For the past 30 years, asthma treatments in Australia have remained relatively consistent. Mild asthma, where attacks are infrequent, has always been treated with “as needed” doses of salbutamol (Ventolin), which is a short acting beta agonist (a type of stimulant). Inhaled corticosteroids (an anti-inflammatory), often combined with a long acting beta agonist, are usually added for treatment when attacks occur more often, as a “preventer” medication.
However, large trial studies have shown that the overuse of salbutamol, which is cheap and readily available, can actually put patients at a higher risk of flare ups; with some experts even claiming that salbutamol is a “killer“.
Recent evidence shows that using an inhaled corticosteroid, in combination with a long acting beta agonist, is much more effective in controlling asthma flare ups. Traditionally, these combinations have been used only as “preventers”, but the evidence suggests they should be used as a “reliever” treatment too, in order to treat attacks.
Changes to the Pharmaceutical Benefit Scheme (PBS) here in Australia were made on the 1st of June this year which reflect this evidence. Symbicort, which is a combination treatment containing budesonide (a corticosteroid) and eformoterol (a long acting beta agonist), has traditionally been a preventer medication. But now it has been approved for use as a first line treatment for all asthmatics, as both a preventer, and effectively replacing Ventolin as a reliever.
The National Asthma Council will be shortly updating their Asthma Management Handbook to reflect these changes; which also reflect the current recommendations laid out by the Global Initiative on Asthma strategy.
But why is this an issue?
HOW THE CHANGES MAY AFFECT ATHLETES
As many would know, salbutamol is a banned substance. Low inhaled doses are conditionally allowed, as long as no more than 8 puffs over a 12 hour period are used. Cyclists such as Alessando Petacchi and Chris Froome have gotten into hot water in the past for misusing their asthma medication.
Unfortunately, eformoterol, the long acting beta agonist found in Symbicort, is also on the banned list. But like salbutamol, there are a few conditions for it’s allowed use. A maximum of 54mcg are allowed to be taken via inhalation over a 24 hour period; with a urine concentration greater than 40ng/ml considered to be a doping violation.
This is where the new guidelines could cause an issue. The PBS schedule indicates that Symbicort can be supplied for mild asthma, with an approved dose recommending:
1 inhalation when needed for asthma attacks, with no more than 6 inhalations in a single occasion; a total daily dose of up to 12 inhalations can be used temporarily
Symbicort comes in three strengths, with the most commonly used containing 6mcg** of eformoterol. Some quick calculations show that, at the maximum recommended dose, 72mcg of the drug can be taken within a 24 hour period……this is much higher than allowed by the anti-doping regulations.
Eformoterol is banned (with limited conditions for use) both in and out of competition. To put it simply, the recommended maximum dosing schedule could lead to a doping violation. Without having access to lab data, I would even suggest that taking 6 inhalations over a short period of time may put your urine levels over the allowed limits.
WHAT SHOULD ATHLETES DO???
If your doctor follows the new guidelines and recommends that you switch over to Symbicort as a reliever medication, make sure you are aware of the anti-doping rules regarding the use of eformoterol.
Depending on the dose you have been prescribed, it is possible that a maximum of 9 inhalations will take you to the 54mcg per day limit; and as suggested above, 6 inhalations in a short period of time may also push your urine levels quite high….which is something you really shouldn’t be pushing your luck with. Nobody wants to get into trouble for using their asthma medication at the recommended dose.
Monitor your use of the medication carefully, and be aware of any Therapeutic Use Exemption rules which are applicable to you as an athlete.
As long as you pay attention to how often you are using your medication, you should be able to effectively manage your asthma without getting yourself into trouble. Remember, as an athlete, you are responsible for what goes into your body.
**Data suggests that from a 6mcg dose, only 4.5mcg is actually inhaled. But when it comes to drugs in sport, I believe it’s not worth taking any risks at all…..hence I have taken a cautious approach with the numbers in this post!
The Sports Pharmacist 