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U.S. Anti-Doping Agency (USADA)

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What Athletes Need to Know About Inhaled Medications: Inhaler FAQ

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Inhaler FAQ

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.

 

Can I use my asthma inhaler in sport?

Metered-dose inhalers that contain glucocorticoids are permitted. However, ALL inhaled beta-2 agonists are either prohibited, or allowed only under a certain dose.

As of 2018, there are three inhaled beta-2 agonists that are permitted under a certain dose:

  • Inhaled albuterol (also called salbutamol): maximum 1600 micrograms over 24 hours in divided doses, not to exceed 800 micrograms over 12 hours starting from any dose;
  • Inhaled formoterol: maximum delivered dose of 54 micrograms over 24 hours;
  • Inhaled salmeterol: maximum 200 micrograms over 24 hours

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

To find out whether your inhaler is permitted in sport, search for the brand (e.g. Advair, ProAir, BREO) 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 fill out the TUE Pre-Check Form to find out if you need a TUE.

 

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.
  • Takeaway: You could take 8 puffs of the albuterol inhaler in a 12-hour period without incurring an anti-doping rule violation.

If you are using a combination product that contains a glucocorticosteroid and a beta-2 agonist, you will probably see two dosage numbers with a slash or a space in between them. There is no limit to how much glucocorticosteroid you can inhale, but the three permitted beta-2 agonists (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 case you would only have to calculate how many puffs you could take of the formoterol.

  • 4.5 micrograms per puff X 12 puffs= 54 micrograms
  • 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?

If you are on a diuretic medication for any reason, then you need a therapeutic use exemption (TUE) for the diuretic and the beta-2 agonist, even if you are using the beta-2 agonist under the permitted dosages. Diuretics affect the way the body metabolizes and excretes beta-2 agonists. A TUE application should be submitted and approval received BEFORE using both medications.

 

What if I use a nebulizer?

If you use a nebulizer instead of a metered dose inhaler, then you might need a TUE. Please fill out the USADA TUE Pre-Check Form and we will advise you whether you need a TUE or not.

 

For more information or assistance, contact USADA’s Drug Reference team at 719-85-2000 x2, or drugreference@usada.org.

 

Last updated 6/18/2019.

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