Pharmacological management in elite athletes

Elite athletes, who participate in sports that involve endurance training, have a high prevalence of asthma, exercise-induced bronchoconstriction (EIB) and airway hyperresponsiveness (AHR). Such prevalence is even higher when their sport necessitates inhaling large minute volumes of polluted or cold air. Elite athletes should be managed according to international guideline recommendations. Asthma guidelines consider inhaled glucocorticoids (GC) to be the gold standard preventive medication commonly supplemented with a long-acting β-2 agonist (LABA), while a short-acting β-2 agonist (SABA) should be inhaled as rescue therapy and pre-exercise. But elite athletes must heed the World Anti-Doping Agency’s (WADA’s) Prohibited List, and failing to do so could result in significant sanctions. Although many drugs prescribed to manage asthma and related conditions are permitted in sport, others are not or may be prescribed with restrictions. The latter includes salbutamol, the only SABA currently permitted. Systemic GC and adrenaline are prohibited in sport but only in-competition. However, a procedure, termed therapeutic use exemptions (TUEs), allows prohibited drugs to be prescribed to elite athletes when there is genuine medical need. The unpredictable pharmacokinetics of salbutamol and GC has and will continue to cause problems for elite athletes and their medical advisors. These topics are discussed in detail with mention of pitfalls for athletes and some of the potential issues that may arise for those who manage elite asthmatic athletes.