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Late last year, the Global Initiative on Asthma announced a fundamental change to the way it recommends treating asthma. As pharmacist Darren Searle writes, if you race bikes and you have asthma, you’ll want to take note of how these changes affect you.
For the past 30 years, asthma treatments have remained relatively consistent. Mild asthma, where attacks are infrequent, has always been treated with “as needed” doses of salbutamol (most widely known as Ventolin), a short-acting beta2 agonist (a type of stimulant). When attacks occur more often, a “preventer” medication is often used as well: inhaled corticosteroids (an anti-inflammatory), often combined with a long-acting beta2 agonist.
However, large trial studies have shown that the overuse of salbutamol, which is cheap and readily available, can actually put patients at a higher risk of flare-ups. Some experts even claim that salbutamol is a “killer” — that “numerous asthma deaths occur in those who are using [short-acting beta2 agonists] for relief in increasing quantities but not using [inhaled corticosteroids].”
Recent evidence shows that using an inhaled corticosteroid, in combination with a long-acting beta2 agonist, is much more effective in controlling asthma flare-ups. Traditionally, these combinations have been used only as “preventers”, but the evidence suggests they should be used as a “reliever” treatment too, in order to treat attacks.
On June 1, changes were made to Australia’s Pharmaceutical Benefit Scheme (PBS) — which subsidises the cost of many medications — to reflect this latest evidence. Symbicort, a combination treatment containing budesonide (a corticosteroid) and eformoterol (a long-acting beta2 agonist), has traditionally been a “preventer” medication. But now it has been approved for use as a first-line treatment for all asthmatics, as both a preventer, and effectively replacing Ventolin as a “reliever”.
The National Asthma Council will be shortly updating its Asthma Management Handbook to reflect these changes, reflecting the current recommendations laid out by the Global Initiative on Asthma strategy.
But why is this an issue?
HOW THE CHANGES MAY AFFECT ATHLETES
As you might already know, salbutamol is on WADA’s list of banned substances. Low, inhaled doses are conditionally allowed, so long as no more than eight puffs over a 12-hour period are used. Pro racers such as Alessando Petacchi and Chris Froome have gotten into hot water in the past for seemingly breaching these guidelines.
Unfortunately, eformoterol, the long-acting beta2 agonist found in Symbicort, is also on the banned list. But like salbutamol, there are a few conditions for its allowed use. A maximum of 54 micrograms can be taken via inhalation over a 24-hour period while a urine concentration greater than 40 ng/ml is considered to be a doping violation.
This is where the new guidelines could cause an issue. The PBS schedule indicates that Symbicort can be supplied for mild asthma, with an approved dose recommendation of “1 inhalation when needed for asthma attacks, with no more than 6 inhalations in a single occasion; a total daily dose of up to 12 inhalations can be used temporarily.”
Symbicort comes in three strengths, with the most commonly used version containing 6 mcg of eformoterol. Some quick calculations show that, at the maximum recommended dose, 72 mcg of the drug can be taken within a 24-hour period: much higher than allowed by the anti-doping regulations. Data suggests that from a 6 mcg dose, only 4.5 mcg is actually inhaled (a total of 54 mcg for 12 inhalations — the WADA limit) but it’s certainly worth being conservative in this regard. Taking in any more than 4.5 mcg per inhalation will put an athlete over the allowable limit.
Eformoterol is banned (with limited conditions for use) both in and out of competition. And to put it simply, the recommended maximum dosing schedule could lead to a doping violation. Without having access to lab data, I would even suggest that taking six inhalations over a short period of time may put your urine levels over the allowed limit.
WHAT SHOULD ATHLETES DO?
If your doctor follows the new guidelines and recommends you switch over to Symbicort as a reliever medication, make sure you are aware of the anti-doping rules regarding the use of eformoterol.
Depending on the dose you have been prescribed, it is possible that a maximum of nine inhalations will take you to the limit of 54 mcg per day. And as suggested above, six inhalations in a short period of time may also push your urine levels quite high. This isn’t something you should push your luck with. Nobody wants to get into trouble for using their asthma medication at the recommended dose.
So, be sure to monitor your use of the medication carefully, and be aware of any Therapeutic Use Exemption rules which are applicable to you as an athlete.
As long as you pay attention to how often you are using your medication, you should be able to effectively manage your asthma without getting yourself into trouble. And just remember, as an athlete, you are responsible for what goes into your body.
About the author
Darren Searle is a qualified pharmacist of more than 15 years who has spent his career working in dispensaries of retail pharmacies across Adelaide. Outside of his daily duties as a pharmacist, he is an avid racing cyclist. Beginning his cycling endeavours as more of an irregular recreational activity, his passion steadily grew and he started his racing career at the age of 31. He now trains most days of the week, with a focus on road races and time trials.
Darren is the founder and author of The Sports Pharmacist, a site all about health, medications and sport.