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Letters to the Editor

Response to the Letter to the Editor

Pitsiladis, Yannis MMedSci, PhD, FACSM; Wang, Guan PhD; Lacoste, Alain MD; Schneider, Christian MD; Smith, Angela D. MD, FACSM; Di Gianfrancesco, Alessia PharmD, PhD; Pigozzi, Fabio MD, PhD

Author Information
Current Sports Medicine Reports: 9/10 2017 - Volume 16 - Issue 5 - p 371-372
doi: 10.1249/JSR.0000000000000405
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As stated by Gerrard et al. (1), representing the WADA Therapeutic Use Exemptions (TUE) Expert Group, “TUE enables athletes with genuine ill-health to compete in fair, equitable competition.” To achieve this undisputed necessity, the outcome of a successful TUE application is the legalization of an illegal substance/method for an athlete, obtained in a manner that ensures confidentiality. Given the equally undeniable fact that athletes wishing to cheat, and those wishing to support them, will go to almost any length, an inevitable consequence of these two facts renders the TUE process the Achilles heel of antidoping.

The misuse of the current TUE process as a “permissive” doping passport (2) is likely when any one of three fundamental principles are violated: (1) an honest athlete, (2) a doctor with integrity/ethics and specialist knowledge of sports and exercise medicine, and (3) transparent and impenetrable system of checks and balances of the overseeing authority (e.g., WADA). The leaks of personal medical records by the “Fancy Bears,” when interpreted in isolation, indeed do not provide evidence that the TUE process has been abused by elite athletes or their medical entourage. Nevertheless, these leaks further undermine the credibility of sport when interpreted in the context of the high-profile doping cases of the past 30 yr, with particular focus on the past 10 yr (3), where doctors also have been at the center of the doping scandals and the antidoping authorities were seemingly powerless to prevent this. Trust in the integrity of sport is understandably at an all time low. A pertinent case is the leaking of the personal medical history of cyclist Bradley Wiggins that included three TUE for the powerful corticosteroid drug, triamcinolone, prescribed before key races in 2011, 2012, 2013 (4)—a case of “permissive doping” or appropriate preventive medical treatment?

Gerrard et al. (1) argue the merits of the current TUE process on the grounds that the standard itself withstood the rigor of scrutiny by the Court for Arbitration in Sport (CAS). Such scrutiny may follow once a healthy athlete will argue being discriminated against by the current TUE system that allows another athlete to use a powerful prohibited drug.

There is much that can be done to help restore sport as a credible brand (3). In terms of the evolution of the TUE process, new ideas, such as more “structured transparency,” may be developed, where obtained TUE are announced per sport per country—the athlete preferably anonymized with the option to be named. Concerns should stimulate further debate on the merits of the practice of providing a TUE for a powerful prohibited drug (e.g., intramuscular corticosteroid injection) in response to an acute medical condition, a drug that allows the athlete to compete. Successful athletes at major championships are not necessarily the most talented athletes but the best-prepared athletes, able to sustain hard training and avoid injury. Therefore, should a powerful prohibited drug be prescribed to allow an athlete to compete? Is this practice compatible with the spirit of sport; one of the three criteria (5) for a substance/method being included on the WADA prohibited list? What research is needed to develop more objective criteria to ensure those authorizing the TUE are confident that the prescribed medication is not enhancing the performance of the athlete above normal levels?

In summary, our intent was not to impugn the TUE process. Quite the contrary, as the opinions of those who authored the article entitled “Make Sport Great Again: The Use and Abuse of the Therapeutic Use Exemptions Process” (2) include well known and respected sports physicians belonging to the Olympic movement, and are consistent with the spirit professed by Gerrard et al. (1). We also encourage discussion and look forward to suggestions for improvement of the TUE process regarding specific medical conditions, not confined only to the medium of symposia but also through peer-reviewed scientific publications, including those that review the athlete’s need for a TUE medication over years, not just for the period of competition.

Yannis Pitsiladis, MMedSci, PhD, FACSM
Collaborating Centre of Sports Medicine
for Anti-Doping Research
University of Brighton
Brighton, UNITED KINGDOM
y.pitsiladis@brighton.ac.uk
Department of Movement
Human and Health Sciences
University of Rome “Foro Italico”
Rome, ITALY
International Federation of
Sports Medicine (FIMS)
Lausanne, SWITZERLAND
Guan Wang, PhD
Collaborating Centre of Sports Medicine
for Anti-Doping Research
University of Brighton
Brighton, UNITED KINGDOM
Department of Movement
Human and Health Sciences
University of Rome “Foro Italico”
Rome, ITALY
Alain Lacoste, MD
International Federation of Sports Medicine (FIMS)
Lausanne, SWITZERLAND
Christian Schneider, MD
International Federation of Sports Medicine (FIMS)
Lausanne, SWITZERLAND
Orthopaedic Center Theresie
Munich, GERMANY
International Bobsleigh and Skeleton Federation (IBSF)
Lausanne, SWITZERLAND
Angela D. Smith, MD, FACSM
International Federation of Sports Medicine (FIMS)
Lausanne, SWITZERLAND
Sidney Kimmel Medical College
Thomas Jefferson University
Philadelphia, PA
Dept of Orthopedics
Nemours/A. I. duPont Hospital for Children
Wilmington, DE
Alessia Di Gianfrancesco, PharmD, PhD
Department of Movement
Human and Health Sciences
University of Rome “Foro Italico”
Rome, ITALY
International Bobsleigh and
Skeleton Federation (IBSF)
Lausanne, SWITZERLAND
Fabio Pigozzi, MD, PhD
Department of Movement
Human and Health Sciences
University of Rome “Foro Italico”
Rome, ITALY
International Federation of
Sports Medicine (FIMS)
Lausanne, SWITZERLAND

References

1. Gerrard D. On behalf of the WADA TUE Expert Group. Letter to the editor. Curr. Sports Med. Rep. 2017; 16:xx.
2. Pitsiladis Y, Wang G, Lacoste A, et al. Make sport great again: the use and abuse of the therapeutic use exemptions process. Curr. Sports Med. Rep. 2017;16:123–5.
3. Pitsiladis Y, Ferriani I, Geistlinger M, et al. A holistic antidoping approach for a fairer future for sport. Curr. Sports Med. Rep. 2017; 16:222–4.
4. Sport Cycling. Bradley Wiggins legacy could suffer because of TUEs. [cited 2017 June 11]. Available from: www.bbc.co.uk/sport/cycling/38593516.
5. World Anti-Doping Agency. 2017 list of prohibited substances and methods. [cited 2017 June 11]. Available from: www.wada-ama.org/en/prohibited-list.
Copyright © 2017 by the American College of Sports Medicine