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Letters to the Editor

The Use and Abuse of the Therapeutic Use Exemptions Process

Gerrard, David

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Current Sports Medicine Reports: 9/10 2017 - Volume 16 - Issue 5 - p 370
doi: 10.1249/JSR.0000000000000404
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Dear Editor,

We, the undersigned, vigorously rebut the inaccurate commentary by Pistiladis et al. which published in the May/June 2017 issue of Current Sports Medicine Reports and impugns the process of therapeutic use exemption (TUE). While the body of the text appropriately highlights the 2016 McLaren Report, systematic state doping, Russian cyber espionage, and breaches of athlete medical confidentiality, the title and conclusion incorrectly infer that the ethos of fair play in sport has been undermined simply through inadequacy of the TUE system. Despite the authors’ contention, the striking feature of the Fancy Bears hack was the complete lack of evidence that the TUE process had been abused by elite athletes or their medical entourage.

In the context of contemporary elite sport, TUE enables athletes with genuine ill-health to compete in fair, equitable competition. And fundamental to this is an International Standard for Therapeutic Use Exemption (ISTUE). To facilitate the clinical implications of the ISTUE, the World Anti-Doping Agency (WADA) is advised by an independent panel of sports physicians with extensive national and international experience. In collaboration with the WADA medical directorate, this TUE Expert group has developed guideline documents to assist physicians in justifying the use of banned substances in treating athletes with documented medical conditions. Regular updates are scrutinized by international specialists in endocrinology, psychiatry, hematology, respiratory medicine, and musculoskeletal medicine, thereby conforming to international best practice. The documents, available on the WADA Web site, assist anti-doping organizations and international federations in evaluating applications for therapeutic use exemption.

By inferring a “…general lack of global consensus on best evidence-based practice in sports medicine…” and “…non-standardized criteria for disease/injury treatment…” the authors reflect poor understanding of anti-doping practice. Equally, to describe the TUE process as a ‘permissive’ doping passport…” and by disparaging the “…Athlete Biological Passport…” they insult the integrity of an initiative evolved through stakeholder consultation and expert scientific input. The authors appear similarly confused by criteria to use prohibited substances including adherence to robust diagnostic criteria and obligatory specialist endorsement.

Any suggestion that independent medical commissions would simplify applications for single clinical entities denies attendant logistics and timely resolution that respects the ailing athlete. In contentious areas of medical management, the existing WADA guidelines represent the collation of international consensus, carefully balancing differences in regional practices yet ensuring a harmonized approach by providing an informed framework for the justified use of prohibited substances. Many of these documents have successfully withstood the rigor of scrutiny by the Court for Arbitration in Sport (CAS).

The suggestion that there needs to be a “… paradigm shift…” in the TUE process from “…political and legal processes…” to a focus on “… the health of the clean athlete…” disregards the integrity of the current process and the athlete-centered approach adopted by the majority of sport physicians.

Claims of a perfect system would be foolhardy and arrogant. For that reason, WADA continues to welcome suggestions for improvement and convenes regular international symposia to encourage discussion on the TUE process and specific medical conditions. The next symposium will take place in Helsinki on September 21 to 22 this year. The TUE process, amenable to updated clinical management, remains a validated instrument to protect the athlete and render equity in sport. Ill-informed commentary is detrimental and unhelpful to all athletes, particularly those challenged by legitimate medical conditions.

On behalf of the TUE Expert Group:

Dr. Katharina Grimm (RSA)

Dr. Ola Ronsen (NOR)

Dr. Katja Mjosund (FIN)

Dr. Susan White (AUS)

Dr. James Kissick (CAN)

Dr. Chin Sim Teoh (SIN)

Dr. John Lombardo (USA)

Dr. Michael Turner (GBR)

David Gerrard
WADA TUE Expert Group

The author declares no conflict of interest and does not have any financial disclosures.

Copyright © 2017 by the American College of Sports Medicine