Sports Medicine

Our top health tips for Sports Medicine are outlined below.

The World Anti-Doping Code, published by the World Anti-Doping Agency (WADA), harmonises anti-doping regulations across all sports and in all countries. The Prohibited List of Substances and Methods is one of the International Standards that are mandatory for all signatories of the Code. The List is a list of substances and methods which are prohibited in sport. Some of these substances are contained in medicinal products marketed in Ireland. However, in recognition of the fact that some prohibited substances may be necessary for legitimate medical treatment, the Code permits athletes and their physicians to apply for a Therapeutic Use Exemption (TUE).

Sport Ireland Therapeutic Use Exemption (TUE) Policy

If a medication is prohibited and requires a TUE, athletes should first seek to use an alternative permitted treatment. If there is no permitted alternative athletes should adhere to the Sport Ireland TUE Policy which states that athletes on the Sport Ireland Registered Testing Pool must apply for a TUE before using the substance (a Pre-Test TUE); athletes not on the Registered Testing Pool may take the substance, and if required, apply for a Post-Test TUE, but should ensure that a medical file* for use of the medication is in place. Athletes who compete at an International Level or who are on their International Federation Registered Testing Pool should check and comply with the TUE requirements of their International Federation.

*Medical file: See Glossary of MIMS Ireland.

Athletes should be advised to declare the use of all medications and supplements taken in the 7 days prior to the drug test on the doping control form (regardless if they have completed and submitted a TUE).

Full details, TUE Application Form and guidelines on the TUE Policy are available at

www.sportireland.ie/anti-doping/athlete-zone/athlete-zone/therapeutic-use-exemptions

Summary of the WADA 2020 Prohibited List

Substances and Methods Prohibited In- and Out-of-Competition

Prohibited Substances

S0 Non-Approved Substances: Any pharmacological substance which is not addressed by any of the subsequent sections of the List and with no current approval by any governmental regulatory health authority for human therapeutic use (e.g. drugs under pre-clinical or clinical development or discontinued, designer drugs, substances approved for veterinary use only) is prohibited.

S1 Anabolic Agents are prohibited. Examples include danazol, testosterone, stanozolol, tibolone and selective androgen receptor modulators (SARMs).

S2 Peptide Hormones, Growth Factors, Related Substances, and Mimetics:

The following substances, including other substances with similar chemical structure or similar biological effect(s) and their respective releasing factors are prohibited:

• 1 Erythropoietins (EPO) and agents affecting erythropoiesis including, but not limited to:
  • 1.1 Erythropoietin-Receptor Agonists, e.g. Darbepoetins (dEPO); Erythropoietins (EPO); Methoxy polyethylene glycol-epoetin beta (CERA);
  • 1.2 Hypoxia-inducible factor (HIF) activating agents, e.g. Cobalt; Daprodustat; Molidustat; Vadadustat; Xenon, etc. Vitamin B12 is not prohibited;
• 2 Peptide Hormones and their Releasing Factors:
  • 2.1 Chorionic Gonadotrophin (CG) and Luteinizing Hormone (LH) and their releasing factors are prohibited in men-only, e.g. buserelin, deslorelin, gonadorelin, leuprorelin, nafarelin and triptorelin;
  • 2.2 Corticotrophins and their releasing factors;
  • 2.3 Growth Hormone (GH), its fragments and releasing factors including Growth Hormone Secretagogues (GHS), e.g. lenomorelin and GH-Releasing Peptides (GHRPs), e.g. alexamorelin etc.
• 3 Growth Factors and Growth Factor Modulators including, but not limited to:
  • Fibroblast Growth Factors (FGFs); Hepatocyte Growth Factor (HGF); Insulin-like Growth Factor-1 (IGF-1) and its analogues; Mechano Growth Factors (MGFs); Platelet-Derived Growth Factor (PDGF); Thymosin-b4 and its derivatives e.g. TB-500; Vascular-Endothelial Growth Factor (VEGF) and any other growth factor affecting muscle, tendon or ligament protein synthesis/degradation, vascularisation, energy utilisation, regenerative capacity or fibre type switching.

S3 All Beta-2 Agonists are prohibited except:

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

To use any other inhaled beta-2 agonist, including terbutaline, indacaterol, vilanterol, olodaterol, formoterol (at delivered doses >54µg over 24 hours), salmeterol (at doses >200µg over 24 hours) and salbutamol (at doses >1600µg over 24 hours or >800µg over 12 hours; such as by nebuliser), an athlete must adhere to the TUE Policy paying particular attention to the requirements of a medical file*. Formoterol is declared in terms of the delivered dose e.g. a Turbohaler device labelled as containing 6µg of formoterol delivers 4.5µg. Check the specific delivered dose of the device when calculating formoterol doses.

S4 Hormones and Metabolic Modulators such as aromatase inhibitors (e.g. exemestane, formestane, letrozole), selective oestrogen receptor modulators (SERMS, e.g. bazedoxifene, raloxifene, tamoxifen, toremifene), other anti-oestrogenic substances (e.g. clomifene, fulvestrant), agents preventing activin receptor IIB activation, including myostatin inhibitors and metabolic modulators including insulins and insulin mimetics and trimetazidine are prohibited.

S5 Diuretics and Masking Agents: Diuretics (furosemide; spironolactone; thiazides, etc., including substances with a similar chemical or biological effect), desmopressin, probenecid, plasma expanders (e.g. IV administration of albumin, dextran, hydroxyethyl starch and mannitol, etc.), vaptans (e.g. tolvaptan) are prohibited. Note: Drosperinone, ophthalmic use of carbonic anhydrase inhibitors (e.g. dorzolamine, brinzolamide) and local administration of felypressin in dental anaesthesia are permitted.

The detection in an Athlete’s Sample at all times or In-Competition, as applicable, of any quantity of the following substances subject to threshold limits: formoterol, salbutamol, cathine, ephedrine, methylephedrine and pseudoephedrine, in conjunction with a diuretic or masking agent, will be considered as an Adverse Analytical Finding unless the Athlete has an approved TUE for that substance in addition to the one granted for the diuretic or masking agent.

Prohibited Methods

M1 Manipulation of blood and blood components by (1) the administration or reintroduction of any quantity of autologous, allogenic (homologous) or heterologous blood or red blood cell products of any origin into the circulatory system, (2) the use of products that enhance the uptake, transport or delivery of oxygen e.g. modified haemoglobins, or (3) any form of intravascular manipulation of the blood or blood components by physical or chemical means is prohibited. Supplemental oxygen, by inhalation, is not prohibited.

M2 Chemical or physical manipulation such as tampering or attempting to tamper to alter the integrity and validity of a sample such as sample substitution and/or adulteration (e.g. addition of proteases to sample) is prohibited.

IV infusions and/or injections of more than 100ml per 12- hour period are prohibited and require a TUE except for those legitimately received in the course of hospital treatments, surgical procedures or clinical diagnostic investigations. Emergency infusions will require a retroactive TUE.

M3 Gene and cell doping.

Substances and Methods Prohibited In-Competition

Prohibited Substances

S6 Stimulants including their related substances and their optical isomers are prohibited. Examples include amfetamine, lisdexamfetamine, modafinil and pseudoephedrine at urinary concentrations >150µg/ml.

Pseudoephedrine is found in many over the counter medicines available in pharmacies including many multi-ingredient products used as cough and cold remedies, hayfever and decongestant treatments. Athletes should stop taking any pseudoephedrine containing products at least 24 hours before competition. For therapeutic applications during the in-competition period, athletes should consider the use of alternative permitted medications after prior consultation with their doctor or pharmacist, or apply for a TUE for the use of pseudoephedrine for therapeutic purpose(s).

Local administration (e.g. nasal, ophthalmologic) of adrenaline or co-administration with local anaesthetic agents is not prohibited. Administration of imidazole derivatives is not prohibited when used by dermatological, nasal and ophthalmological routes.

S7 Narcotics: Prohibited narcotics include buprenorphine, dextromoramide, fentanyl and its derivatives, hydromorphone, methadone, morphine, nicomorphine, oxycodone, pethidine.

Note: Codeine, dextromethorphan, dihydrocodeine, pholcodine and tramadol are permitted.

S8 Cannabinoids (natural and synthetic) including cannabimimetics are prohibited except cannabidiol (CBD), available in Ireland as a food supplement (please see Sport Ireland’s Supplements and Sports Food Policy). Athletes should be aware that some CBD products extracted from cannabis plants may also contain THC and other cannabinoids that could result in a positive test.

S9 Glucocorticoids are prohibited and require a TUE when administered by oral, rectal, intravenous or intramuscular routes. Glucocorticoids administered by all other routes do not require a TUE.

Substances Prohibited in Specific Sports

P1 Beta-Blockers: Prohibited in-competition in certain sports such as automobile (FIA), golf (IGF) and darts (WDF). Prohibited both in- and out-of-competition in Archery (WA) and Shooting (ISSF, IPC).

WADA 2020 Monitoring Programme

In order to detect patterns of misuse in sport, the following are included in the 2020 Monitoring Programme:

1. Anabolic agents: In- and Out-of-Competition: Ecdysterone;
2. Beta-2-agonists: In- and Out-of-Competition: Any combination of beta-2-agonists;
3. 2-ethylsulfanyl-1H-benzimidazole (bemitil): In- and Out-of-Competition;
4. Stimulants: In-Competition only: Bupropion, caffeine, nicotine, phenylephrine, phenylpropanolamine, pipradrol, synephrine;
5. Narcotics: In-Competition only: Hydrocodone, tramadol and codeine;
6. Glucocorticoids: In-Competition (by routes of administration other than oral, intravenous, intramuscular or rectal) and Out-of-Competition (all routes of administration).

This summary is deliberately concise and is intended to be used as a guide only. For an authoritative reference source consult the complete World Anti-Doping Code, The 2020 Prohibited List and the International Standard for TUE (ISTUE) which are available from Sport Ireland or www.wada-ama.org. WADA have undertaken to update the Prohibited List regularly. All information correct at time of going to press.

Only those products with a marketing authorisation or CE mark can be classified. Products should only be used in accordance with their marketing authorisation.

Classification: See list of Sport symbols in the Glossary of MIMS Ireland.

Compiled by Eirpharm.com on behalf of Sport Ireland for MIMS Ireland. More information is available from Sport Ireland (telephone: (01) 8608818; website: www.sportireland.ie/anti-doping), www.eirpharm.com and National Governing Bodies of Sport.

Published December 2019

* Medical File: All Therapeutic Use Exemption (TUE) applications MUST be accompanied by a medical file reflecting current best medical practice to include:

1. A complete medical history
2. Copies of all relevant examinations and clinical notes (for example, if a clinic visit is referenced in a letter or summary, a copyof the clinical notes taken during the visit must be included)
3. Copies of laboratory results/reports, and imaging studies
4. Exact name, speciality, address (including telephone, e-mail, fax) of examining physicianFor asthma TUE applications, the medical file should also specifically include:
5. A comprehensive report of the clinical examination with specific focus on the respiratory system
6. A report of spirometry with the flow volume curve and the measure of the Forced Expiratory Volume in 1 second
7. If airway obstruction is present, the spirometry will be repeated after inhalation of a short acting β-2 agonist to demonstrate thereversibility of bronchoconstriction
8. In the absence of reversible airway obstruction, a bronchial provocation test is required to establish the presence of airway hyperresponsiveness
9. If the athlete reapplies for a TUE that has expired, the application should include documentation that confirms the initial diagnosis as well as the reports and pulmonary function tests from regular asthma follow-up visits.

World Anti-Doping Agency announces changes to its Prohibited List for 2020

The World Anti-Doping Agency (WADA) has issued a new Prohibited List of Substances and Methods which will come into effect from 1 January 2020. The WADA List Expert Group reviews the List annually and considers submissions from stakeholders, advancements in science and medical research, information on doping practices etc. A substance or method is added to the List if it meets two of three criteria: it has performance-enhancing potential, poses a danger to athletes’ health or its use is against the spirit of sport.

Changes of note to prescribers include:

• S4 Hormone and Metabolic Modulators: Bazedoxifene and ospemifene which are marketed internationally in medicinal products were added as additional examples of selective estrogen receptor modulators.
• S6 Stimulants: It is clarified that administration of imidazole derivatives is not prohibited when used by dermatological, nasal and ophthalmological routes.
• M2 Chemical and Physical Manipulation: The wording was changed to clarify that the context of protease prohibition refers only to the Tampering of samples. Topical and systemic use of proteases are not prohibited.
• S7 Narcotics: For clarity it was stated that all optical isomers are prohibited. This clarifies the prohibited status of optical isomers such as levomethadone which is available in some countries.

While not directly a prescribing issue, prescribers may be queried on the status of now widely available Cannabidiol (CBD). Pure CBD is not prohibited. However, athletes should be aware that CBD products extracted from cannabis plants may also contain r9-tetrahydrocannabinol (THC) and other cannabinoids that may result in a positive test. Please see Sport Ireland's advisory note concerning CBD products www.sportireland.ie/anti-doping/athlete-zone/advisory-notes.

Prescribers working with athletes should also have a clear understanding of the issues surrounding consumption of nutritional and dietary supplements. Supplement producers conform to different manufacturing standards than those involved in the production of pharmaceutical products. Supplements can pose risks to athletes due to contamination which may be accidental or deliberate. Evidence suggests that 10-25% of widely available supplements on the UK, European and USA markets are contaminated (Russell et al, 2013). Please see Sport Ireland’s Supplement Risk Minimisation Guidelines www.sportireland.ie/anti-doping/athlete-zone/supplements-and-herbal-remedies.

Dr Una May, Sport Ireland’s Director of Participation and Ethics stated “Athletes look to Athlete Support Personnel to provide advice in relation to treatment of their illnesses and injuries. MIMS is an essential element of Sport Ireland’s Anti-Doping Education programme. It is an important resource for Athletes and Athlete Support Personnel and ensures that athletes are provided with correct information in relation to the use of medications regarding WADA’s Prohibited List.”

The updates to the 2020 List will be reflected in the Sport Ireland Athlete’s wallet cards, MIMS Ireland, the Eirpharm.com Drugs in Sport Database and the Medication Checker App which allows users to access the live Eirpharm Drugs in Sport Database. More information is available from Sport Ireland at (01) 8608818, website: www.sportireland.ie/Anti-Doping, www. eirpharm.com and National Governing Bodies of Sport.

Reference: 1. Russell C, Hall D, Brown P. European Supplement Contamination Survey 2013. HFL Sports Science.

The following is a summary of the abuse of drugs in sport, their side effects and why they may be used.

EPO

EPO is also known as Epoetin or Erythropoietin it is the best known of this class of drugs, which stimulate erythropoiesis which is the formation of red blood cells.

EPO enhances athletic performance by increasing the supply of oxygen to muscle tissue and is in particular useful in endurance sports such as long distance cycling, distance running, cross country skiing. It also enables the athlete to recover faster from an endurance event.

While this substance is naturally produced in the body and it can also be made by recombinant DNA technology. It is pharmacologically classified as a haematopoietic growth factor which means it promotes the growth of red blood cells in the body. Red blood cells carry oxygen through the body. EPO is used clinically in the management of anemia associated with chronic renal failure in dialysis and predialysis patients, in conjunction with other treatments for HIV and as a part of a drug-treatment regime for those undergoing chemotherapy.

The abuse of EPO by athletes can have particularly serious consequences as its abuse can result in changes in thickness of the blood thus affecting the rate at which blood flows through the body. This can be further exacerbated by dehydration potentially leading to a life-threatening situation for the athlete. The effects of EPO is often measured by a haematocrit reading which is a measure of the volume percentage of the red blood cells in blood. Haematocrit readings above 55% have been reported to result in coronary and cerebral circulatory problems.

Other side effects include iron overload, flu-like symptoms such as headache and joint pain and high blood pressure.

Anabolic Agents

Anabolic Agents enhance muscle mass, enabling athletes to train harder, develop greater strength and power. They are abused in power events such as sprinting, weight lifting and field sports such as rugby and American football. This category includes the designer steroid "THG"(tetrahydrogestrinone). Samples are tested against specifically known anabolic agents. The designer steroid THG was specifically designed to avoid detection as its existence and chemical structure was not known to authorities until recently.

Side Effects at high doses include jaundice, acne, unwanted facial hair, liver damage, mood swings and aggression, nausea, headaches, raised heart rate; infertility, heart problems; diabetes, fertility problems.

Diuretics

Diuretics can be used as masking agents to allow other drugs to be flushed out of the body. These drugs could be potentially abused in all sports. They are also abused in weight-controlled sports such as weight lifting, power lifting, bodybuilding, boxing and karate as a means of reducing weight quickly. At higher does diuretics are associated with dehydration, cramps, heart problems, lethargy, drowsiness, restlessness and gastrointestinal disturbances.

Beta Blockers

Beta Blockers can be used in precision sports to steady nervous twitches improve accuracy and could potentially be abused in sports such as Gymnastics, Motorcycling, Archery and Shooting They tend to be used at the same levels as for therapeutic use associated with their use for hypertension, some cardiac arrhythmias, or migraine. Side effects of beta-blockers when used in healthy individuals may include cardiac problems including slow heart rate and low heart rate, dizziness and impotence.

Stimulants

Stimulants enhance speed, cardiovascular activity and reaction times. They also reduce fatigue and can make athletes more aggressive and competitive. They could be abused by sprinters, short distance swimmers and in contact sports such as soccer, rugby, football, boxing etc. Stimulants at high doses have been associated with heart problems including palpitations, irregular heartbeat, changes in blood pressure, and even convulsions and irrational behaviour.

Insulin

Insulin controls the blood sugar levels and the amount of glycogen in the body and interacts with growth hormone, glucocorticosteroids and adrenaline to regulate the energy supply to the body. Insulin has potential for abuse in many sports including cycling, athletics and swimming and may be used in conjunction with other doping agents.

Growth Hormone

Growth Hormone promotes growth of skeletal, muscular and other tissues and changes how carbohydrates are metabolized in the body. This enables athletes to train harder and more frequently and recover faster after training. It has been reported to improve bone density, decrease fat mass and increase lean body-mass, resting metabolic rate, and in some cases improve feelings of well being. Most of the activity from Growth Hormone is associated insulin-like growth factor-1 (also known as IGF-1).

It has potential to be used by all sports where endurance and energy is required such as cycling and athletes.

Enlarged hands, feet and face and some cancers, diabetes, fertility problems are associated with the abuse of growth hormone.

Too much fluid bad for athletes, how much fluids such athletes consume?

Athletes who overdrink water may be at risk of fatal hyponatraemic encephalopathy according to Professor Timothy Noakes, professor of exercise and sports science at the University of Cape Town, in South Africa has warned in an article published in the British Medical Journal.

This comes after a report of a number of deaths of athletes associated with excessive fluid intake. In particular the death of a female runner due to hyponatraemic encephalopathy of a female marathon runner in the 2002 Boston marathon because she ingested excessive volumes of a sports drink before and during the race. Hyponatraemic encephalopathy, is a condition in which the blood becomes so diluted that the salt level falls and fluid is drawn into the brain under osmotic pressure, causing it to swell. According to Professor Noakes, there have been seven recorded deaths and 250 cases of hyponatraemic encephalopathy associated with athletes overdrinking.

Professor Noakes concludes that the personal dictates of thirst seems to be safe and effective and that "such fluid intake typically ranges between 400 ml and 800 ml per hour in most forms of recreational and competitive exercise; less for slower, smaller athletes exercising in mild environmental conditions, more for superior athletes competing at higher intensities in warmer environments.

To read the full article

Sale of Ephedra Supplements to be prohibited in the US - Feb 2004

The Food and Drug Administration (FDA) prohibited the sale of Ephedra containing supplements in 2004 citing them as presenting "a significant and unreasonable risk to human health".

Ephedra which is also known as Ma Huang contains the active substance Ephedrine and has been promoted to aid weight loss or enhance sports performance and energy. According to the FDA they have received unsubstantiated reports of at least 70 deaths and more than 1,400 adverse events linked to Ephedra. Such adverse reports have included high blood pressure, insomnia, nervousness, tremors, headaches, seizures, heart attacks and strokes.

Prior to the ban US Manufacturer Metabolife, was found to have failed to forward details of over 13,000 adverse reactions associated with their Ephedra product. The FDA, at that time, recommended a criminal investigation of Metabolife to determine if they had lied about the dietary supplement s safety. Of the adverse reactions recorded by Metabolife, although 80 mention serious disease or death, and a company attorney said 100 to 200 others deal with people hospitalised but insists they did not prove that Ephedra is dangerous when used as directed.

According the the FDA, "the totality of the available data showed little evidence of ephedra s effectiveness except for short-term weight loss, while confirming that the substance raises blood pressure and otherwise stresses the circulatory system. These reactions have been conclusively linked to significant adverse health outcomes, including heart ailments and strokes."

In 2000, U.S. sales of weight-loss products containing Ephedra is worth about $1 billion.

In Ireland, Ephedrine is subject to prescription as controlled under Medicinal Products (Prescription and Control of Supply) Regulations. Ephedra has been in the past been found to be illegally present in some herbal sports and weight loss supplements marketed both in Ireland. Athletes subject to drug testing should remember that Ephedrine is prohibited in sport under the World Anti-doping Code.

It is recommended that those who have taken Ephedra or Ma Huang should contact their doctor.

IOC study leads to warning against the use of nutritional supplements by athletes.

Based on the results of a study of 634 nutritional supplements, the Medical Commission of the International Olympic Committee (IOC) warned athletes against their use and strengthened its call for industry and government action to ensure their quality.

The 13 country study found out of 634 samples tested, 94 (14.8%) contained substances, not listed on any label, that would have led to a positive doping test. Out of these 94 samples, 23 contained precursors (building blocks) of both nandrolone and testosterone, 64 contained precursors of testosterone alone and 7 contained precursors of nandrolone alone.

In addition to these 94 samples, 66 others (10.4%) returned borderline results for various unlabeled substances.

The 634 non-hormonal nutritional supplements were gathered from 215 different providers in 13 countries from October 2000 to November 2001. Ninety-one percent were purchased in stores or over the Internet. The others were obtained from the manufacturers. The IOC-accredited laboratory in Cologne, Germany, tested all supplements.

The country with the highest "percentage positive" was the Netherlands with 25.8%, followed by Austria at 22.7%. Results from the UK showed 18.9% or 7 out of 37 products gave "positive tests", almost identical to the US result of 18.8% from a larger sample size of 240 products.

No products from Ireland were tested. However, since most nutritional supplements in Ireland are sourced from overseas manufacturers there is no reason to believe that the situation in Ireland would be different from the international norm.

Under the WADA rule of strict liability, athletes are responsible for whatever substance is found in their bodies. Athletes should be aware of the risks associated with the use of unlicensed nutritional supplements. We can safely recommend only the small number of nutritional supplements which carry a product authorisation from the Irish Medicines Board as these have been officially assessed for quality and safety.

There is no statistical data on the use of nutritional supplements in Irish Sport.

The IOC said the results of this study demonstrate to governments and the industry the need for greater quality control to ensure substances not found on the label are not found in the product. The IOC Medical Commission recommended controls, similar to those pertaining to the manufacture of pharmaceuticals, be applied to the production of nutritional supplements.

The IOC also stated that they will recommend to National Olympic Committees (NOCs), International Federations (IFs) and Organizing Committees (OCOGs) that they adopt a cautious stance toward forming relationships with companies that produce nutritional supplements of which the quality cannot be guaranteed.

Therapeutic Use Exemption (TUE) Committee Policy on Glucocorticosteroid Injections for Hay Fever (updated 11th March 2013)

Depo-Medrone (Methylprednisolone) and Kenalog (Triamcinolone) administered by intra-muscular injection as treatment for hay fever are prohibited in sport and therefore their use requires the athlete and their physician to strictly adhere to the TUE Policy. The TUE Policy is available at www.irishsportscouncil.ie/tue.

• Athletes included in their International Federation Registered Testing Pool and/or athletes competing at International Competition will require a Therapeutic Use Exemption in advance of using an intra-muscular glucocorticosteroid. These athletes should contact their sport’s Anti-Doping Officer for assistance in identifying International Competitions and establishing the requirements for a TUE Application.
• Athletes included in the Irish Sports Council Registered Testing Pool that are not competing at an International Competition should apply to the Irish Sports Council for a Pre-test Therapeutic Use Exemption, using the information in the Medical File section below to aid them, prior to using an intra-muscular glucocorticosteroid.
• Athletes eligible for a post-test TUE application (see www.irishsportscouncil.ie/tue) should ensure that they are capable of providing a medical file to the standard outlined below, prior to the administration of any intra-muscular glucocorticosteroid injection by a physician. Athletes may be required to submit this medical file to support a TUE application at a later date.

Medical File

Intra-muscular glucocorticosteroid TUE applications MUST be accompanied by a medical file reflecting current best medical practice to include:

• A complete medical history i.e. when the hay fever began; the associated symptoms, their severity and effect on sporting performance; and symptoms suffered in previous hay fever episodes.
• Clinical evidence of attempting to use alternative permitted oral, nasal and/or ophthalmic medications and justification as to why alternative permitted medications are not sufficient.
• Copies of all relevant examinations, laboratory results/reports and clinical notes (for example, if a clinic visit is referenced in a letter or summary, a copy of the clinical notes taken during the visit must be submitted); provide details of any known allergens or allergic history including results of any previous immunological testing.
• Exact name, speciality, address (including telephone, e-mail, fax) of examining physician

Athletes and their physicians are reminded that there are a number of permitted medications, both over-the-counter and prescribed, that can be used for the treatment of hay fever (as checked on the Drugs in Sport Database on www.eirpharm.com, 04th March 2013) such as:

Over-the-counter medications

• Oral: e.g. Cetirelief Allergy, Clarityn, Zirtek, Lorat
• Nasal drop/spray: e.g. Otrivine nasal drops, Otrivine nasal spray, Nasobec Allergy nasal spray
• Eye drops: e.g. Otrivine Antistin eye drops, Vividrin Antiallergic eye drops

Prescribed medications

• Oral: e.g. Neoclarityn, Telfast, Grazax, Oralair
• Nasal spray: e.g. Avamys nasal spray, Rhinolast nasal spray, Nasonex nasal spray

Note: While Kenalog Injection has been discontinued from the Irish market some unlicensed product may be available.

Nandrolone (19-nortestosterone) is a prohibited anabolic steroid. All the anabolic steroids are related to the naturally occurring male sex hormone testosterone. It is anabolic in nature, i.e. promoting the build up of some body tissues like muscle.

Nandrolone is also closely related to two other banned steroids 19-norandrostenedione and 19-norandrostenediol.

Nandrolone can have beneficial effects in clinical medicine for example, to treat certain cancers such as breast cancer, some types of blood disorders and manage conditions such as postmenopausal osteoporosis.

Nandrolone is prohibited in sport, as an anabolic steroid it can offer an unfair advantage to those taking it by improving body build, increasing muscle size, strength and power, facilitating harder and longer training and increasing aggression and competitiveness.

Anabolic steroids can have extremely damaging side effects such as liver and heart damage, an increase in violent and aggressive behaviour, irreversible increase in facial and body hair growth etc.

Testing

Urine tests determine the presence of the main metabolite, 19-norandrosterone.

(A metabolite is simply a by-product left after a substance has been modified by a chemical reaction while passing through the human body. An simple analogy would be putting coal on a fire and being left with ash and soot at the end.)

Nandrolone occurs naturally in the body but only in small amounts. Trace amounts can occur in normal urine samples. For anti-doping testing purposes a limit has been set to take this factor into account.

Doping violation occurs at levels of

19-noradrosterone is not just a marker for nandrolone use but for all testosterone related compounds Nadrolone is also closely related to two other banned steroids 19-norandrostenedione and 19-norandrostenediol, which are all classed as 19-norsteroids. These agents produce the same metabolite in the urine. These agents are usually offered as nutritional supplements with their presence declared or undeclared on the label.

It is important that health supplements and vitamins are bought from a reliable source. Ideally the product should be approved by a national authority such as the Irish Medicines Board. Some health supplements may contain stimulants or caffeine despite not having such a declaration on the label.

Creatine

Creatine has been used by a number of athletes to increase muscle mass.

There have been number of varying reports on the efficacy of the product, and as to how it should be used effectively. There also has also been some debate as to the classification of creatine as a medicine or as a food substance and currently there is no product authorised as a medicinal product. There is little conclusive data on the long-term effects, on the use of creatine. There have been reports, mainly in the US, of products labelled as creatine which when tested also contained the stimulant ephedrine. Athletes should be aware of the dangers of taking any such substance.

If an athlete does decide to take creatine, it should be done under medical supervision.

Ginseng

Ginseng has been used for many centuries as an aid to reduce fatigue and improve concentration. Pharmaton which contains standardised extracts of Korean Ginseng is the only ginseng-containing product available in Ireland which carries a product authorisation.

Please note that there are several versions of Pharmaton products available. Care should be taken to ensure that the version you check carries a product authorisation (PA) number on the pack.

If in any doubt whatsoever consult your pharmacist or doctor.

THG or tetrahydrogestrinone is pharmacologically classified as an anabolic agent. Anabolic androgenic steroids include both natural present and synthetic substances which have an effect on the body similar to that of Testosterone.

THG has been labelled as a "designer" steroid as it would appear to have been specifically chemically synthesised to be undetectable using traditional drug testing methods.

It is not legitimately available or licensed for use as a medicine. While its full pharmacological effects have not been published or perhaps even fully studied, THG would appear to be chemically similar to the synthetic steroidal hormone gestrinone reported to have androgenic, anti-oestrogenic, and antiprogestogenic properties.

THG is prohibited for use in sport. According to the codes, all analogues of anabolic agents are prohibited whether specifically named or not in the code.

EPO is also referred to as Epoetin or Erythropoietin. While this substance is naturally produced in the body and it can also be made by recombinant DNA technology. It is pharmacologically classified as a haematopoietic growth factor which means it promotes the growth of red blood cells in the body. Red blood cells carry oxygen through the body. EPO is used clinically in the management of anaemia associated with chronic renal failure in dialysis and predialysis patients, in conjunction with other treatments for HIV and as a part of a drug-treatment regime for those undergoing chemotherapy.

The abuse of EPO by athletes can have particularly serious consequences as it use can result in changes in thickness of the blood thus affecting the rate at which blood flows through the body. This can be further exacerbated by dehydration potentially leading to a life-threatening situation for the athlete.

According to the WADA 2004 code EPO is prohibited and "unless the Athlete can demonstrate that the concentration was due to a physiological or pathological condition, a Sample will be deemed to contain a Prohibited Substance where the concentration of the Prohibited Substance or its metabolite and/or relevant ratios or markers in the Athlete s Sample so exceeds the range of values normally found in humans so as not to be consistent with normal endogenous production. The presence of analogues mimetics, diagnostics marker(s) or releasing factors of the hormone or any other finding which indicate(s) that the substance detected is not the naturally present hormone, will be reported as an adverse analytical finding."

'References' Sources

• Martindale
• The Merck Manual
• WADA List of Prohibited Substances