Team Sky TUE controversy: Why one medical expert has real concerns

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In recent days one of the biggest news topics has been the leak by Russian hackers of medical data relating to Team Sky riders Bradley Wiggins and Chris Froome. The so-called Fancy Bears hackers released confidential Therapeutic Use Exemption (TUE) documents relating to the two Tour de France winners, showing the medical substances they had been cleared to use by cycling’s governing body.

Froome’s use of the corticosteroid prednisolone for asthma was previously known. Of greater media interest was the list of substances Wiggins has taken, including inhalers containing Salbutamol plus a combination of Budesonide and Formoterol and, in particular, injections of triamcinolone acetonide (Kenalog).

The latter is a synthetic corticosteroid used to treat allergies and was used by Wiggins prior to his Tour de France campaigns in 2011 and 2012, and his Giro d’Italia ride in 2013.

Given that Wiggins’ autobiography My Time stated that he had not received injections and given that Team Sky stated in the past that it would send a rider home rather than give them TUEs when ill, the information has led to plenty of debate. Had Wiggins been truthful? Had the team stayed true to its claim that it was ethical and transparent?

And, not least, should we be concerned that injected corticosteroids have known performance-enhancing benefits?

One of those who added his voice to the matter on Saturday was South African exercise physiologist Dr. Jeroen Swart.

Swart has long been involved in cycling, racing professionally on the mountainbike circuit after finishing studying medicine, and then becoming a sports scientist. He has worked with cyclists for many years and made headlines in 2015 when he carried out extensive physiological testing on Chris Froome.

Swart concluded that Froome’s data explained his rise to greatness and added legitimacy to the rider’s insistence that he won his Tours clean. He has since defended the rider against questions raised by others on social media and elsewhere.

However on Saturday Swart made clear his unease with Team Sky.

Following those tweets, he spoke at length to CyclingTips and elaborated on his feelings. “I am not comfortable with them trying to say they are a scrupulously clean team that does things by the book and with ethics,” he said.

In the course of the below interview, Swart discusses the TUE situation, the team’s claimed transparency, its hiring of the now-banned doctor Geert Leinders, his views on Bradley Wiggins, and what he thinks the team must do next.

He also explains why, despite his unease about Sky and the TUE leak, he believes Froome actually comes out looking more credible as a result of what has happened.

‘You are not likely to forget an intramuscular injection before every Grand Tour that you have competed in for the win.’

CyclingTips: What is your reaction to what has been happening in the last few days?

Jeroen Swart: As you know, I have always been supportive of Sky. [I’ve been] taking an approach of lack of evidence is evidence of innocence.

But although this isn’t any evidence of any doping practice, it just is a little too far in terms of my comfort with respect to the ethical boundaries of the sport. That is really what it comes down to.

Taken in the context of everything else, there comes a point where that presumption of innocence…well, I can’t say presumption of innocence, because then we are talking about doping…I’m not talking about any evidence to say that they have doped anybody.

But just in terms of them portraying the image of the team as being squeaky clean, cleaner than the rest, leave no stone unturned to do the right thing, this doesn’t fit with that.

Wiggins himself in his autobiography said he had only ever received an injection for an immunisation and some drips. You are not likely to forget an intramuscular injection before every major Grand Tour that you have competed in for the win.

The second aspect is that Triamcinolone acetonide is used to control severe asthma or other allergies that are unresponsive to other forms of treatments.

It is not a first-line therapy and it certainly wouldn’t be something that I would be comfortable giving to a rider as a preventative medicine. So one of two things is going on: either they have prescribed it as a preventative medicine, which doesn’t sit well with me, or he had such serious symptoms that they were completely uncontrollable, and that just happened to happen coincidentally a couple of days before he contested a Grand Tour. And at different times of the season, because the Giro isn’t anywhere near pollen season and nobody suffers from dramatic allergies in the Giro.

So just before you are contesting that for the win, is your asthma so badly flaring up that you need to have an intramuscular injection of a potent corticosteroid?

That doesn’t make [sense]…I stand to be corrected, and maybe the guy was lying in bed coughing and spluttering and sneezing, and needed this just before the Giro and just before the Tour, and then went on to win the Tour. It seemed unlikely. And then you are using it to prevent a flare-up.

But the benefits of corticosteroids are documented. Not only in peer-reviewed scientific manuscripts that have demonstrated statistically-significant performance enhancing effects of corticosteroids in endurance sport. But you have also got the testimony from a large number of riders, ex professionals. David Millar’s testimony in his book. Laurent Fignon when he got diagnosed with cancer. Armstrong admitted to the use of corticosteroids. There are probably dozens of others if you went hunting for them.

The use of corticosteroids as a performance-enhancer in cycling is, from an anecdotal perspective, is very well founded and from a performance perspective in science in competition, definitely evidence is there.

So you are taking a long-acting corticosteroid just before a Grand Tour, and the chances are you can gain a performance benefit out of it.

Michael Rasmussen talked about applying for a TUE to get this injection. He said that Geert Leinders did exactly that for them. He would apply for a TUE for some arbitrary illness, and then inject them with exactly the same substance, Triamcinolone acetonide, just before a Grand Tour.

If they were doing that as a doping practice, now you have Wiggins doing it for his asthma in exactly the same manner and circumstances. It doesn’t look good.

2012 Tour de France winner Bradley Wiggins & 2 & 3

‘Eventually it adds up to a point where you have to say enough is enough’

CT: I spoke to a doctor who has treated cyclists. He said that it is generally discouraged to give these injections due to problems such as osteoporosis and avascular necrosis. He said that oral or an inhaler is much preferred and generally pretty effective.

JS: Yes, you have got the option of using pretty much topical, inhaled or nasal, corticosteroid as you like. I am not aware of a limit on that. You could shove bucketloads up your nose and down your throat and inhale it, and you wouldn’t be doing anything that would end up with systemic effects. And you would be avoiding the interpretation that there is a performance-enhancing effect. From that perspective it doesn’t look good.

And if you add the hiring of Geert Leinders to it and you add a couple of other things together where there has been the odd contradiction of things or things that didn’t seem as kosher as they were trying to portray, eventually it adds up to a point where you have to say enough is enough, I am not comfortable with this any more.

That is where I am at. I am not comfortable with them trying to say they are a scrupulously clean team that does things by the book and ethics. Yes, they haven’t cheated, but it doesn’t sit well with me.

CT: It does seem to contradict what the team said in the past, that they wouldn’t give TUEs. For example, it said that if a rider had asthma, they would rather pull him out of a race than give them such a substance.

JS: Yes, that contradicts their own policy. Okay, you could say, ‘well, we changed policy,’ but you didn’t tell anybody that you had actually done that. That’s not being transparent. Nobody would have been wise to it had they not been hacked and leaked.

CT: Do you feel that team hasn’t been straight with you?

JS: I have had no interactions with the team since 2010. And my interactions in 2010 was when Richard Freeman came to our sports science institute in Cape Town, on a fact-finder looking for elements that they could bring back to the team.

We had a one-day mini conference with many of our top physiologists. He presented their vision of the team and we gave them some input in terms of the research that we had done and things that they might find useful. I visited the team headquarters in I think September 2010, which was after a conference which was in Glasgow. I went straight after that Manchester to basically just say hi and see if there was any interest in any collaborative work. But they didn’t really show any interest. A few people said hi and then I left again.

I haven’t had any formal or informal interaction with the team since 2010, although I did email Richard Freeman back and forward once or twice with John Lee Augustyn’s hip. We were doing surgery on him and helping him. That was the last time that I actually had an interaction with them.

Dr. Jeroen Swart conducting physiological tests with Johan Rabie (Team Bonitas)
Dr. Jeroen Swart conducting physiological tests with Johan Rabie (Team Bonitas)

‘There was nothing untoward or hidden from Chris’ side’

CT: Chris Froome is part of the team. Does this affect your thoughts about Chris?

JS: Interestingly, it actually does the opposite for a number of reasons. One, when those documents were leaked, there was nothing new on Chris. It seems Chris has been completely transparent and open about his TUEs and the documents back that.

There was nothing hidden or untowards from Chris’ side. I think it was David Walsh who wrote that Chris had been offered a TUE for cortisone in 2015 when in the last week of the Tour he was starting to develop a chest infection or an asthma exacerbation, and declined. He rode on without one.

Based on that perspective, he actually comes out looking all the better after this. It is really Wiggins and the team who are having a negative light cast on them. From Chris’ side, it is actually quite positive.

CT: What would you like the team to do now?

JS: Well, that is a difficult question. I think the first thing is just be very open and transparent about it. If they have got nothing to hide and it has all been done above board and there were clear reasons for it, from the outset they should have been very, very transparent about this.

Other than there was a brief statement released from the team, just a couple of words, I think it is a paragraph. In this sort of situation, it just doesn’t seem like the kind of response that is required. I would have liked to have seen an open press conference. ‘Fire away, ask me about anything you want, we will give you the details.’ To hell with the privacy of medical records. I mean, how private can it be that you had an asthma exacerbation, if that’s the case?

It is a disclosed illness anyway. So from a privacy perspective it is not an issue. Be open and be honest, and be ready to answer any question. If you have got nothing to hide, then you should have no problem answering any question. But we haven’t seen that.

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