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What Athletes Need to Know About Inhaled Medications: Inhaler FAQ

Last Updated January 1, 2021.
 

Hand holding an orange inhaler on a white background.Athletes are often prescribed medication delivered by inhalers, but for athletes subject to anti-doping rules and drug testing, it’s critical to understand how to use inhaled medications within the rules. Below are frequently asked questions about inhalers in sport, along with answers that will help athletes determine how they can and can’t use inhalers under the rules.

Can I use my asthma inhaler in sport?

Metered-dose inhalers that contain glucocorticosteroids are permitted.

However, ALL inhaled beta-2 agonists are either prohibited, or only allowed under a certain dose.

As of 2021, there are four inhaled beta-2 agonists that are permitted by inhalation under a certain dose:

  • Inhaled albuterol (also called salbutamol): maximum 1,600 micrograms over 24 hours in divided doses, not to exceed 800 micrograms over 12 hours starting from any dose, as long as it is not used in conjunction with a diuretic or masking agent
  • Inhaled formoterol: maximum delivered dose of 54 micrograms over 24 hours, as long as it is not used in conjunction with a diuretic or masking agent
  • Inhaled salmeterol: maximum 200 micrograms over 24 hours
  • Inhaled vilanterol: maximum 25 micrograms over 24 hours

All other beta-2 agonists, regardless of route of administration, are prohibited at all times and at all dosages!

For example, the threshold doses above do not apply to arformoterol or levalbuterol. Athletes using inhalers containing arformoterol or levalbuterol should see the Therapeutic Use Exemption (TUE) section below. 

To find out whether your inhaler is permitted in sport, search for the brand or individual ingredients on GlobalDRO.com.

  • If the status says “Not Prohibited,” then you can use your inhaler as prescribed.
  • If the status says “Conditional,” it means there is a dosage threshold. The Additional Information section on your Global DRO search results will describe the permitted dose.
  • If the status says “Prohibited,” then you should see the TUE section below.

How do I figure out the dosage per puff on my inhaler?

Your inhaler will show the dosage of each active ingredient in milligrams (mg) or micrograms (mcgs). You can use the dosage per puff, and the permitted dose, to calculate how many puffs you can have per day in sport.

For example, for an albuterol (salbutamol) inhaler that delivers 90 micrograms/puff:

  • 90 micrograms per puff X 8 puffs = 720 micrograms
  • From the WADA Prohibited List, the maximum permitted dosage of an albuterol (salbutamol) inhaler is 1,600 micrograms over 24 hours in divided doses, not to exceed 800 micrograms over 12 hours starting from any dose
  • Takeaway: You could take 8 puffs of the albuterol inhaler in a 12-hour period without incurring an anti-doping rule violation, but 9 puffs would exceed the dose allowed over a 12-hour period

Some products contain a combination of a glucocorticosteroid and a beta-2 agonist. There is no limit to how much glucocorticosteroid you can inhale, but the four permitted beta-2 agonists (vilanterol, formoterol, albuterol, and salmeterol) have limits to calculate.

For example, Symbicort is a combination product that contains budesonide and formoterol. It is common to see the dosages (prescription dependent) listed in this format: 160/4.5. One number is the dosage of the budesonide and the other number is the dosage of the formoterol.  If you read the packaging carefully, it will state exactly how much of each ingredient is in each “actuation” (puff, or inhalation).

In this example you only need to calculate how many puffs you could take of the formoterol.

  • 4.5 micrograms per puff X 12 puffs= 54 micrograms
  • Per the WADA Prohibited List, the maximum permitted dose of formoterol is 54 micrograms over 24 hours
  • Takeaway: You could take 12 puffs of Symbicort per day without incurring an anti-doping rule violation.

What if I’m on a diuretic or water pill?

Diuretics affect the way the body metabolizes and excretes beta-2 agonists. If you are on a diuretic medication for any reason and you are using an inhaler that contains salbutamol (albuterol) or formoterol, then you may need a TUE. Please see the TUE section below. 

What if my doctor prescribes an albuterol syrup or tablet?

Use of an oral (swallowed) form of any beta-2 agonist, such as a tablet or syrup, is prohibited at all times and requires an approved TUE. Please see the TUE section below.

What if I use a nebulizer?

If you use a nebulizer instead of a metered dose inhaler, then you might need a TUE. See the TUE section below for more information.

Do I need a TUE for my inhaler?

Based on the prohibited status of your inhaler and your competition level, you may need a TUE.

Any athlete in the Registered Testing Pool (RTP) or the Clean Athlete Program (CAP) who needs to use a prohibited inhaler must apply for a TUE. All other athletes should submit a TUE Pre-Check Form to determine if a TUE is necessary. If you’re unsure if you are an RTP or CAP athlete, please submit a TUE Pre-Check Form.

More questions?

For questions about specific products, substances, and methods, contact USADA’s Drug Reference Line at drugreference@usada.org or call (719) 785-2000, option 2.

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