THE PHYSICIAN AND SPORTSMEDICINE - VOL 30 - NO. 1 - JANUARY 2021
IOC Asks Athletes for Asthma Proof
Request Raises Complex Issues
Written notification is no longer acceptable for Olympic athletes who wish to take inhaled beta2 agonists for asthma. They must now submit clinical proof. When the diagnosis is questionable, the athletes will be required to take on-site airway function tests to assess their need for the medication.
The new rule, adopted in June 2021 when the IOC and the World Anti-Doping Agency finalized the IOC antidoping code, took effect in September 2021 in time for the 2021 Winter Olympic Games. The revised antidoping code allows use of inhaled formoterol and salmeterol (as long as the new rules requiring proof are met).
Why Focus on Asthma?
Rules changes were established in response to several trends involving asthma and the use of beta agonists. In May, the IOC Medical Commission convened a workshop to examine the patterns. The commission concluded that:
Recent studies (1,2) have found that the prevalence of EIB in competitors at the 192021 Winter Games was between 17% and 23%, but as high as 50% in particular sports. The condition was more prevalent in endurance sports, particularly cross-country skiing, and in women (1). Asthma appears to be more common in winter athletes than in those who compete in summer events (2). "There are reasons for that, such as the well-known effect of cold, dry air," says Kenneth W. Rundell, PhD, senior sports physiologist at the US Olympic Training Center in Lake Placid, New York. Other contributors may include fumes from ice resurfacing vehicles and vapors from ski waxing.
The rising number of athletes using inhaled beta agonists leads observers to question if the rule changes address cheating concerns, medical concerns, or both. In its report (3), the IOC Medical Commission did not analyze the possible reasons for the asthma trends. Rundell says cheating is unlikely to be an issue; although some athletes might misuse inhaled beta agonists thinking any drug that's banned must be "good," while others—even some who might need the drug—hesitate to take any medication.
John M. Weiler, MD, an allergist who is a member of the sports medicine service at the University of Iowa in Iowa City, says he believes there may be two types of exercise-induced asthma in athletes: the chronic kind associated with chronic asthma, and the kind associated only with exercise, often with tremendous airway drying and cooling that occurs when world-class athletes push themselves. "If that's true, should asthma associated only with exercise be treated, or is treatment unfair?" he asks. "But in my view, there's no way that this is cheating."
New Workup Expectations
Rundell says he believes the main focus of the IOC's rule changes are to ensure that athletes are appropriately diagnosed. "We have many people coming in for testing who have been diagnosed with asthma, but they have not had pulmonary function tests to appropriately evaluate the condition. The pulmonary function tests are important for identification of chronic inflammation or bronchial hyperreactivity," he says. "We ask them how the diagnosis was made, and the athletes often say they were wheezy and were given a prescription for albuterol." Rundell says after thorough testing, many cases turn out not to be EIA, and in some cases, vocal cord dysfunction or other airway disorder may be the appropriate diagnosis.
The bulk of the IOC Medical Commission's report (3) details how athletes must document their condition. They must submit a notification form from the team or respiratory physician along with:
A medical panel will review each athlete's documentation, and those who have not provided such confirmation must undergo EVH (4) or a field exercise challenge (5). Rundell says these two tests were selected because the intensity of standard exercise testing protocols generally isn't high enough to reproduce symptoms in elite athletes. As a result, there are also concerns that asthma is underdiagnosed in elite athletes.
Exercise challenge testing of elite athletes is controversial among asthma experts. Proponents of EVH believe the test is superior because it is specifically designed to identify EIB and can be modified to reproduce symptoms in athletes. However, those who support use of the field-based test believe that EVH may produce too many false-negatives because the exercise intensity is inadequate for elite athletes. Rundell says false-positives are a problem, too.
Symptoms vs Test Results
Weiler says he's concerned about the new policy's heavy focus on algorithms. "This has been taken to a new level of control," he says. "The IOC is no longer allowing physicians to use judgment in making the diagnosis of EIA," Weiler says. Making an asthma diagnosis is often a challenge because physical symptoms don't always correlate with test results—particularly in active people. He notes that diagnosing asthma relies heavily on a finely tuned sense of intuition that balances test results with physical symptoms. Rundell says testing, however, is crucial because athletes have been shown to be poor at assessing their own symptoms (6).
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