Why do so many top pros have asthma?

As Chris Froome’s salbu­ta­mol case rum­bles on, Cy­clist looks at whether asthma re­ally is com­mon among elite ath­letes, or if it’s a smoke­screen for some­thing more shady

Cyclist - - Lead Out - Words PE­TER STU­ART

Surely asthma suf­fer­ers don’t make top en­durance ath­letes? No, but the truth is there are plenty of rea­sons why cy­cling leads to asthma. ‘Re­search in­di­cates that ex­er­cise-in­duced asthma may be up to five times more com­mon in Olympians than in the gen­eral pop­u­la­tion,’ says Dr James Hull, con­sul­tant res­pi­ra­tory physi­cian at the Royal Bromp­ton Hos­pi­tal and an au­thor­ity on asthma in sports medicine.

Asthma is an in­flam­ma­tion and ir­ri­ta­tion of the air pas­sages in the lungs that causes dif­fi­culty in breath­ing. It’s a se­ri­ous con­di­tion that killed 1,300 peo­ple in the UK last year.

While some peo­ple grow up with what may be termed ‘gen­eral’ asthma, oth­ers en­counter it dur­ing pe­ri­ods of in­tense res­pi­ra­tory strain. The lat­ter is of­ten called ‘ex­er­cise-in­duced asthma’, al­though Hull sug­gests it should be named dif­fer­ently: ‘As 90% of all asth­mat­ics are trig­gered when ex­er­cis­ing, I pre­fer the term “sport asthma” when re­fer­ring to the symp­toms ex­pe­ri­enced by elite ath­letes.’

If rid­ers such as Froome and Wig­gins are gen­uinely asth­matic, what’s the prob­lem?

‘Cyn­ics sug­gest ath­letes are fak­ing symp­toms to take asthma med­i­ca­tion,’ says Dr Jar­rad Van Zuy­dam, physi­cian for Team Di­men­sion Data. While many treat­ments ac­tu­ally of­fer no com­pet­i­tive ad­van­tage, more se­ri­ous con­di­tions (in­clud­ing ‘sport asthma’) may re­quire med­i­ca­tion that’s strong enough to of­fer some ad­van­tage to the ath­lete us­ing it.

What kind of ad­van­tages?

Asthma can be treated with cor­ti­cos­teroids, which in some cases can in­crease en­ergy and im­prove re­cov­ery. Pro rid­ers need a Ther­a­peu­tic Use Ex­emp­tion (TUE) to use them, and it’s the job of the World Anti-dop­ing Agency (WADA) to en­sure the TUE re­quest is gen­uine.

‘We want to make sure a provo­ca­tion test and proper phys­i­ol­ogy vari­ables are pro­vided to us, so we can en­sure proper asthma di­ag­no­sis has been es­tab­lished,’ says Dr Olivier Rabin, head of sci­ence at WADA.

What does this test in­volve?

‘We need to chal­lenge the ath­lete in some way to bring about their symp­toms,’ says Van Zuy­dam. ‘This can be done us­ing chem­i­cals [such as metha­choline] or ex­er­cise.’

First a base­line spirom­e­try test mea­sures lung vol­ume and ex­pi­ra­tion ve­loc­ity. Then the lungs are tested dur­ing ex­er­cise. ‘Ath­letes ex­er­cise at 85% of their max­i­mum heart rate for at least four min­utes be­fore un­der­go­ing a se­cond read­ing. A drop of 10% or more of a mea­sure called FEV1 is con­sid­ered di­ag­nos­tic.’

The re­sult may war­rant a daily ‘pre­ven­ter’ in­haler of cor­ti­cos­teroids.

Is that what Froome took?

No. Froome took salbu­ta­mol, more com­monly known as Ven­tolin and seen in a blue in­haler. Salbu­ta­mol is a bron­chodila­tor that re­laxes the mus­cles in the air­ways, help­ing to re­lieve symp­toms of asthma but not treat­ing it.

‘There are a great num­ber of stud­ies now that in­di­cate that, when taken at nor­mal pre­scribed doses, in­haled salbu­ta­mol does not ben­e­fit ath­letic per­for­mance,’ says Hull.

Rabin at WADA agrees: ‘We’re not go­ing to re­quest a provo­ca­tion test for ev­ery sin­gle ath­lete on a salbu­ta­mol pre­scrip­tion. We know that tak­ing salbu­ta­mol in­hala­tion of 800mg per 12 hours is not per­for­mance-en­hanc­ing.’

So why is Froome fac­ing a po­ten­tial ban?

WADA only al­lows a max­i­mum salbu­ta­mol dosage of 800 mi­cro­grams per 12 hours (or eight puffs), which Froome’s post-race blood test sug­gests he ex­ceeded.

‘We have an up­per limit be­cause we have mul­ti­ple pub­li­ca­tions show­ing that sys­temic use of beta-2 an­tag­o­nists [bron­chodila­tors] in­clud­ing salbu­ta­mol can be per­for­manceen­hanc­ing – they can be an­abolic agents if taken by sys­temic routes,’ says Rabin.

‘Sys­temic routes’ means in­jec­tion or in­ges­tion of a pill, but not an in­haler. These pub­li­ca­tions also rely on stud­ies in­volv­ing rats, not hu­mans. WADA sets the up­per limit on salbu­ta­mol, then, to dis­cour­age ath­letes ex­per­i­ment­ing with, say, in­ject­ing salbu­ta­mol for its an­abolic mus­cle-grow­ing prop­er­ties.

The up­per limit is also in line with the max­i­mum dosages rec­om­mended by phar­ma­ceu­ti­cal com­pa­nies. Those are in place not to pre­vent ath­letes cheat­ing, but to dis­cour­age the use of ex­ces­sive amounts of salbu­ta­mol to man­age asthma when a more pow­er­ful treat­ment is re­quired.

To pre­vent a ban, Froome has to prove that his ad­verse an­a­lyt­i­cal find­ing could have been brought on by a le­gal dose of salbu­ta­mol.

Wouldn’t it be sim­pler to get rid of TUES?

‘I do feel that the process of ap­ply­ing for and be­ing granted a TUE needs to be more trans­par­ent to re­duce the risk of a TUE be­ing abused,’ says Van Zuy­dam. Oth­ers have sug­gested that TUES be re­moved en­tirely and that rid­ers who are sick sim­ply shouldn’t race, but that might be a lit­tle short-sighted.

‘My main con­cern is that if a team doc­tor or coach chooses to keep an ath­lete strug­gling with asthma in a com­pe­ti­tion by us­ing a strat­egy that avoids a TUE, then that ath­lete’s health may be at in­creased risk,’ ar­gues Hull.

In other words, an asthma at­tack at the top of Alpe d’huez could have se­vere con­se­quences and those con­se­quences may well be far worse for the sport than, for in­stance, cy­cling’s great­est star be­ing banned for over-us­ing asthma med­i­ca­tion.

‘When taken at nor­mal pre­scribed doses, in­haled salbu­ta­mol does not ben­e­fit ath­letic per­for­mance’

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