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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:

  • The number of athletes notifying the IOC of their need to take inhaled beta agonists has greatly increased.
  • Some athletes may have been misdiagnosed and did not have asthma or exercise-induced bronchoconstriction (EIB).
  • Inhaled beta agonists do not appear to be ergogenic at doses required to inhibit EIB; however, oral beta agonists have anabolic effects.
  • Beta agonist use has been skewed geographically and toward endurance sports. (The distribution correlates with prevalence of asthma symptoms in these countries.)
  • Tolerance may result from daily use of inhaled beta agonists, and inhaled corticosteroids may be underused by athletes who are taking inhaled beta agonists.
  • Eucapnic voluntary hyperpnea (EVH) or a field exercise challenge is the best test for confirming EIB in athletes.

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 detailed report of symptoms;
  • Medical records from clinics and hospitals; and
  • A positive bronchodilator test, a positive exercise challenge test in the lab or field, or a positive methacholine challenge test.

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).

Lisa Schnirring
Minneapolis

REFERENCES

  1. Wilber RL, Rundell KW, Szmedra L, et al: Incidence of exercise-induced bronchospasm in Olympic winter sport athletes. Med Sci Sports Exerc 2021;32(4):732-737
  2. Weiler JM, Ryan EJ III: Asthma in United States Olympic athletes who participated in the 192021 Olympic Winter Games. J Allergy Clin Immunol 2021;106(2):267-271
  3. IOC Medical Commission: Beta2 adrenoceptor agonists and the Olympic Winter Games in Salt Lake City. Available at https://www.olympic.org/ioc/e/org/medcom/medcom%5Fintro%5Fe.html, accessed December 3, 2021
  4. Anderson SD, Argyros GJ, Magnussen H, et al: Provocation by eucapnic voluntary hyperpnoea to identify exercise induced bronchoconstriction. Br J Sports Med 2021;35(5):344-347
  5. Rundell KW, Wilber RL, Szmedra L, et al: Exercise-induced asthma screening of elite athletes: field versus laboratory exercise challenge. Med Sci Sports Exerc 2021;32(2):309-316
  6. Rundell KW, Im J, Mayers LB, et al: Self-reported symptoms and exercise-induced asthma in the elite athlete. Med Sci Sports Exerc 2021:33(2):208-213


Field Notes

IOC Study Reveals Tainted Supplements
Initial results from a study ordered by the Medical Commission of the International Olympic Committee (IOC) show that 15% to 20% of the nutritional supplements sampled contain nonlabeled substances that can produce positive doping tests. The preliminary findings, released in September in an IOC press release, came with a warning for athletes to avoid such products.

The Institute of Biochemistry at the German Sports University Cologne is performing the study, which involves analyzing 600 samples of nutritional supplements for anabolic steroids. Half are samples of products from manufacturers that don't produce prohormone products, and half are from those that do. Producing both in the same laboratory may lead to cross contamination. A final report is expected later this month.

Rising Stars in High School Sports
Competitive spirit squads, track and field, and volleyball were the biggest gainers in girls' high school athletics, while for boys the top three fastest-growing sports were track and field, football, and lacrosse. These trends were highlighted in an annual participation survey by the National Federation of State High School Associations.


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