren, I know this is kind of a weird forum to bring it up in, but I’m a US Med-student studying in Brisbane and was wondering if you knew any cycling/sports docs in the area I could speak with about doing a short observership. Cheers! Jeff

        • Warren J

          Google “sports physician Brisbane” for the main clinics. Hislop, Brown, and Friis are some good names. Not sure of cycling oriented docs in practice but some may mention triathlon.

          Or Google Queensland academy of sport, they may have medical links.

          Good luck.

    • James Powers

      It seems that you’ve commented without reading the article.

      I’ll give you a clue “when Simon Yates was tested in Paris nice in March he marked on the doping control form he was using the substance”

      • MadBlack

        I have read the article. Your clue right here ‘However the Orica-GreenEdge team doctor had apparently forgotten to apply for a TUE…’

        My point is that if it’s my career on the line I would make sure that all paperwork is in order.

        • PsiSquared

          That’s a great position in a perfect world. Alas, we don’t live in a perfect world, and sometimes shit doesn’t happen the way it’s supposed to, and sometimes stuff falls through the cracks. This is true of any human system, including systems fare more strict–i.e. requirement/spec/rules intensive– than cycling.

        • James Powers

          If you force the doctor to sign the form the whole system is useless. It has to be independent. This whole incident shows not how cycling struggles with doping but more how dumb the idiots who follow it to say “I told you they are all doping” are. They really have not got a clue about the real world,

          • MadBlack

            Not entirely sure what you’re on about. Noone said anything about forcing a doctor to sign – not even the article. Merley the doctor should have applied for the TUE but failed. My opinion is, and yes you may beg to differ, that as a PROFESSIONAL the bug stops with the athlete not with the team doctor because ultimately it’s the athlete getting sanctioned/fined not the doctor.

          • Dave

            The team doctor only applies for the TUE on behalf of the rider, the UCI’s panel then assesses it and decides whether to grant the exemption.

            Different processes apply for Sky and Katusha riders.

  • PeteM

    About two years ago I interviewed one of the world’s leading specialists in beta-2 agonists, Dr Glenn Jacobson from the University of Tasmania, just after Diego Ulissi was banned at the 2014 Giro for an adverse finding to the asthma drug, salbutamol. At the time Dr Jacobson was leading a WADA-funded research project seeking to find ways of better differentiating between the therapeutic and non-therapeutic of salbutamol in elite athletes. He said a lot of really interesting things that day. But perhaps most relevantly here, and somewhat contrary to Dr McGrane’s view in the above interview, he explained the concern surrounding the use of asthma drugs wasn’t solely to do with the drug being used for cardio-respiratory issues. I quote Dr Jacobson directly here:

    “To date, most studies have focused on the acute effects (immediately before or during competition) related to cardio-respiratory performance. However if you look at the use of beta2-agonists in the field of primary meat production [clenbuterol is from the same family of drugs] they’re used as repartitioning agents, that is specifically to increase muscle bulk and reduce fat. We believe it’s therefore quite reasonable to presume that oral salbutamol used over a period of time could increase muscle bulk and strength in humans too, hence the project to discriminate between oral and inhaled dosing.”

    Not saying Yates is guilty of anything more serious than an administrative error, but could it be we’re focused on the wrong issue when it comes to the potential overuse of asthma drugs by athletes? WADA pretty clearly felt there was a need to look deeper into it.

    • PsiSquared

      “We believe it’s therefore quite reasonable to presume that oral salbutamol used over a period of time could increase muscle bulk and strength in humans too, hence the project to discriminate between oral and inhaled dosing.”

      That presumption needs a lot experimental support, specifically human data. Many things presumed to work in human in a specific way because these things work that way in animal trials. Many of those things then fail to manifest in human studies.

      • PeteM

        Completely true. Which I guess is why WADA is investing 6-figure sums to find out. I’m no scientist, but having spoken with several people who are, it seems quite reasonable and prudent to at least query the proliferation of salbutamol and terbutaline in cycling, especially given clenbuterol comes from the same family of drugs.

        • Paul Jakma

          From some brief scanning of the literature, your comment seems completely in keeping with scientific knowledge: these 3 drugs all decrease fat and increase protein in skeletal muscle mass in a range of animals. I.e. they help lean and build your muscles. Salbutamol and terabutaline less effectively so than clenbuterol, but they still do.

        • PeteM

          Some more details on Dr Jacobsen’s work at UTAS, plus some additional media links at the bottom of the page. Their work is ongoing.

          http://www.utas.edu.au/health/research/groups/beta2-agonist-enantiomer-clinical-pharmacology

    • Sean parker

      Where do you find oral salbutamol?
      salbutomol is an inhalaled or IV drug. At least in Australia.
      Moreover it is quite sodt acting – which is why terbutaline exists.

      • Alan Doughty

        Oral salbutamol is available in the US, my recollection (sometimes faulty) is that it has a different mixture of optical isomers (more reflecting a different source of raw material than any specific difference in functionality). This is part of the motivation for developing methodology for discriminating the isomers, and the different half lives of the isomers in the body.

    • Neuron1

      These are excellent comments. I see two separate issues here: 1) The use of beta 2 agonists as appropriate anti-asthma drugs and 2) Use of these meds to increase “leanness” and therefore potentially power output. Regarding number one. Yates may have asthma and been using the drug for legitimate purposes. However, if he did not have a TUE for the drug, regardless of the circumstances, he should receive a ban. Why, because many others before him have had the same penalty applied. Consistency is very important in the rule of law and the law says you need a TUE. Regarding two. Levels of the drug are important here. If they are in the “allowable range” and consistent with typical inhaled doses, then ther is an argument for a reduced ban. If they are supratherapeutic, then a longer ban is warranted, as consistent with a doping product. I was saw an interview in the past with Petacchi immediately following a race, he was audibly wheezing and used his inhaler during the interview. He tested positive for elevated levels shortly thereafter. If you don’t sanction Yates, do you give Petacchi back his victories? How do you undo the bans metted out in the past? This is a slippery slope, therefore the rule of law must be blind. Again, I don’t dislike Yates or OGE but you can’t have “exceptions” like this.

  • Warwick

    “So you feel the only way that people who don’t have asthma might be getting a boost is if they are injecting these substances rather than inhaling them?” “Yes”
    I guess this then begs the question; can a positive result for these substances differentiate whether they have been injected or taken orally? If not it would seem a pretty easy way to dope.
    Not suggesting that’s the case with Yates but would make sense as to why to keep them on the banded list.

    • Read another interview today which said that the tests can differentiate between inhaled & injected for these except in the case of terbutaline. Hence terbutaline still requires TUE to show it’s medically ordered/supervised.

  • Vlaamse Dunny Bowl

    Cycling attracts asthmatics because:
    “…it’s a more progressive sport”
    He said it.
    BS waffle indeed

    • dypeterc

      What the fuck is a “progressive sport”?

      • Vlaamse Dunny Bowl

        He’s talking PR shite
        He works for the world cycling body

        • Shane Stokes

          He doesn’t work for the world cycling body. And the clarification you need is above.

          • Vlaamse Dunny Bowl

            ok – on the ‘progression’… But we is not an independent voice… Cycling Federation? = vested interest
            I was ignorant of the specific term usage… hard to believe that factor accounts for the asthmatic predilection

            • Shane Stokes

              He doesn’t have a vested interest. He’s been very outspoken about doping – and Pat McQuaid when PMQ was the UCI president – in the past. Conor is very independent.

              • Vlaamse Dunny Bowl

                I take it you have faith in him…

                I don’t like to be taken as a proponent of the view that “they’re all doping & it’s a conspiracy”
                But
                Being described as a ‘federation doctor’ however indicates vested interest…
                Even Armstrong was outspoken against doping

              • Nathan

                Something is happening to the CTips comments. Looking more and more like Cyclingnews on this issue. I am all for vigorous debate, but it should be informed and undertaken with a degree of maturity and respect that is sadly lacking in some of this articles frequent posters.

      • Saeba R.

        Grow a brain. Although I suspect you know he means because you can go at your own pace etcetera.

        • Vlaamse Dunny Bowl

          Go smarty pants in the sneer down!

          • Saeba R.

            Oh, I’m not saying that I’m smart…

            • Vlaamse Dunny Bowl

              “Oh!”
              Then, in that case: ‘go the troll with the gutless side step’

              • Saeba R.

                Ha! Well you started it!? Since I don’t want to be considered a troll so I’m bowing out…

                • Vlaamse Dunny Bowl

                  You started it! By saying “grow a brain” over the ‘progressive sport’ thing.
                  I’m pleased you bowed out.

        • dypeterc

          Could I get some Ativan to grow my brain. Seems like I have ADD

          • Saeba R.

            If it helps you.

      • Stephen Butler

        “Progressive sport” is that the demand for lung capacity has a gradual increase for output put on it generally from normal and progressing to full capacity not instant demand like a sprinter that is going from a “relaxed” resting demand to a full out sprint demand for lung capacity, which tends to trigger asthma.

      • Vlaamse Dunny Bowl

        They allow gays, lesbians, transgenders and non Christians

      • Vlaamse Dunny Bowl

        And asthmatics… Who are often vilified in other sports like darts

    • Shane Stokes

      Eh…progressive. As in progressive ramping up of efforts, unlike the intensity of, say, 400 metre running.

      • Vlaamse Dunny Bowl

        put like that it’d be a clear link regards sport selection by athletes… But it’s not quite like that is it?
        My brother was an asthmatic… Quite severe
        That’s how I know I have had an asthma attack … But only once in my life. I wouldn’t have known what it was otherwise!
        am I asthmatic?
        Am I entitled to use ventolin et al?
        That depends on perspective & motivation… And ability to justify

        • bugwan

          No, there is a simple test to determine whether asthma is a factor. It’s called Spirometry – basically a measure of ‘peak flow’, which can be severely compromised in asthmatics.

          Elite sportspeople will either know they have asthma, or be diagnosed by a team doctor/GP.

          • Vlaamse Dunny Bowl

            Spirometry aside which could only diagnose in the midst of an attack…
            Umm

            I guess I was alluding to the self diagnosis possibilities (which you seemed to confirm)… And that a mild asthmatic is ‘entitled’ by a TUE to use a PED whether really needing it or not.
            Not a level playing field

            • Will

              As stated above, it’s only a PED if you’re an asthmatic, as it’s restoring you to normality.

  • dypeterc

    If one athlete is a allowed to use an inhaler because they have “athsma”, then everyone should be able to use one and a TUE isn’t necessary. In fact, let’s open the floodgates and let everyone dope away because it seems these elite athletes have some sort or other health problem than needs fixing with “medicine”.

    • Vlaamse Dunny Bowl

      Would that be ‘progressive’?
      Or ‘regressive’?

      Maybe we should have an asthmatics Olympics !
      Shame Sitton can call them HuffyPuffs and be lambasted for it

      • Pete

        He is a competitive bike rider and therefore a cheat by nature.

        • Vlaamse Dunny Bowl

          Ha!
          The desire to win by cunning. Cloak & dagger!
          That (and bicycles themselves) attracted me to the sport away from cycle based multisport ( couldn’t win much there)
          Your assertion rings uncomfortably true?

    • H20

      No, if you can be shown by tests to have a specific medical condition, then you get to use treatment for it. It’s really not that hard.

      • dypeterc

        I get winded and short of breath when I exert myself. I should be rx’ed some inhaler and epo then.

        • H20

          So do the formal medical tests and, if you are formally diagnosed with asthma, get some inhaler. If you are not formally diagnosed with asthma after the standard tests, you don’t have the medical condition so don’t get the medication. It’s really very simple.

          There’s no more of a link between asthma medication and EPO than there is between antibiotics for a leg infection and EPO.

        • bugwan

          Lung capacity tests are extremely simple. You test during an ‘attack’ or during an asthma episode, then again when you’re ok. There is a marked difference between both – I’ve been there and it’s a pretty simple medical diagnosis and subsequent treatment.

          • dypeterc

            If you think that the team doc (conflict of interest) is actually performing these tests I have a bridge to sell you

            • bugwan

              I was just pointing out that they’re easy to do.

              If a pro cyclist has asthma, it would have been identified well before they could ride a bike, in most cases. I’d be interested to know the medical history of riders, but I doubt Yates’ mum is going to hand them over to the CT comments section.

  • PeterM

    Useful info and discussion.

  • Paul Jakma

    Elite athletes have a higher incidence of asthma than the general population? Elite athletes also have a much greater desire to find excuses as to why they would need to take performance enhancing drugs than the general population too..

    • H20

      I’m not elite, but I suffer from asthma more when cycling than at other times, because I’m working harder when cycling. As the article says, it works the same for elite cyclist. It’s no surprise that people who push their lungs to the limit suffer more from a limiting condition affecting the lungs than people who sit on their bums or ride gently.

      • Paul Jakma

        I agree it’s not surprising. However, why should one be allowed to take medicine to “lift a limit” on one’s performance?

        • The easy answer is to ban anyone with asthma from competition. This would be a safer option, unlikely to endanger the athlete.

          • H20

            So we remove 10% of current riders at a stroke? And of course it won’t just be the 10%o of the population that suffers asthma, because to be consistent we’d have to also ban anyone who takes other medication that does not improve performance. How will that help clubs? How will that help the cycling industry? How is that an appropriate response to using medication that does not improve performance to treat a common medical condition?

            By the way, I only get asthma after a bout of other illness, and after being sick I’m not in top racing conditions anyway, so I wouldn’t be affected personally much by a ban on this medication.

            • The quick answer for the sport of cycling is that it would eliminate perceptions in the public that everyone is doping, or that many are faking an illness to get around doping controls. Yes, eliminate 10% of racers, though I think many could fill their ranks. I don’t think this affects amateurs at all, because it’s only addressing professional ranks.

              I don’t have asthma, but I do suffer from a long term illness, and multiple injuries that I need to work around in order to cycle. Even if I would consider competition, if there was a medicine I needed to take, that was on a banned list, and I could not compete without it, then I would be accepting of a ban. I imagine others would want exceptions, but where would anyone draw a line on exceptions? Medical conditions may not keep someone from enjoying cycling, though I have no problem with it keeping people from competing at the top level. The perceptions in public about doping are so prevalent, that a huge portion of the population simply thinks everyone is on something, and that perception needs to change for sport to move forward.

              • Mark

                Note it would effect amateur ranks, given they do in fact test amateur ranks.

                • Thanks for the clarification. My only competition experience was triathlons and running many years ago.

          • Mark

            I ask the same question as I did to Paul Jakma, do you even understand what Asthma is? I’m failing to see the dangers to the athlete who suffers Asthma?

            • I’ve had a few friends over the years with asthma, including one I took to the hospital after he suffered an acute asthma attack. I’m less certain what the difference is with “exercise enduced asthma”, though it would seem to be equally serious. People do die from asthma, so it does not seem to me that situations that could trigger an asthma attack would be beneficial for an athlete. Competition seems to be more of a risk, than it is a therapy or help.

        • H20

          So to be consistent, we must therefore ban other medical interventions designed to “lift a limit on one’s performance.” That means that if you happen to have weaker than normal tendons and injure one, no surgery. If you get an infection that imposes a limit on your performance, no antibiotics – just sit there and suffer because medicine to get rid of the infection will ‘lift your performance’. To take it to the logical limit, if you crash and break a leg, you won’t be allowed surgery to fix the bones and get you back to racing – or at least no surgery unless it can be proved that the injury wasn’t caused by that particular rider having weaker than usual bones.

          Hmmmmm. Doesn’t sound too good. Maybe we should allow the medications that treat common medical conditions but which do no not increase performance above that of a ‘normal’ athlete – like the asthma medication under discussion.

          Asthma is a medical condition that kills almost 400 Australians per year. Taking treatments for it is not like dropping ‘roids.

          • Actually, it would mean not racing when physically injured. Consideration would be given whether racing would risk further injury, or be more likely to result in injury due to impairment of bike handling. We’ve seen injuries being repaired, and racers sitting out while healing. I don’t think someone in physical pain should be given pain control injections in order to compete, because that pain is there to alert someone that they need to give time to heal. I’ve had many orthopedic operations, so I know all too well bad pain and the need for recovery time.

            To contrast, asthma cannot be “fixed” by an operation. It can be controlled through medication. I don’t have any problem with that at all. You seem to be defending asthmatics. I’m trying to suggest a path for professional cycling, a sport with a massively poor perception in the public. Read the comments about Adam Yates on various internet forums, and you will find a huge number of them implying that he was faking his asthma, and purposefully trying to gain an advantage. I don’t agree with that assessment, but how do you get past that?

            • H20

              I’m defending the right of people suffering a common medical condition to lead a normal life. You appear to be ready to sacrifice that for 10% of the overall population and a larger proportion of the pro riders, so that you can say that cycling ignores normal anti-doping rules and ignores medical science.

              Banning asthmatics would probably be a PR disaster, and rightly so. It’s easy to imagine the tear-jerking .interviews with pros cut off from their career because they are not allowed medication that doesn’t make them go faster. The medicos are trying to promote asthma detection and care – they’d probably be aghast. And the 10% of the populace (in some countries) who are asthmatic would probably be appalled at the fact that their condition was being singled out. The cynics would probably just see it as a shonky distraction from real doping issues – which is actually how it comes across.

              You can get past assessments that people are faking asthma for an advantage by referring to medical science that shows they are not, not by making many pros and aspiring pros into sacrificial goats in a move that would be seen as appallingly cynical by many.

              • No performance advantage by faking asthma and taking asthma medications? Then why would some asthma medications be on the banned list at all?

                • H20

                  Well, a quick Google says that the former head of WADA’s prohibited substances committee said it was because if non-asthmatics took them in an attempt to go quicker, they would thereby violate the spirit of sport. Source – the NYT.

                  Another source says that there was concern that the unfounded belief that anti-asthmatics improved performance in non-asthmatics could lead to excessive use, with harmful effects. As Faster Skier blog puts it;

                  “one criteria for prohibiting a medication is that it is detrimental to athletes’ health. This was a concern for WADA – salbutamol has been shown to have tough side effects when used over the long term – as well as the fact that long-term use of ?-2 agonists decreases the drugs’ effectiveness over time.

                  “Inhaled ?2 agonists are the most effective drugs for… relieving intermittent symptoms of asthma,” the IOC’s asthma committee wrote in a 2008 report. “However… athletes who use either short- or long-acting ?2-agonists on a daily basis should be advised that their effectiveness to prevent EIB will partially diminish. Frequent use of ?2 agonists may also increase the bronchoconstrictor response to exercise and allergens. Strategies to avoid these problems could include restricting ?2 agonists to infrequent use…”

                  According to Rundell, who was part of that committee, the consensus by the IOC’s scientists and doctors seems to have had diverged from the rhetoric by its anti-doping leaders.

                  “The reason was not because they provided any type of performance enhancement, but that the athletes thought that they provided performance enhancement,” Rundell told FasterSkier of the drugs’ ban. “Clenbuterol has been shown to do that, but that’s not an inhaler. At any rate, there was rampant use of the bronchodilators, so it was more out of concern for the athletes’ health that they had to provide documentation showing that they had hyper-reactive airways.”

                  There may be other reasons and better reasons (professional investigators and regulators know that for operational reasons you have to be discrete about some things) but it’s easy to find out at least some of WADA’s reasoning.

                  • Seems that there were good reasons to include certain drugs on the banned list, regardless of their effectiveness in treating asthma.

          • Paul Jakma

            Does fixing a tendon increase your performance to higher than before the tendon was injured? Does fixing a tendon require regularly taking a medicine that helps to reduce fat and increase muscle?

            • H20

              Taking asthma medication does not increase your performance to higher than it was before the medical condition was suffered either.

            • Nathan

              And neither does asthma medication. You have shown studies that have found an anabolic effect using large dose of this medication, and you have hypothsised that a similar effect may be linked to the small doses used to treat asthma. At this point you are merely shouting your opinion and should probably stop. You started off sounding quite learned, but now you sound like a guy with an axe to grind.

        • Mark

          Do you even understand what Asthma is?

          • Paul Jakma

            Do you understand we’re talking about exercise-induced asthma?

            • boalio

              So in other words no. You don’t know what asthma is.

              • Paul Jakma

                Exercise induced asthma has a specific trigger. It has it’s own (more difficult) testing protocols. There is a distinction, and if you don’t believe there is, then explain why not. “Oh no it’s not!” – no credibility.

        • H20

          It’s not lifting performance any more than fixing a broken leg is.

    • Mark

      Ok… let’s keep it sensible here first. The article says they drugs in question (unless extreme doses and non standard delivery mechanisms) are not actually performance enhancing…

      • Paul Jakma

        The article is not a review of the scientific literature. My own brief scan of the literature (e.g. using a query of “clenbuterol terbutaline salbutamol muscle” on Google Scholar) suggests that these 3 drugs have similar effects in general, and that salbutamol and terbutaline both can reduce fat and increase protein content in skeletal muscle as clenbuterol is known to – though slightly less effectively.

        I ask again, the message is ringing out from top-level sport to the amateur world that we all should be taking muscle-leaning+building drugs regularly – how on earth is that a good message to send out?

        • If clenbuterol was not a questionable and problematic drug, and “causes no performance advantage” (as claimed by some), then Alberto Contador should be handed back his 2010 Tour de France win.

    • Laquedem

      Of course, Paul, if the drug isn’t performance enhancing, then there is no reason to take it unless you need it to address a medical condition.

      Turns out Yates was using a medication that doesn’t enhance performance in people without asthma, but simply allows a competitor with that condition to breathe normally and to perform accordingly.

  • Paul Jakma

    Is there evidence that EID is actually a medical condition, in the sense that prescribing medicine is the correct response? I mean, lots of parts of the body can start to hurt and degrade under extreme performance. Muscles get sore – why not give them painkillers or anti-inflammatories? Over the course of a stage race, the blood is affected, erythrocytes lifespan decreases and haematocrit decreases – so should athletes be allowed to take EPO to compensate?

    An easy fix to EID is to *reduce effort*. It does _not_ need drugs! So why allow it? And if one athlete is less susceptible to EID than another, isn’t that just genetics? Isn’t that no different than one athlete having naturally better lung capacity or haematocrit than another? Otherwise, why can’t I take EPO to allow me to make up for the the medical fact that my blood cell count isn’t as good as top athletes?

    • Paul Jakma

      The message that seems to be ringing out from pro-cycling out to around the amateur world is “If you’re not taking salbutamol you should be” and that amateurs should be going to their doctor’s complaining of wheezing (while under effort of course) and get pre-scription. Then, later, come back and say the salbutamol isn’t working and get terabutaline. And it’s not just for pulmonary effects, from an initial glance at the literature both salbutamol and terabutaline may have clenbuterol like effects on metabolism to reduce fat and increase relative muscle mass.

      This is an *awful* message being sent out from the top of the sport.

      • H20

        Yeah, the message “10% of the populace should be banned from the sport” is SO much better……

        • Paul Jakma

          So 10% of the populace “banned”, versus 40%+ of athletes taking muscle-leaning+building medication? And no doubt that 40% will increase as the rest of the athletes realise they’re competing against legalised dopers? Is that really better for sport and athletes?

          • H20

            A few posts above you were saying that your brief research “suggests” that these drugs have “similar” results – suddenly you have morphed this into referring to this medication as “muscle leaning+building.” To make a leap from possibilities to apparent certainties to now calling asthmatic pros “legalised dopers”….well, let’s just say this place is becoming like The Clinic at the moment.

            Papers like the 2014 J Physiol one specifically state that there is no clear link between the tested meds and improved sports performance. In the minds of reasonable people, unproven allegations do not equal proof.

            You really want to ban 1 in 10 (and more) people on the basis of logic that leaps from suggestions of similarity in drugs to clear allegations of doping? And you want the UCI to try to defend that sort of ‘logic’ in the court of popular opinion and potentially against legal challenges? And you reckon that will help the sport?And do you want to live in the sort of society that takes away careers because of “suggestions”, because of papers that specifically say there is no clear link between the substance and improved performance, and does all this just as a PR exercise?

            • Paul Jakma

              Are you seriously suggesting there is evidence that salbutamol has tissue-building effects? There appears to be a wealth of evidence that salbutamol has such effects in a range of animals, as clenbutorol does, both being agents acting on similar receptors in the body (though, less effectively than clenbutorol). Why do you think farmers in certain regulation-light countries spend money on these substances? Not for fun.

              Your use of “1 in 10” suggests you’re referring not to EIA but other forms of asthma. No, I am not suggesting banning such users, per se. My concern here is specifically EIA and it being wide-open for abuse, and that the increased and *significant* use of these substances in the peloton will mean others will also feel compelled to take them.

    • H20

      Of course it’s a medical condition, and even the most basic of searches demonstrates that.

      http://www.nhlbi.nih.gov/health/health-topics/topics/asthma

      http://www.healthdirect.gov.au/asthma

      • Paul Jakma

        Exercise-induced asthma is somewhat different from other asthma. The clue is in it having a distinct name. It only occurs with exercise (extreme in the case of top-level sports), and it generally can be resolved without medicine, by not doing the (extreme) exercise.

        • boalio

          It’s not. It’s exactly the same. Exercise is just a trigger. You can asthma that is sometimes triggered by exercise and sometimes by pollen etc.

          It’s not a different disease.

          • Paul Jakma

            So you acknowledge there is a specific trigger, and it’s somewhat different to the triggers of the more common “1 in 10” (as keeps being referred to) group of asthmatics in the population. Thanks.

  • jon

    “…to be honest, there are small studies that suggest everything. You can find a study to prove what you want if you pick one in isolation…it is to bring you back to normal from sub-normal.” This has to be my favorite quote of the article. And it essentially highlighted the issue with our society today. People tend to lose sight of logic and reasoning; trying to beat something to death based on one or few isolated studies is like lynching a person without proper trial. Give it a rest people. Stop giving in to the sensationalism of sports doping, try to embrace the beauty of the sport and move on.

  • Derek Maher

    An inhaler will allow the user to benefit from his or her maximum lung capacity. It will not increase that maximum capacity that’s down to training and genetics.

    • Paul Jakma

      There appears to be evidence in the literature that consistent use of these drugs increases performance. Both in animal studies which show clenbuterol like decrease of fat and increase of muscle, and human studies suggesting increases in performance.

      • Neuron1

        Paul, the effects of terb and salbutamol/albuterol are dose related. Typical inhaled doses, due to minimal absorption and very small quantities, would be very unlikely to have the “leaning” effect. Oral doses which are massively higher and taken over long periods of time are what has been studied for the anabolic effects.

        • Paul Jakma

          Yes, the studies I’ve found are on higher, oral doses that would spread globally and have more systemic effects than an inhaler. And they show dramatic effects. However:

          1. Is there reason to believe that at low doses the muscle leaning+building effect disappears /completely/? It is reasonable to think there may still be some effects?

          2. An athlete could surely take oral doses and ‘manage’ their salbutamol levels to stay up near, but below, the “no-TUE” limit while maximising the anabolic effects – particularly while away from racing?

          From my reading of the literature, to catch oral dosing of salbutomol requires detecting high concentrations output in urine from oral doses immediately after. So this sounds like a case where athletes could play the probabilities game, particularly for off-season.

          • Nathan

            I understand where you are coming from however….. Previous posts of yours suggested you had read the literature and there is a clear anabolic improvement using these drugs. Now you are say, ‘Well yeah, those studies were using huge doses which is nothing like what is inhaled, but hey, it seems to support my conclusions so I’ll go ahead and argue it anyway.’ I was convinced by those earlier posts, but now it just seems like you extrapolating with no real basis or actual knowledge.

            • Paul Jakma

              I have skimmed the literature. There appears to be extensive evidence that these beta-2 adrenergic agonist substances have tissue-building effects in a range of animals. The effects of drugs do not suddenly “switch off” below a certain dose. Rather they attenuate. The lower the dose, the lower the probability the drug will bind to receptors in the tissues. However, it will still happen, and as these are tissue-building effects that can persist without the drug (and again, there seem to be studies suggesting this is quite possible), there could very likely still be effects, particularly with training and time.

              I don’t see studies on exactly what levels of dose have what effects in the long-run on trained humans. However, the onus on demonstrating the “insignificant effect” level of a known muscle-building substance surely *SHOULD NOT* be on those who want a clean sport? For, those are the most *expensive* types of studies, requiring humans and time.

              The onus on showing these PEDs do NOT give noticable performance benefits over time should be on those who claim they must take them for medical reasons!

              FWIW, there *are* animal studies showing significant tissue building effects even at doses *below* the WADA limit (with corrections for body size to equate the animal dose to normal human doses somewhat). E.g.: http://www.sciencedirect.com/science/article/pii/002604959490054X (WADA limit is 1.6 milligrammes/24 hours; that’s around 20 to 24 µg/kg; the paper says their ~1mg/kg/day dose is somewhat equivalent). Also, it seems the studies that show salbutamol have little tissue-building effects tend to be short-term, but that longer term use (even oral) does show effects. See, e.g., this letter to the Lancet: http://www.sciencedirect.com/science/article/pii/0140673692931109.

              So, again, there seems to be a good bit of evidence that salbutamol IS a muscle-tissue increasing substance. There seems to be a wealth of evidence for that. Further, there seems to be evidence suggesting that even at therapeutic-equivalent doses (potentially under the WADA limit) there are noticable such effects (unless I’ve read that paper completely wrong).

              Why must the onus be on the NON-EIA-asthmatics (or their representatives) who would like to err on the side of clean sport, to conduct the most expensive type of human, long-term studies needed to show these *known tissue-building* PEDs do not have effects in athletes training over seasons and using these substances? That’s a ludicrous standard to ask of *athletes*. Hell, given how difficult such studies are to conduct and papers are to publish, that’s a non-trivial standard to ask even of a *scientist working in the field*!

              • Saeba R.

                Hahahaha you ‘skimmed the literature’ did you?

                I’d day you spent two weeks deeply analyzing things you don’t know about in order to pretend to be an expert on a cycling forum…

                • Paul Jakma

                  Scientific research is deliberately written in a structured way that facilitates quick skimming through articles, and deeper diving into the methods, as needed.

                  • Saeba R.

                    So I skimmed what you have been writing, ‘dived into the methods’ a couple of times then came to the the conclusion that you are full of…

                    • Paul Jakma

                      It is fascinating how invested some people are in arguments to authority and ad hominem. Not very productive though.

                    • Saeba R.

                      Paul Jakma you are NOT an authority. You work in the IT field. That is the whole point.

                    • Paul Jakma

                      You do not know how science works.

                    • Saeba R.

                      hahaha I actually studied science and work in the field. But I didn’t study medical science so I know anything about it. #notarrogant

              • Paul Jakma

                Oh, the paper I link to there, their dose is a couple of times above the WADA limit. However, still combined with the fast metabolisation of salbutamol + the issue that substance effects attentuate rather than disappear, the questions on the limit enabling off-season abuse + the question of where the burden of proof on performance-enhancing should lie remain.

  • Medical clearance to compete on a given day, would be one way to control all this. We saw recently with Fernando Alonso not being allowed to compete after a massive crash in Formula 1, due to the potential of an injury becoming far worse under adverse conditions. This is not to diminish the capabilities of Adam Yates, nor anyone else with asthma, but if competition makes a condition worse, it would seem that protecting athletes is not a primary goal of the UCI. People with medical conditions can compete, but should go through additional clearance checks, because that is the safe and ethical thing to do.

    • boalio

      Like a TUE?

      Or are you saying that everyone with asthma (which could be as high as 40% of the peleton), should be checked to see if they think they may have asthma sometime during the day before a race?

      • Perhaps as simple as whether they had an asthma attack during a previous race, or the day before a race. This would be a safety consideration. I’m not certain how tough it is to get a diagnosis of “exercise induced asthma”, as compared to a diagnosis of asthma. That would be another issue. My point is about not putting athletes at risk. We certainly don’t need to have someone collapse or die on a race course, for any reason.

      • Dave

        Perhaps shifting to having riders get off their bike and retire if they are too sick to continue instead of taking corticosteroids would be a step forward.

  • Hamish Moffatt

    “Extends and purposes “?!!

  • Neil

    A sensible, rational, explanatory article really has brought out the Cycling News crowd.

    • Saeba R.

      I wonder if many deep down hope that the scene is full of cheats – feeds a delusion that that is why the couldn’t make it?

      • Dave

        I’m surprised we haven’t yet heard from Du**** R***r, patron saint of the butthurt wannabes.

    • Mark

      The comments on this article make me want to scratch my eyes out and die. Seriously, ban people with asthma from competing…

      • Neil

        Thank you Mark. Far more eloquent than myself. As much as that idea is ridiculous, the tone of some of the comments is terrible. Vlaamese Dunny Bowl, Paul Jakma, Dypertec – I’m looking at you.

        • Mark

          Ha ha… I don’t you’ve misread my comment, but on second reading, my second sentence can be read as if I actually agree to that. I’m trying not to feed the trolls, but being asthmatic myself, who races (a complete hack), and have checked all my medication to see if I need a TUE, I’m personally saddened that people don’t even have a simple understanding of what the problem with asthma is, to begin with. You then need to overlay this against this how the medications works. Sadly reason doesn’t help.

          • Paul Jakma

            EI asthma is not quite the same as general asthma, right?

            • Mark

              Paul you don’t know what you are talking about so please stop now.

              • Paul Jakma

                Ad hominem again. Have you got an actual argument? You are conflating exercise-induced asthma – where the asthmatic episodes are triggered by exercise specifically; with asthma generally, where there could be a wide range of triggers. There’s an obvious way to avoid EIA.

                Further, watching races, it does seem some racers are taking inhalers not because they are experiencing the build-to of an attack, but because they anticipate a high-effort coming up (e.g. start of a hill/mountain). Though, that’s a separate issue to the issue that long-term consistent use of these substances may well have a muscle leaning+building effect.

                • Mark

                  My argument is you have no idea what you are talking about so you need to stop.

                  You are doing 2 min google searches and then adding 2 plus 2 and getting 5.

                  • Paul Jakma

                    I’m reading scientific papers on salbutumol, terabutaline and clenbuterol.

                    • Mark

                      That does not make you qualified to comment. Your comment above is evidence of that.

                      eg. “Further, watching races, it does *seem* some racers are taking inhalers not because they are experiencing the build-to of an attack, but because they anticipate a high-effort coming up (e.g. start of a hill/mountain). Though, that’s a separate issue to the issue that long-term consistent use of these substances *may* well have a muscle leaning+building effect.”

                      I’ve emphasised two simple points. The first “seem”… you are speculating, and have no idea about asthma management. None.

                      The second… “may”… may is not definitive. But geeze I wish it did. A life time of taking these medications and I don’t at all look lean, but I do have muscle.

                      Two plus two does not equal five. But as you seemed to be in support of banning asthmatics from competing, then I say go ahead Dr Google!

                    • Paul Jakma

                      Asthma management is – as I acknowledge – separate from the other issue that these ?-2 agonists have muscle leaning+building effects. There are studies on this. If you’re going to try argue that *your* impression from *your* body is a data-point that I should take seriously and qualifies your knowledge *over* peer reviewed studies in the literature, then you don’t know what you’re talking about.

                    • boalio

                      That’s why there are limits to the amount os Salbutamol. Show me one single piece of evidence that there is a ‘muscle leaning +building effect’ with a standard inhaled dosage.

                      It was talked about and acknowledged in the article that when it’s injected in higher amounts it has an anabolic effect.

                    • Paul Jakma

                      That research, on what level of effect lower doses have over time on humans, has not been done. The issue is: That’s the _most_ expensive type of research to do. Why should the onus be on those who’d prefer to err on the side of clean sport to do that research? Why shouldn’t the onus be on those who want to allow the drugs instead?

                      Basically, from what Conor says, WADA removed TUEs on these drugs not because of any evidence that there was no (or next to no) performance effect at those doses, but just cause many doctors involved in sport found the TUE paperwork annoying and lobbied WADA to remove the need.

                      That really doesn’t sound good.

                      We know _for a fact_ athletes are abusing beta-2 agonists, cause they’re catching people. Even with levels of salbutamol higher than the limit (e.g. Ulissi), and that’s despite it metabolising quickly.

                      What message is this sending to amateur cyclists? To aspiring young riders wanting to make the pro ranks? To the general public?

        • Paul Jakma

          Ad hominem, the classy way to make an argument. Well done.

          • Neil

            Paul, unlike your good self I don’t trawl the internet with the purpose of making an argument. Good day.

      • Neil

        Jules! Michele! We need a considered thought! Help!

      • Paul Jakma

        Versus have ever growing numbers of athletes taking muscle leaning+building drugs?

        I didn’t say all people with asthma should be stopped from competing. I’m just saying the current situation tilts things towards *everyone* having to take beta2-agonists, in order to get a level playing field. How is that better? If there is a way to address this without banning asthmatics, that’s fine. The status quo however is effectively legalised doping, from my (brief/shallow) scan of the literature on the effects of these drugs (and they’d be most useful in training).

  • Lo2

    Conor McGrane is wrong with this statement:

    “There are two medications that are used as immediate relief. Salbutamol and
    Terbutaline. Salbutamol doesn’t need a TUE as long as you don’t exceed a
    certain amount. And, to be honest, you can’t go near that amount using an
    inhaler, unless you are taking 20 to 40 puffs [a day]. You just can’t.”

    He should have looked at this study:
    http://onlinelibrary.wiley.com/doi/10.1002/dta.1828/abstract;jsessionid=CCE77883BBD2C475D4DE0316EB48AE6F.f02t01
    , which shows that you can exceed the salbutamol urinary threshold with a lot
    less than 20 puffs a day.

    And another statement:

    “I have looked into this, researching it last night, and I can’t see any use for
    Terbutaline as a performance boosting drug, other than for people with asthma.
    If you have asthma it will improve things, but if you don’t have asthma that it
    won’t have any effect on you.”

    These studies show performance enhancing effects of terbutaline in non-asthmatics:

    http://www.ncbi.nlm.nih.gov/pubmed/25113095

    http://www.ncbi.nlm.nih.gov/pubmed/26197029

    http://www.ncbi.nlm.nih.gov/pubmed/25344552

    Regarding the Simon Yates case it could be interesting to know his levels of terbutaline
    in serum and urine, since it its relatively well-known that acute high-dose
    intake boost your springting performance.

    Here is a link to an update on the recent research in beta2agonists:

    http://www.multibriefs.com/briefs/acsm/active022316.htm

    • Paul Jakma

      I concur, my own scan of the literature disagrees with Conor’s assessment, as there seems to be a lot of evidence that ?2-agonists lean and build muscle. Which I’d expect would lead to performance increases, even if there’s insufficient human performance studies on that at the moment to make the direct conclusion from.

      • Saeba R.

        Are perhaps some of you confusing your google searches with his medical degree?

        • Paul Jakma

          You havn’t worked in research, have you?

          • Saeba R.

            Not about me mate, I’m not the one pretending to be a medical expert.

            A quick google of your name shows you are an IT nerd… not a doctor nor a biomedical researcher.

            • Paul Jakma

              Well, Conor above is a general practitioner in medicine, not a doctor. Nor do I know of any reason for Conor to be an authority on the effects on performance of broncho-dilators and ?-2 agonists.

              Seriously, scientific research is meant to be written up in a way so that you *don’t* have to take people on authority. That’s the whole point of it. You can go and gather the papers on a particular topic, survey them, and draw your own conclusions.
              Though, annoyingly, a lot of research is locked away behind paywalls – despite it having been produced by publicly funded research – and if you don’t have access to a good University’s library access, you won’t get to read more than the abstract. I have that access at least, I don’t know about Conor.

              • Saeba R.

                So a GP is not a medical expert? And may have no access to medical knowledge?

                Yet on the otherhand anyone with access to journals can be a medical expert.

                Ok. Next time I’m in need of medial advice I will just contact Mr Paul Jakma.

                • Saeba R.

                  BTW Paul what do you think Uni. of Glasgow would think of you using your position (as a an IT research student) to pass yourself off as a medical expert?

                  • Paul Jakma

                    I’m not a student. I passed my doctoral viva last year.

                    Further – *AGAIN* – the whole point of the modern scientific process is that it should NOT RELY ON AUTHORITY. Rather, the point is that it produces documents, which objectively state the case and evidence for a hypothesis, such that any intelligent person can take that document and – in context with other such works on the topic – evaluate the case for themselves. To this end, scientific papers are carefully structured to enable readers to sift through many of them and identify which are relevant, and then further be able to drill down into their context, hypothesis and conclusions.

                    Your obsession with my status and that of Conor McGrane is therefore ridiculous. However, if status does matter to you, note that a General Practitioner in Medicine need only have a Bachelor’s degree in Ireland. That’s not a research degree, and that doesn’t make them a doctor either (in the formal sense). I’m not downplaying the hard work that goes into becoming a medical practitioner, far from, note.

                    Even a doctoral research degree does not make one an authority on anything, but perhaps the *tiniest* sliver of knowledge – of the core of one’s research. However, a doctoral degree /should/ mean the recipient has demonstrated an ability to read through scientific papers, filter out the relevant material, and reason critically about them.

                    So… authority just doesn’t matter. Even if it does, AFAIK Conor doesn’t have a research degree on the effect of beta2-agonists on performance. If anyone needed clinical advice on salbutamol, Conor’s the man to talk to. For the rest, he’s as reliant on reading papers as I am, and I am at least as qualified to read scientific papers as he is (and from sad experience, I know I can use my library access to get up to speed on very specific areas quite quickly, even compared to consultant-level medical specialists).

                    The questions remain:

                    There is *PLENTY* of evidence that salbutamol has significant effects on muscle tissue and fat. If you will only believe Conor, “A lot of these studies are, for example, on animals rather than humans”. He’s not kidding with a “a lot” either.

                    Now, Conor, as a GP, in his medical work will be very sceptical of animal studies for good reason, because medicine needs very definite evidence that a substance has an effect and that the positive effects outweigh the negative, under whatever conditions. This is because medical practitioners carry such “authority” with many, and because of the risks of quackery, and because the stakes are so high.

                    However, the salbutamol limit is quite different. Applying clinical standards of evidence to the question of “Should the burden of proof that a low dose of a known muscle protein increasing and fat decreasing agent be on those who want clean sport?” is – in view – wrong. This is not a clinical medical question! Those who abuse beta-2 agonists – and we KNOW THERE ARE(e.g. Contador with clenbuterol, Ulissi with salbutamol, etc) – are taking it based on the animal study evidence and perhaps semi-anecdotal professional experience.

                    It is WRONG to require that it should be the *clean* athletes (and those who represent them) who must prove that KNOWN muscle-building+leaning agents should be the ones who must prove that lower doses do not improve human performance. For those are the *most expensive* types of studies!

                    Further, if Conor’s view in this article is correct, the WADA limit is based NOT on any good evidence that this limit has no effect on performance, but rather merely on avoiding giving doctors paperwork:

                    “The WADA rules are being constantly revised. We used to have to provide TUEs for Salbutamol and that was a nightmare. Various people in Ireland and the UK repeatedly lobbied WADA to remove Salbutamol from needing a TUE and eventually it was.”

                    That’s _not_ a good approach to building confidence in the system of limiting performance-enhancing agents in sport, in my view.

                    Again, why should the burden of proof for showing that a *known* muscle-building+leaning agent across a wide number of animals doesn’t affect performance below a certain dose, be on those who want clean sport? When that requires the most expensive studies to show? Why should those who do not want PEDs in sport be required to prove that?

                    If you’re big on evidence driven WADA rules, surely it should have been incumbent on the asthmatics to _prove_ the clinical dose didn’t have long-term performance benefits?

                    • Saeba R.

                      http://www.merriam-webster.com/dictionary/doctor

                      The dictionary can also be used to search such other basic job terms as Police, Baker, Train Driver etcetera. Or alternatively you could confer with a preschooler.

                      You are clearly trying to diminish the skills and knowledge of medical professionals. But it is blatantly obvious you do not know what you are talking about. You may have a PHD or whatever in hooking up a modem but the human body is an entirely different beast.

                      When a matter is above a GPs understanding, would they refer you to a specialist in Medicine or a Computer Science expert???

                    • Paul Jakma

                      Again, the obsession with authority. Science *rejects* authority (precisely because humans are so prone to being swayed by authority, even in the face of evidence and logic).

                      If you have evidence, or logical arguments – that do not revolve around your opinions of people – those would be interesting to hear.

                    • Saeba R.

                      Do you honestly believe what you say or are you just trying to win an argument?

                      Are you deceitful, self deluding or just plain stupid?

                    • Paul Jakma

                      Note: When it comes to cycling, weight is as important as power on performance. Even if a study finds no effect on “performance” in terms of power, if weight is reduced then that will improve power:weight and performance on climbs. And beta-2 agonists are _known_ to lean muscle.

                • Paul Jakma

                  If I have a medical problem I’ll go to a GP. However, there’s no reason why a GP would know anymore about a non-medical performance issue than anyone else. Also, I’m not a “Mr.”.

                  • Saeba R.

                    I guess that is the difference between our opinion:

                    I believe that GPs (i.e the doctor – yes that is what they are called) study Medical Science.
                    You seem to think there is some other sort of pathway to becoming a GP where you don’t learn about things like Asthma and how the human body works and responds to medicine etc.

                    Well I wonder who of us is correct?

    • Neuron1

      Fantastic literature search! My research concurs with yours. I find it very interesting that all of this hand wringing did not occur following the Ulissi and Petacchi elevated salbutamol levels. Only when one of their own is implicated. As an anesthesiologist that deals with pulmonary and asthma issues daily, my reading of the experts comments above is that they are not really all that “expert” and not supported by the literature.

  • J Evans

    I’d like to hear opinions of doctors NOT involved with cycling. For once.

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