This guide is intended to provide practical guidance on how the World Anti-Doping Agency (WADA) Prohibited List may affect an athlete. This guide is not intended to be exhaustive, or a substitute for the Prohibited List, therefore it should be read in conjunction with the Prohibited List.
Ultimately, the athlete is solely responsible for the substances in his or her body and the methods used to administer those substances. Athlete support personnel are also liable for anti-doping rule violations if determined to be complicit.
Further information on the topics contained in this guide can be obtained by consulting the references and resources below.
- The 2018 Prohibited List can be downloaded.
- A Summary of Major Changes pertaining to the 2018 Prohibited List is available here.
- Global DRO (GlobalDRO.com) is a searchable online database of ingredients and medications that details the prohibited and permitted status of relevant medications available in Australia, Canada, Japan, Switzerland, the United Kingdom, and the United States.
- Contact USADA’s Drug Reference Department for questions on Therapeutic Use Exemptions at firstname.lastname@example.org or on the status of medications at email@example.com.
- Determine if you need a TUE.
Note: USADA does not provide medical advice or recommendations. An athlete should make all treatment-related decisions with his/her physician, in consultation with the Prohibited List.
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. Any athlete, including elite (Registered Testing Pool) or non-national level (e.g. Masters, juniors, recreational) athletes, can be tested for these substances at any time:
S0. Non-Approved Substances
This “open” section addresses the abuse of pharmacological substances for performance enhancement that are not included in other sections of the Prohibited List. It includes substances that are not approved by any governmental regulatory health authority for human therapeutic use (e.g. drugs in pre-clinical or clinical trials, under development, discontinued, designer drugs, or substances approved only for veterinary use). These substances are prohibited at all times (in-competition and out-of-competition).
- An athlete who wants to participate in clinical drug research trials for drugs that are not yet approved for human use by the FDA should contact AthleteExpress@USADA.org for further information on their prohibited status in sport
- An athlete participating in research projects (academic or otherwise) involving prohibited substances or methods must contact USADA before participation to determine TUE requirements. Generally, TUEs will not be granted for participation in such projects, as use of prohibited substances or methods would not meet the WADA ISTUE criteria.
S1. Anabolic Agents
This category includes the use of any prescription testosterone products such as topical (e.g. Androgel), intranasal (e.g. Natesto), buccal (e.g. Striant), oral (e.g. Andriol), injection, pellet (e.g. Testopel), and/or the use of any other anabolic substances (e.g. DHEA) in any form, including dietary supplements. 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.
- Clenbuterol is sometimes prescribed outside of the U.S. to treat asthma, and 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.
- Clenbuterol may also be found in some products marketed as dietary supplements, and may be marketed as a weight loss drug.
- 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. In 2018, LGD-4033 and RAD140 were added as further examples of SARMs. There have been many instances of products marketed as dietary supplements that contain one or more anabolic agents. 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. It also lists tissue growth and equilibrium related hormones or substances that change hormone levels, the biological response to hormone release.
Erythropoietin-receptor agonists and anything that stimulates erythropoiesis, meaning the production of red blood cells, is prohibited. Also prohibited are hypoxia-inducible factor (HIF) stabilizers and HIF activators, pituitary gland hormones, and many growth hormones and releasing factors. 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).”
Growth hormone (HGH), its fragments or releasing factors, and growth-hormone releasing-hormone are prohibited. Growth factors or their modulators and peptide hormones or their modulators and analogues, including insulin-like growth factor-1 (IGF-1) and corticotrophins, are all prohibited. The WADA definition of growth factors includes 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.”
Chorionic gonadotropin (hCG), luteinizing hormone (LH), and their releasing factors are prohibited for use by men only.
- All Hypoxia-inducible factor (HIF) stabilizers (e.g. Cobalt, molidustat, roxadustat) and HIF activators (e.g., Argon, Xenon) are prohibited.
- Vitamin B12 (also called cobalamin), which contains trace amounts of cobalt, is permitted.
- Non-erythropoietic EPO-receptor agonists are prohibited, and in 2018, this section is divided into subsections to further clarify these substances.
- Some products marketed as dietary supplements claim to contain these substances or boost the release of EPO, IGF-1, and other growth hormones. Peptide hormones, their releasing factors, AND other substances with similar chemical structure or biological effect(s) are prohibited. If such products actually contain what they claim, they are prohibited.
- 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, which depends 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
All beta-2 agonists are prohibited at all times by any route of administration (oral, inhaled, injected), except for:
- Inhaled Albuterol (also called salbutamol) in dosages under 1600 micrograms (mcg) in any 24-hour period taken in divided doses and not to exceed 800 mcg over 12 hours starting from any dose
- Inhaled Formoterol in dosages less than 54 mcg in any 24-hour period
- Inhaled Salmeterol in dosages not to exceed 200 mcg in any 24-hour period
You are required to submit a TUE for use if:
- You use more than these amounts of albuterol, formoterol, or salmeterol.
- You are taking a diuretic medication in conjunction with these inhalers. You must have a TUE for both the diuretic and the inhaler, even if taking less than the threshold.
- You use an inhaler with different beta-2 agonists (like pirbuterol, indacaterol, procaterol, reproterol, terbutaline, fenoterol, olodaterol, vilanterol or any other beta-2 agonist).
The table below is a guide to determine the dosage of albuterol, formoterol, and salmeterol inhaled beta-agonists that may be used in sport without a TUE. However, an athlete should examine his/her inhaler closely to determine the exact dose delivered.
|Examples of Inhaler Brands and Strengths||Recommended Dosing by Manufacturer||WADA MAXIMUM doses per 24 hours|
|Advair Diskus 100/50, 250/50, or 500/50
Each has salmeterol 50mcg per puff
|1 puff twice each day
(=100 mcg salmeterol)
|Do not take more than Salmeterol 200 mcg in 24 hours|
|Advair HFA 45/21, 115/21, or 230/21
Each has salmeterol 21 mcg per puff
|2 puffs twice each day
(=84 mcg salmeterol)
|Do not take more than Salmeterol 200 mcg in 24 hours|
|Albuterol 108 mcg per puff
(dosing 90 mcg of salbutamol)
ProAir, Proventil, Ventolin or levalbuterol (Xopenex) inhaler 45 mcg per puff
|1-2 puffs every 4 to 6 hours as needed for wheezing||Do not take more than 8 puffs in 12 hours|
|Bevespi Aerosphere 4.8/9||2 puffs twice each day
(=9.2 mcg formoterol)
|Do not take more than 11 puffs a day|
|Dulera 100/5 or 200/5
Each has formoterol 5 mcg per puff
|2 puffs twice each day
(=20 mcg formoterol)
|Do not take more than 10 puffs a day|
|Foradil Aerolizer 12 mcg per puff||1 capsule inhaled every 12 hours
(=24 mcg formoterol)
|Do not take more than 4 puffs a day|
|Serevent Diskus 50 mcg per puff||1 puff twice each day
(=100 mcg salmeterol)
|Do not take more than Salmeterol 200 mcg in 24 hours|
|Symbicort 80 /4.5 or 160 /4.5
Each has formoterol 4.5 mcg per puff
|2 puffs twice each day
(=18 mcg formoterol)
|Do not take more than 12 puffs a day|
- Use of oral beta-2 agonists are prohibited even if the athlete has a TUE for the same inhaled beta-2 agonist. If the athlete’s doctor prescribes an oral beta-2 agonist, the athlete should submit an application for a TUE.
- Prohibited Inhalers that require a TUE contain indacaterol, olodaterol, procaterol, reproterol, terbutaline, tulobuterol, vilanterol
- Use of multiple inhaled beta-agonists is permitted, but remains on the Monitoring List.
- Nebulizers use a much greater amount of beta-2 agonists than a metered dose inhaler (MDI), making it possible to exceed the WADA thresholds using a nebulizer device. If you use a beta-2-agonist in a nebulizer, contact USADA to discuss submitting a Therapeutic Use Exemption.
- 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.
- 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.
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 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 affect myostatin. 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. However, these substances are synthesized by clandestine laboratories around the world but are still not approved for human use.
Meldonium, which was added to the Prohibited List in 2016, 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.
- 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.
S5. Diuretics and Masking Agents
Masking agents are prohibited, including diuretics (water pills), desmopressin, probenecid, and plasma expanders, which increase blood volume.
- 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.
- 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. If there is any reason you need to be on a water pill for blood pressure and take an asthma medication at the same time, for instance, please email AthleteExpress@usada.org.
- 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.
- Supplemental oxygen (e.g. breathing an oxygen rich air mixture temporarily, such as on the side-lines) 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 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 in order 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 any substance containing more than 100 milliliters in less than a 12-hour period are prohibited, unless it is administered legitimately during the course of hospital treatments, surgical procedures, or clinical diagnostic investigations.
- 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 not prohibited. For instance, an antibiotic diluted in 100mL and infused every 12 hours, is now permitted.
- TUEs are still required for all IV infusions that exceed this volume when received outside of hospital treatment, surgical procedures, or clinical diagnostic investigations. IV infusions provided outside of a hospital including, but not limited to, on-site event medical services, ambulatory treatment, outpatient clinics, doctors’ or medical offices, home visits, mobile IV clinics, boutique IV clinics, etc., ALL require a TUE and will be strictly evaluated under the ISTUE criteria.
M3. Gene 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.
Substances and Methods Prohibited In-Competition Only
This section focuses on substances that are prohibited in-competition, only. These substances are not tested for through out-of-competition collections.
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 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.
All stimulants and their optical isomers are prohibited, except for clonidine, imidazole derivatives for topical (nasal)/ophthalmic use, and stimulants on the 2018 Monitoring Program (i.e., buproprion, caffeine, nicotine, phenylephrine, phenylpropanolamine, pipradrol, and synephrine).
- 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. All elite-level athletes as defined on the “Determine if you need a TUE” page, should apply for a TUE. An athlete who is not competing does not need to obtain a TUE in order to use these medications.
- An athlete should obtain a TUE if diagnosed with Parkinson’s Disease and taking selegiline, or diagnosed with narcolepsy and taking modafinil or armodafinil.
- Nicotine and caffeine are permitted, but continue to be part of the WADA Monitoring Program.
- Pseudoephedrine is an ingredient in many cold and flu medications.
- 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.
- Levmetamfetamine (nasal inhaler) and racepinephrine (nebulizer) are prohibited in-competition but are found in some cold and flu products. 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.
- Opium, the latex extract of the poppy plant, contains morphine and therefore it is 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, but 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.
- Cannabidiol, including CBD oil, is no longer prohibited. Synthetic cannabidiol is not a cannabimimetic. However, cannabidiol extracted from cannabis plants may contain varying concentrations of THC, which remains a prohibited substance.
- An athlete should be aware that cannabinoids 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 cannabinoid 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 systematic 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).
- 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 these routes of administration shortly before or during competition, he or she must obtain a TUE.
- 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 can help determine clearance. Read the Clearance Time FAQ on the TUE page.
- Injections of glucocorticoids into joints, and epidural spaces (into the spine) are permitted, but an injection into a muscle or tendon is prohibited.
- Inhalation of glucocorticoids (e.g. for asthma) is permitted.
- 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, triamcinolone; however, this is not an exhaustive list
Substances Prohibited in Particular Sports
Some sports have additional rules about the use of beta-blockers. If participating in any of the following sports, please consult the current WADA Prohibited List or Global Drug Reference Online (GlobalDRO.com) before using beta-blockers.
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.