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by Shane Stokes
December 19, 2017
Photography by Kristof Ramon
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Dr. Conor McGrane has been involved in the sport for many years, and has served as Cycling Ireland’s doctor since 2005. Last year he gave an important interview to CyclingTips, explaining from a medical standpoint why so many elite cyclists have asthma. While he has long expressed strong anti-doping views, he does believe the use of inhalers by many riders is genuine. He also believes that when used correctly, it doesn’t give them any unfair advantages.
However the Chris Froome case is one which is different to the standard use of inhalers. The four-time Tour de France winner was tested after stage 18 of this year’s Vuelta a Espana, and that urine sample was found to contain 2,000 nanograms per millilitre of salbutamol, double the permitted maximum set by WADA.
While Froome has claimed that he didn’t break the rules and that he will prove his innocence, the levels involved are astonishing and may well result in the loss of his Vuelta title plus the imposition of a suspension.
Dr. McGrane spoke in detail about this subject to CyclingTips, talking about the possible reasons for such a high dose, giving a warning of extremely serious health risks and talking about what he believes will happen next.
Read on for that discussion.
CyclingTips: What is your reaction to the Chris Froome news?
Dr. Conor McGrane: Like everybody else, I was a bit surprised and shocked. The levels really stood out for me. From what I have seen reported, his levels were about 2000 nanograms per millilitre in urine, which is massive. It is twice the maximum permitted limit, which is quite a generous limit as well. It is one that was designed to allow people to use it to the maximum with a fair bit of wiggle room at the end, so that they wouldn’t be at the borderline.
Do you have any estimate as to how many puffs of Ventolin would be needed?
It is a little bit hard to say because how much Ventolin you get in depends on how good your inhaling technique is and how long you can hold your breath for. But somewhere between 20-30 puffs would be equivalent to what it is over a 12 hour period.
I was just looking at a research paper in relation to this. There was a study in the academic journal Medicine and Science and Sport and Exercise. They measured urine samples in a number of cyclists and triathletes after giving them very difference dosages of salbutamol. These were from 200 micrograms up to 800 micrograms. 800 micrograms would be eight puffs of your inhaler, which would be the maximum recommended dose.
They found that there was a very significant correlation with hydration levels, but 831 nanograms per millilitre of urine was the maximum they got. And that was a fairly decent-sized study with 37 cyclists. That could give you an idea of what to expect.
So you are saying that you would need at least 20 puffs to reach double the threshold…
At least that, yes.
But it’s important to say that this is not just potentially an anti-doping infraction; having such high levels is actually very bad for you. Overuse of salbutamol is actually associated with an increased risk of sudden cardiac death. So there is a substantial health risk involved too. It is lethal stuff at those sorts of levels.
Do you see any other possible explanation for having such a high amount in the system, other than taking a massive amount of puffs of this substance?
The obvious other way that you would get a very large dose is if someone gets nebulised salbutamol. That is a machine that creates a steam or a mist of a medication that someone can breathe in. It is usually someone with very severe asthma attacks. You can get very high doses in through that.
I don’t know if that has been offered as an explanation, but that is something that could be used. It would more tend to be used in general practice or in casualty departments when people come in with severe asthma attacks. Where they have difficulty speaking and breathing at rest.
I have never seen it used in cycling. To the best of my knowledge, it is not the sort of equipment that most doctors would carry with them as a routine thing on sports events. But it would be a possibility. [Note: during in the Bradley Wiggins ‘Jiffy Bag’ investigation, Team Sky Principal Dave Brailsford claimed that the mystery package contained the legal decongestant Fluimucil. He said that this was administered to Wiggins via a nebuliser, thus suggesting it is, or was, a practice at the team.]
The other way you can get high doses of salbutamol is that it is available as an oral syrup and there are tablets. And it is available as an injection as well.
If Team Sky had decided to nebulise the substance rather than using an inhaler, would that change the dosage that should be administered?
Yes. It is given at a different dosage level because it is delivered by a different method. It is a not a direct equivalent. There are 2.5 and 5 milligram vials that go into the nebuliser.
We were always given the impression that a nebuliser of 2.5 is probably the equivalent of roughly 20 puffs of an inhaler. Again, it depends on how long it is being kept on for, how well you are inhaling it and how deep a breath you are taking. There are an awful lot of variables with it. It is a big dose of it.
But would the doctors be normally expected to know that, okay, we are using this different method and therefore know the precautions that they would have to take to not go over the threshold? Should that be well known?
Yes, it would. I think most doctors would be aware that if you use a nebuliser, that you could push very close to it, if not go over it.
Chris Froome secured his first Vuelta a España victory in 2017, becoming only the third rider in history to complete the Tour de France/Vuelta a Espana double in the same season. That statistic is now under threat as a result of his anti-doping case.
In terms of salbutamol, I understand the issue with high doses is that it is linked to a muscle-building effect over a certain amount…
It is. It is thought that high doses…it is a similar class of drug to Clenbuterol and it is thought that can build up lean muscle mass and maintain muscle mass at very high doses.
The reason it is banned at high doses in sport is for two reasons. One, for the health effect – it is dangerous. And the second is the anabolic effect.
In the past we have had riders like Alessandro Petacchi and Diego Ulissi who had smaller amounts of the substance. They were still over the threshold and they both had long bans. Do you see any way that the same won’t apply to Chris Froome?
As far as I am aware, if you can prove that under the same situation as taking a prescribed dose, which would be eight puffs in a 12-hour period, that your metabolism shows up levels like that, then it is permitted as a once-off.
I presume he is probably going to go down that route, but I am not aware of any cases where that has been proved to be the case. I think every time that has been tried [it hasn’t worked]. I think Diego Ulissi did that trial and didn’t get anywhere near the levels that his failed test showed.
So that potential explanation is a long shot.
And I guess the previous cases do set a sort of precedent as to what could happen if this is upheld… That he would be losing his Vuelta title, losing his world championship bronze medal and probably be sidelined for at least a few months?
Yes, I think that unless they overturn the test, or show that the test was not taken properly – and that is very unlikely, as the officers are very well trained and very meticulous about that. Or unless it is proved that his metabolism is extremely unusual, then yes, he is out from that date onwards and will probably get something between six and 12 months.
It is not considered to be the same level of doping as say, for example, EPO or synthetic testosterone. So a potential four-year ban is probably not going to be mentioned. But I can’t see any situation where he is not going to get some sort of backdated ban.
And I remember from the Alberto Contador case that once you have got a substance in your system that is above a certain limit – in other words, this situation – that the result of the race you were competing in is gone straight away.
Yes. And the principle of strict liability applies in some ways as well. It doesn’t really matter how it got there, it is up to the athletes to make sure that your level is still within the permitted levels.
The normal advised dose for Ventolin is a maximum of eight puffs a day. That can sometimes be exceeded in severe cases. But it is up to the asthmatic, no matter how bad their asthma is, to stay within the limits.
I have no doubt that Chris Froome has asthma, that is pretty much a given. I don’t think anyone would disagree with that. But for someone who has asthma, having a very bad attack means it is difficult to walk up a set of stairs. You are not going to be so strong on a mountain stage.
He was photographed before at a race using an inhaler, so he has gone on record before about having asthma. Presumably there would be…
…There is nothing to be ashamed of, a lot of people have asthma…
Sure, but presumably he has got prior knowledge of the rules in this area.
Yes, he should know. And he also would have been tested multiple times and presumably would have had salbutamol in his system. So he would have an idea that as long as he stays within the dosages, he is not triggering an infraction.
So this wasn’t an isolated use of an inhaler that he might perhaps not have understood. I guess that is going to be something that is going to be considered.
Yes. And you would expect that his doctors would have [known]… The doctors Sky has tend to be highly trained and very well qualified. I can’t see them making massive mistakes with this, because it was in the past one of the most common causes for doping problems.
Former pro Joerg Jaksche suggested that if somebody used a blood bag, and had been using an inhaler at the time when the blood was taken out, that this could be carried over. Is this suggestion unfounded?
I think that would be very, very unlikely. That would be within the grounds of science fiction, rather than a real scenario.
You would have to have an absolutely massive dose of Ventolin the day he gave the blood. And then it would have to stay stable and not degrade over the period of time that it was being kept. It is off the wall, that, I think.
Froome’s positive test is not the first cloud for Team Sky. In fact, over the past 15 months, the team has repeatedly been in the headlines. Like many, McGrane is concerned at what this might mean, and believes the team’s image and credibility has been badly affected.
We have got this Chris Froome case and then everything that happened with Bradley Wiggins plus the jiffy bag. There were changing explanations for what the jiffy bag and who it was intended for, etcetera. How do you feel this makes the team look, that you have had this succession of things in the last 15 months or so?
It certainly doesn’t look good. These are all permitted medications that seem to be pushed to the absolute limit of what is allowed. Certainly the jiffy bag and the use of corticosteroids…it was in my opinion pushing the limit of what the TUE system was designed for. It seemed to be more to maximise a performance within an allergy rather than purely treating the allergy.
Using the level of salbutamol that seems to have been used here was either a very severe attack after the stage before the doping control, or just using unhealthy doses to try to push things to the limit.
It reflects badly on everyone involved, really. And we are not talking about a neo pro here in a Continental team with very minimum backup. You are talking about a team which supposedly has the best sports medicine, the best medical advice that they can get. Basic mistakes like this shouldn’t happen.
And you are also putting the athlete’s health at risk. That has to be a huge matter to be taken into consideration as well.
You mentioned earlier that there have been incidences of sudden cardiac arrest…
Yes, there are higher incidences of sudden cardiac death, arrest, with the over-use of Ventolin. Also, the overuse of Ventolin actually causes asthma to become a bit more unstable as well. It tends to make your asthma very twitchy and very reactive.
It is a sign that long-term preventative medications aren’t being used properly.
There was a line in the Team Sky press release which to me seemed to be about damage limitation. It said, ‘the notification of a test finding does not mean that any rule has been broken.’ Do you know what they mean by that? Surely once you are over that threshold a rule has been broken…
I think it is to do with the fact that there is an allowance that if you can prove under replicated efforts that you have abnormally high levels of salbutamol with permitted dosages, then it is not considered an adverse finding. That is probably what they are getting at there.
But without that in place, it is. It is an adverse finding unless you can prove otherwise.
Do you have any idea why an athlete might potentially have such a high concentration? I mean, in terms of being able to prove that you do have naturally high amounts of salbutamol in the system, what physiological variation would potentially lead to that?
Oh, you are probably talking dehydration, some sort of metabolic disorder in the system. Potentially thyroid issues. It is not something that I have really come across too often. You would have to look at dehydration or some proven effect that you don’t metabolise it quickly.
That showing up 10 years into a professional career after 100 tests or more is [unusual]. This is one of the substances that is tested for in every test. It is not like some of them where they only test them very now and again. Salbutamol levels are checked in every sample that is given.
You say there is a threshold there and they are looking for this in each test that somebody does. Would a rider be informed of the salbutamol level in every test, only if they approach the threshold, or only if they cross the threshold?
It is only if they cross the threshold.
So he may potentially have sailed close to the threshold in the past and not realised that?
He may have, yes, but he certainly wouldn’t have passed it. And this isn’t an 801-level test or a 1002 level test [note: 800 micrograms is the maximum permitted 12-hour intake of salbutamol, while 1000 nanograms/ml is the WADA threshold in urine samples]. It is double the maximum dose.
And I think it is important to remember that the 1000 nanograms of this isn’t the expected dose. It is above the maximum dose that anyone should be using, ever.
So even that WADA threshold is unusual…
Yes. It is not like you should be using Ventolin to the point where you are at 900 nanograms all the time. It is something that should never get to that.