Sports Medicine - Therapeutic use exemption

Dr Chris Jarvis explains the therapeutic use exemption for athletes taking prohibited substances.

Athletes found to have used a prohibited substance or method outlined by the World Anti- doping Agency (WADA) prohibited list face a sanction for breaking the rules of sport.

An athlete who commits a doping violation faces a ban of up to two years for a first offence and a lifetime ban following a second offence.

Olympic skier Alain Baxter forfeited a bronze medal after accidentally taking a banned amphetamine

Legitimate medical use
While all sporting authorities wish to deter the misuse of drugs by athletes, some athletes have genuine medical problems that require treatment with prohibited substances. It was therefore essential that a system was set up to allow athletes to medicinally use prohibited substances in order to compete.

These concerns were first discussed more than 20 years ago.

Initially, ad hoc medical committees were established at various games to review the cases of individual athletes and, where appropriate, give consent to allow athlete participation while taking the necessary, yet prohibited, medication.

The philosophy behind these committees was to provide athletes with medical problems the opportunity to perform on a level playing field.

However, certain medical problems require treatment that can be used to enhance performance. For example, insulin can be misused because of its anabolic properties, but is essential for diabetics.

It is therefore necessary for those taking insulin to demonstrate conclusively that they are bona fide sufferers of insulin dependent diabetes mellitus. Similarly, some patients with ulcerative colitis, for example, will require oral steroids during treatment to prevent exacerbation of their illness.

Therapeutic use exemption
The WADA has recognised the need to monitor the legitimate use of prohibited substances by individual athletes and has produced internationally accepted standards, known as therapeutic use exemptions (TUEs).1

This system includes the concept of an abbreviated and standard TUE application process, which are both administrated by UK Sport, granting athletes from Great Britain and Northern Ireland a limited time period of consent to use prohibited substances.

To maintain the integrity of the TUE process, exemptions are granted for a specific substance rather than for a medical condition.

Recently, Scotland Rugby Union player Scott MacLeod returned an accidental positive drug test for terbutaline. He had an exemption in place for another asthma medication, salbutamol, but was unaware that a new TUE was required when his medication changed.

MacLeod was given a warning and reprimand, and was informed that future violations would lead to a two-year ban.

An even more tragic example was the skier Alain Baxter, who in 2002 made the error of assuming that Vicks inhalers in the US had identical components to those in the UK. Unfortunately, US inhalers contain a banned amphetamine and he forfeited his Olympic bronze medal.

TUE applications
Applications for standard TUEs are submitted by UK Sport to an independent committee comprising three sport and exercise medicine (SEM) physicians.

The decision must be unanimous and if there is any dispute within the committee the application is referred to a separate group of SEM physicians for their consideration.

Should the decision not be forthcoming then the appeal can be passed to the WADA. If that appeal is unsuccessful a final appeal can be made to the Court of Arbitration for Sport.

The TUE committee uses the following criteria:

  • The athlete would experience significant health problems without taking the prohibited substance or method.
  • The therapeutic use of the substance would not produce significant enhancement of performance.
  • There is no reasonable therapeutic alternative to the prohibited substance or method.
  • The necessity for the use of the otherwise prohibited substance or method is not a consequence of prior non-therapeutic use of any substance from the prohibited list.

In the TUE committee's experience, the vast majority of doctors making an application on behalf of their patient fill in the forms adequately. However, problems can arise when providing supportive evidence.

It is essential that copies of hospital letters and/or GP records documenting diagnosis and management are submitted with the formal application. The committee often has to request that these be provided.

Ultimately, this leads to a delay in the process and an athlete could be left waiting.

Emergency situations
There are occasionally situations when a prohibited substance has to be administered in an emergency where there is no opportunity to apply for a TUE or for the committee to consider an application.

This situation is uncommon. However, in such circumstances documentation is essential to justify to the committee the need for treatment.

In these situations it is acknowledged that the athlete's health is the priority and is at the heart of the decision-making process of the TUE committee.

Guidance notes
There are also some applications that cause frequent problems to the committee and among these is the use of steroids administered by injection for hay fever, or orally following the exacerbation of asthma.

To help applicant doctors, details of problematic areas are highlighted with guidance notes on the UK Sport dedicated anti-doping website.

In preparation for Beijing there is also a dedicated micro-site where you can pledge your support for a drug-free games.

Dr Jarvis is a GP in Boscastle, Cornwall, and a medical officer to the Commonwealth Games Council for England and to British Cycling

Many thanks to Nick Wojek and Mike Stow at UK Sport for their suggestions and help in the preparation of this article.



1. The World Anti-Doping Code: International Standard for Therapeutic Use Exemption

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