Athlete Guide to the 2019 Prohibited List
To many athletes, the Prohibited List seems like a long and complicated list of chemical compounds. It can be hard to figure out all the ways the Prohibited List affects you as an athlete.
If you are using any medications at all, a good place to start is by always checking the permitted or prohibited status on www.GlobalDRO.com.
The rest of this page highlights various categories and substances on the Prohibited List that might be relevant for you.
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Substances Prohibited at All Times
(Both In-Competition and Out-Of Competition)
The first section of the Prohibited List discusses substances and methods that are prohibited at all times, both in-competition and out-of-competition. It doesn’t matter what level of athlete you are (elite, pro, masters, junior, weekend warrior) and it doesn’t matter if you are actively competing, just training, or if it’s the off-season for your sport…if you are a member of a sport that is a signatory to the World Anti-Doping Code, then you can be tested for these substances at any time.
S0. Non-Approved Substances
By “non-approved,” WADA is referring to substances that are not approved by any governmental organization anywhere in the world for medical use. This might include drugs in pre-clinical or clinical trials, undergoing research and development, discontinued (taken off the market), designer drugs, or substances approved only for veterinary use.
In order for a substance to be Prohibited under S0, a substance must meet three criteria:
- Be “non-approved” anywhere in the world (as defined above)
- Have the potential to be performance enhancing
- Not fit in other sections of the Prohibited List
What you need to know:
- An athlete who wants to participate in clinical drug research trials should contact AthleteExpress@USADA.org for further information. Depending on whether the substance has the potential to be performance enhancing, athletes might need a Therapeutic Use Exemption before participating in a clinical trial.
- Avoid using any product that says it is a research chemical, or “not for human use”.
S1. Anabolic Agents (Steroids)
Anabolic agents are substances that build muscle and are more commonly called steroids. The list of anabolic agents is extensive and even if one is not specifically listed, it is still prohibited. If it is a metabolite or has “a similar chemical structure or similar biological effect(s)” to anabolic agent, it is prohibited.
What you need to know:
Prescription testosterone is a prohibited steroid. Just because your doctor prescribes it doesn’t mean you can use it in sport. You must first get an APPROVED therapeutic use exemption before using testosterone in sport, or you are committing an anti-doping rule violation.
- Clenbuterol is sometimes prescribed outside of the U.S. to treat asthma. Clenbuterol is considered an anabolic agent by WADA.
- Clenbuterol may be used in other countries to “bulk up” livestock. There is no urinary threshold limit for clenbuterol, meaning the detection of any amount of clenbuterol an athlete’s sample is a positive test.
- DHEA and the related compounds 7-hydroxy-DHEA and 7-keto-DHEA are prohibited in sport as anabolic agents, but they are commonly found in dietary supplements.
- SARMS (selective androgen receptor modulators), such as andarine and ostarine, are prohibited under this category. The unfortunate reality is that some dietary supplement manufacturers illegally put SARMs in their products, and some omit these substances from the label entirely or use misleading names to confuse consumers. For a few examples, see the High Risk List on Supplement411.org. The use of any supplement is at an athlete’s own risk.
S2. Peptide Hormones, Growth Factors, Related Substances, and Mimetics
This section includes substances that increase red blood cell count, blood oxygenation, or oxygen-carrying capacity (like EPO and Hypoxia inducible factors (HIF stabilizers), and other drugs to treat anemia.
Also prohibited are pituitary gland hormones, and many growth hormones, growth factors, and hormone-releasing factors (sometimes called “secretagogues”) and any “other growth factor or growth factor modulators affecting muscle, tendon, or ligament protein synthesis/degradation, vascularization, energy utilization, regenerative capacity or fiber type switching.”
The list of S2 agents is long and even if a substance is not specifically listed, it is still prohibited if it has “a similar chemical structure or similar biological effect(s).”
What you need to know:
- Many drugs in this category are still in clinical trials and are not approved for medical use. However, many unapproved drugs can be purchased on the black market. Make sure to only use approved medications to treat anemia and check the status on GlobalDRO.com.
- Inhaling Xenon or argon is extremely dangerous as well as being prohibited. Please read the Xenon FAQ.
- Cobalt is on the Prohibited List, but there are trace quantities in some foods and vitamins. For example, vitamin B12 (also called cobalamin) contains trace amounts of cobalt, but WADA has clarified B12 is permitted.
- Some products marketed as dietary supplements claim to contain, or boost, the release of EPO, IGF-1, or growth hormones, or they claim to contain growth factors. To be safe, athletes should simply avoid any dietary supplement that claims to contain a prohibited substance no matter what the level. By the same token, athletes should avoid dietary supplements that claim to deliver the same effects as performance-enhancing drugs. Please visit Supplement411.org to learn how to reduce your risk.
- Human chorionic gonadotrophin (hCG) is prohibited in sport at all times for males, but is a Food and Drug Administration (FDA)-approved prescription medication for the treatment of female infertility. It is not approved as a weight loss drug. The FDA warns consumers to avoid “homeopathic” hCG weight-loss products because they are illegal. These are sold in the form of oral drops, pellets, and sprays and can be found online and in some retail stores.
- Even though Platelet Rich Plasma (PRP) contains some growth factors, WADA has clarified that PRP is not prohibited. Be aware, though, that individual growth factors are still prohibited when given separately as purified substances as described in S.2.5.
- Stem cell injections may or may not be prohibited, depending on how the product is manipulated or modified for use. Contact AthleteExpress@USADA.org for specific guidance.
- According to a WADA statement, colostrum is not specifically listed as prohibited; however, these contain certain quantities of IGF-1 and other growth factors that are prohibited and can influence the outcome of anti-doping tests. Therefore, WADA recommends against the use of such products.
S3. Beta-2 Agonists
Beta-2 agonists are used to treat asthma. When inhaled, they relax the muscles in the airways making it easier to breath. Beta-2 agonists are usually inhaled by a metered dose inhaler or by a nebulizing device, but they can also be given orally. Beta-2 agonists can also be mixed with other medications in an inhaler, like corticosteroids.
What you need to know:
All beta-2 agonists are prohibited at all times by any route of administration (oral, inhaled, injected), and require a TUE. The only exceptions are:
- Albuterol (also called salbutamol) by inhalation through a metered-dose inhaler in dosages under 800 mcg over 12 hours.
- Formoterol by inhalation through a metered dose inhaler in dosages less than 54 mcg in any 24-hour period.
- Salmeterol by inhalation through a metered dose inhaler in dosages not to exceed 200 mcg in any 24-hour period.
In order to calculate how many puffs you can have per day, you need to find the medication and dosage on your inhaler and then multiply it by the number of puffs per day you have been prescribed, and then compare that dosage to WADA’s permitted dosage range. As an example, albuterol is commonly delivered in a dosage of 90 micrograms per actuation. You might see “90 MCGs per actuation” or just 90mcgs. This means you are getting 90 micrograms per “puff.” The WADA permitted dosage is 800 mcgs over 12 hours, which means you could use up to 8 puffs in 12 hours and still stay within the permitted dosage range (90mcgs x 8= 720 micrograms).
- If you use albuterol, formoterol or salmeterol by a nebulizer, you need a TUE. Nebulizers use a much greater amount of beta-2 agonists than a metered dose inhaler (MDI), making it possible to exceed the WADA permitted dosages for albuterol, formoterol, or salmeterol.
- If you need to use more than the permitted dosage of albuterol, formoterol, or salmeterol, then you must apply for a TUE.
- WADA has clarified that the purified isomers of albuterol and formoterol, namely levalbuterol and arformoterol, are prohibited at all times and that the permitted dosage thresholds DO NOT APPLY TO THESE PURIFIED ISOMERS. If you are prescribed levalbuterol (Xopenex) or arformoterol (Brovana) you need to apply for a TUE.
- If you are taking a medication that falls into the category of “Diuretics or Masking Agents” on the Prohibited List in conjunction with any beta-2 agonist, then you must have a TUE for both the diuretic and your inhaler, EVEN IF you are using the “permitted dosage” for albuterol, formoterol, or salmeterol as described above. The use of diuretic negates the permitted dosage of these three medications.
- Some dietary supplements claim to contain ingredients that have beta-2 agonist activity, such as higenamine (also known as norcoclaurine). Higenamine is prohibited at all times as a beta-2 agonist. Higenamine is often marketed in dietary supplements as a stimulant and is appearing in a lot of pre-workout or energy products. However, WADA does not consider higenamine a stimulant. WADA has classified higenamine as a beta-2 agonist, which means it is prohibited at all times, both in and out-of-competition. This means you could test positive for using a higenamine-containing pre-workout product out-of-competition (e.g. during training, in the off season).
- The presence in urine of salbutamol in excess of 1000 ng/mL, or formoterol in excess of 40 ng/mL, is presumed not to be an intended therapeutic use of the substance and will be considered as an Adverse Analytical Finding (AAF).
- Some inhalers have more than one active ingredient. Make sure to check all active ingredients on GlobalDRO.com.
- Some cold and flu medications have oral beta-2 agonists in them. Make sure to read the ingredient label for any over-the-counter medication you are using and check the status of each ingredient on GlobalDRO.com.
S4. Hormone and Metabolic Modulators
Hormones and metabolic modulators are a group of substances that are not limited to hormones themselves. This group of substances often modifies how hormones work, either by blocking the action of a hormone or by increasing the activity of a hormone. There are many substances that fall into the category of “Hormone or Metabolic Modulator.” Some of these substances are discussed here.
Aromatase inhibitors are hormone modulators that bind to aromatase and stop it from working. The aromatase enzyme is responsible for synthesizing estrogen in the body by turning testosterone and other androgens into estrogen. Aromatase inhibitors like exemestane, anastrozole, and letrozole are FDA-approved drugs that are used to treat some kinds of breast cancer. Some cancers grow faster in the presence of estrogen. By blocking the synthesis of estrogen there is less estrogen circulating in the body.
Likewise, selective estrogen receptor modulators (SERMs) (like tamoxifen and raloxifene) bind to estrogen receptors in breast tissue and block the effect of estrogen. Athletes in strength sports, or athletes who are trying to prevent the effects of estrogen on their bodies, might abuse aromatase inhibitors or SERMs.
Clomiphene is prohibited at all times as an anti-estrogenic substance. A selective estrogen receptor modulator (SERM), clomiphene is used in female fertility brand name prescription medications, such as Clomid. In women, clomiphene acts on the pituitary gland to stimulate the release of specific hormones responsible for ovulation. In men, clomiphene can alter testosterone levels by interfering with the negative feedback loop of the hypothalamic–pituitary–gonadal axis. Clomiphene is not FDA-approved for use by men for any condition and TUEs are unlikely to be granted to men who receive off-label prescriptions for clomiphene.
Another group of metabolic modulators are agents that prevent activin receptor IIB activation.
Myostatin is a growth factor that controls and limits the amount of muscle a person makes. Myostatin inhibitors (substances that block the action of myostatin) can cause an increase in muscle mass. A number of experimental compounds that modify myostatin are being evaluated to treat muscle wasting diseases, but there are currently no FDA-approved medications that modulate myostatin.
Other metabolic modulators include substances that affect how the body processes energy. For example, substances that mimic the effects of insulin can change how the body processes sugar, causing a person to burn more or less glucose. Insulin is also anabolic (muscle building), so substances that mimic the effects of insulin could build muscle.
Substances that activate AMP-activated protein kinases, for example AICAR, show promise in protecting cells against oxidative damage during stroke or in certain diseases like diabetes. Similarly, substances that activate peroxisome proliferator activated receptor modulators (PPARs) like GW1516, GW0742, L1655041 are experimental drugs under study to treat diabetes, lipid disorders, and metabolic syndrome. AMP-activated protein kinases and PPARs are experimental drugs with no approved medical use at this time. Despite not being approved for human use, these substances are synthesized by clandestine laboratories around the world.
Meldonium is a drug registered for use in some Baltic countries, but it is not approved for use in the U.S., Canada, or Western Europe. Meldonium has very long urinary excretion times so it is especially difficult to estimate clearance times for this substance.
All of the substances discussed in this section are prohibited in sport at all times. Please consult the Prohibited List for more examples of substances this class.
What you should know:
- An athlete diagnosed with insulin-dependent diabetes is required to submit a TUE for use of insulin.
- Female athletes using clomiphene for fertility purposes must submit a TUE before use.
- Many of substances in this category are sold on body building or steroid websites as dietary supplements or as products that say they are “for research purposes only” or “not for human use.” In addition to being prohibited in sport, such products can pose serious health risks. Athletes are advised not to use such products.
S5. Diuretics and Masking Agents
Masking agents are prohibited, including diuretics (water pills), desmopressin, probenecid, and plasma expanders, which increase blood volume.
What you should know:
- WADA has clarified that drospirenone, pamabram, carbonic anhydrase inhibitors used as eye drops (dorzolamide and brinzolamide), and the local administration of Felypressin for dental anesthesia are permitted.
- Spironolactone is sometimes prescribed for acne, but it is a prohibited medication. Please read more on spironolactone.
- Hydrocholorothiazide is a commonly prescribed diuretic. It is often abbreviated as HCTZ and prescribed in combination with other medications (for example, lisinopril). Make sure to check all of your medications on GlobalDRO.com, and when searching GlobalDRO.com, make sure to also search for abbreviated terms, like HCTZ, to find out if they stand for a prohibited medication.
- The use of any amount of a threshold substance (i.e., albuterol, cathine, ephedrine, formoterol, methylephedrine and pseudoephedrine) at the same time as a diuretic or other masking agent requires a TUE for the threshold substance AND the diuretic/masking agent. This means two TUEs are needed.
- Some dietary supplements that claim to be “natural” water pills may contain prescription diuretics that are not listed on the label. The use of any dietary supplement is at the athlete’s own risk. For a few examples, see the High Risk List on Supplement411.org.
Methods Prohibited At All Times
(Both In and Out-of-Competition)
M1. Manipulation of Blood and Blood Components
Blood doping, the use of red blood cells from any source, or otherwise artificially enhancing the uptake, transport, or delivery of oxygen, is prohibited. Any type of intravenous (IV) manipulation of the blood or blood components by physical or chemical means is prohibited. This also means that blood or portions of a person’s blood cannot be reinjected.
What you should know:
- Supplemental oxygen (e.g. breathing an oxygen rich air mixture temporarily, such as on the sidelines) administered by inhalation is permitted.
- Use of hyperbaric or hypobaric tents is permitted. Similarly, training or sleeping/living at high altitudes is permitted. Cryogenic chambers for whole body cryotherapy are permitted.
- Hemodialysis is prohibited under M1.1, as blood is taken out from the patient (in a closed circuit) and reintroduced into the circulatory system. An athlete needing this treatment requires a TUE.
- Whole blood donation, when no blood is returned to the donor, is permitted.
- Donating plasma or plasmapheresis (when the rest of the blood components are reinjected into the donor) is prohibited for the donor because the donor’s own red blood cells and other blood components are being reintroduced into the circulatory system after the plasma has been separated. Please see the WADA FAQ.
- Intravenous laser therapy, such as ozone therapy and/or ultraviolet light therapies, which includes the removal, treatment, and manipulation of blood or blood components, are prohibited.
M2. Chemical and Physical Manipulation
Tampering or attempting to tamper with a collected sample to affect its integrity or validity is prohibited. This includes providing synthetic urine or urine that is not the athlete’s own, or any modification of the urine sample, such as addition of proteases.
Intravenous infusions and intravenous injections of more than 100 milliliters in less than a 12-hour period are prohibited, unless they are administered legitimately during the course of hospital treatments, surgical procedures, or clinical diagnostic investigations.
What you should know:
- In an emergency, an athlete should always receive appropriate medical care. If the emergency medical providers insert an intravenous line or provide medications as a life-saving procedure, the athlete should later request copies of all the clinical documentation for the diagnosis, the decision to start the IV, and the amount of fluid administered. Once the emergency is over, the athlete should contact USADA to determine if a TUE is required.
- The use of IV infusions in place of, or in addition to, oral fluid intake, such as to relieve dehydration caused by gastrointestinal distress during travel, without hospitalization, is prohibited and requires a TUE. Also, WADA clarified “the use of IV fluid replacement following exercise to correct mild dehydration is not clinically indicated nor substantiated by medical literature.”
- Small volume intravenous injections (less than or equal to 100 mL per 12 hours) are permitted as long as the substance delivered is permitted. For instance, an antibiotic diluted in 100mL and injected intravenously is permitted, as long as no more than 100mLs of fluid is administered intravenously in a 12-hour period.
- TUEs are still required for all IV infusions that exceed 100mLs in 12 hours when received outside of hospital treatment, surgery, or clinical diagnostic investigations. “Boutique” or “concierge” IV infusions, “hang-over cure” IV infusions, IV drips, vitamin IV infusions, mobile IV infusion units, ambulatory treatment by IV infusions, or IV infusions receive in outpatient clinics, medical offices, or home visits ARE ALL PROHIBITED and require a TUE.
M3. Gene Doping & Cell Doping
With the potential to enhance sport performance, the use of polymers of nucleic acids or nucleic acid analogues, or the use of normal or genetically-modified cells is prohibited. Gene editing technology designed to alter genome sequences and/or the transcriptional or epigenetic regulation of gene expression, in both germ line and somatic cells, such as CRISPR/Cas 9, are also prohibited when they have the potential to enhance performance.
Substances and Methods Prohibited In-Competition Only
This section focuses on substances that are prohibited in-competition only. These substances are not tested for out-of-competition.
It is very important to understand the definition of “in-competition.” Knowing how the sporting event defines the “in-competition” period is the athlete’s responsibility. Each International Federation (IF) may have a different definition and it may vary by event. For some events, this period may be defined as 12 hours before the start of the competition and different rules may apply to multi-day events (e.g, the Olympic Games).
An athlete must ensure that all substances prohibited in-competition have been completely cleared from his/her body before an event period. This means the substances are not detectable in the athlete’s sample. It is not possible for USADA to list specific stop times to ensure clearance for substances prohibited in-competition. If the on-going or daily use of a substance is needed, or the medication cannot be stopped before an event long enough to allow it to clear from the body, an application for a Therapeutic Use Exemption (TUE) should be submitted. The best way to start this process is by filling in the TUE Pre-Check form. After filling in this form, USADA will notify you if a TUE is needed.
All stimulants and their optical isomers are prohibited, except for clonidine, imidazole derivatives for topical/ophthalmic use, and stimulants in the Monitoring Program.
What you should know
- An athlete who has been diagnosed with Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD) and is taking stimulants should apply for a TUE for their medication.
- Some medications used to treat Parkinson’s and/or narcolepsy are prohibited in-competition. If you are taking medications to treat these conditions, make sure to check the status on GlobalDRO.com and apply for a TUE if necessary.
- Some non-drowsy or 24 hour cold and flu medications contain Pseudoephedrine, which is prohibited in-competition.
- WADA advises athletes to discontinue taking the standard daily dose of 240mg or less of pseudoephedrine AT LEAST 24 HOURS prior to the time defined as “in-competition.” Be advised, in some cases, such as slow metabolism or drug interactions, this may not be enough time for the medication to clear the body. USADA recommends avoiding pseudoephedrine-containing cold and flu products for several days in advance of competition.
- If you need to be on a diuretic for any reason, and you also need to use a medication that has pseudoephedrine in it, you need a Therapeutic Use Exemption for BOTH the diuretic and pseudoephedrine.
- There are many novel and designer stimulants in dietary supplements. Please check all ingredients on GlobalDRO.com and Supplement411.org to find out if they are prohibited.
- Levmetamfetamine (nasal decongestant inhaler), ephinephrine (inhaler), and racepinephrine (nebulizer) are prohibited in-competition but are found in some cold and flu products, as well as products used to treat mild breathing difficulties. Read the label of your cold and flu, or allergy product, carefully and check the active ingredients on GlobalDRO.com.
- Common cough, cold and flu active ingredients are in the label below.
Certain narcotics are prohibited in-competition: Buprenorphine; Dextromoramide; Diamorphine (heroin); Fentanyl and its derivatives; Hydromorphone; Methadone; Morphine; Nicomorphine; Oxycodone; Oxymorphone; Pentazocine; Pethidine (meperidine). Use of these narcotics in-competition requires an approved TUE.
What you should know:
- Opium, the latex extract of the poppy plant, contains morphine and is therefore also prohibited. Poppy seeds can contain trace amounts of opium.
- Several of these narcotics are made as extended-release or slow-release products and will take longer to clear from the body.
- Codeine, hydrocodone, and tramadol are in the Monitoring Program and are currently permitted.
The following cannabinoids are prohibited:
- Natural cannabinoids, e.g. cannabis, hashish and marijuana
- Synthetic cannabinoids, e.g. Δ9-tetrahydrocannabinol (THC) and other cannabimimetics
What you should know:
- Please read the detailed educational articles on THC and marijuana.
- Cannabidiol is not prohibited. However, cannabidiol extracted from cannabis plants may contain varying concentrations of THC and other cannabinoids, all of which are still prohibited. Please read our educational article on CBD.
- An athlete should be aware that THC may be retained in fat tissue following frequent, repeated use and may be detected weeks after use. Also, significant weight loss over a short-period of time has caused THC metabolites stored in fat to be released in detectable levels, even if not used recently. USADA strongly advises athletes not to consume cannabinoids at any time.
- An athlete who chooses to consume hemp products may be at risk for a positive anti-doping test, even though many of these products claim not to contain THC.
While the use of medical marijuana may be decriminalized in some states, it is still illegal under federal law. USADA will consider a TUE application for medical marijuana, but only for certain conditions as per the WADA TUE Physician Guidelines for Neuropathic Pain and ISTUE criteria.
The systemic use of glucocorticoids (often also called “steroids” by prescribers) is prohibited in-competition. WADA defines systemic routes as oral intake (taken by mouth and swallowed, such as prednisone or Medrol Dose Pack), a systemic injection into the vein (IV) or muscle (IM), or rectal use (e.g. suppositories or inserted creams).
What you should know:
- An athlete who is prescribed oral, rectal, IV, or IM glucocorticoids may take these medications out-of-competition without submitting a TUE, as long as the prohibited substance has cleared their system prior to the time defined as “in-competition.”
- If an athlete needs to use corticoids by a systemic route (intramuscular, oral, rectal, or intravenous) shortly before or during competition, he or she must obtain a TUE.
- If you are not sure if you need a TUE or not, based on your competition level or clearance time or the corticosteroid, please fill out a TUE-Pre-check form.
- The time it takes for glucocorticoids to clear from an athlete’s body depends on many variables and cannot be predicted by USADA. An athlete’s doctor or pharmacist may help determine clearance times, but make sure to read the Clearance Time FAQ on the TUE page. Doctors and pharmacists often refer to the half-life of a drug, but this is different from the clearance time of the parent compound and metabolites.
- Injections of glucocorticoids into joints, tendons, and epidural spaces (into the spine) are permitted, but an injection into a muscle is prohibited.
- Inhalation of glucocorticoids (e.g., for asthma) is permitted. Make sure your inhalation technique is good, and that you are not swallowing the product. If you’re not sure if your inhalation technique is good, consult your physician.
- Topical use of glucocorticoids (e.g., anti-rash cream, hemorrhoid creams used on the surface, etc.) is permitted. Be aware, however, that some hemorrhoid suppositories or inserted rectal creams contain glucocorticoids and are prohibited in-competition.
- In 2018, the following were added as examples of prohibited glucocorticoids: betamethasone, budesonide, cortisone, deflazacort, dexamethasone, fluticasone, hydrocortisone, methylprednisolone, prednisolone, prednisone, and triamcinolone. However, this is not an exhaustive list. Make sure to consult GlobalDRO.com or the WADA Prohibited List for any corticoid you are prescribed.
Substances Prohibited in Particular Sports
Beta-blockers (including, but not limited to atenolol, bisoprolol, carvedilol, esmolol, labetalol, metoprolol, propranolol, sotalol, and timolol) are prohibited for the following sports:
- Prohibited at All Times (in-competition and out-of-competition): Archery, Shooting
- Prohibited In-Competition Only: Automobile, Billiards, Darts, Golf, Skiing/Snowboarding in ski jumping, freestyle aerials/halfpipe and snowboard halfpipe/big air, and Underwater Sports as specified.