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Simon Yates receives four month suspension for Terbutaline

Simon Yates

Simon Yates adverse finding for Terbutaline on 12th March 2016 results in a four month suspension until 11th July.

The UCI has issued a statement today stating that after returning an 'adverse analytical finding' in a drugs test on 6th March 2016, Simon Yates will be suspended from all competition until 11th July as per the WADA code. 

The case was interesting because Yates had previously had a TUE (theraputic use exemption) for Terbutaline, although it transpires the team doctor failed to apply for a TUE in this instance. 

Why was Simon Yates using terbutaline?

29/04/2016

After it emerged that Simon Yates had returned an adverse analytical finding in a drugs test on 6th March, at Paris Nice, a statement from his Orica-Greenedge team read thus:

  • The positive result is for the substance Terbutaline.
  • The substance was given to Simon Yates in the form an asthma inhaler and accordingly this was noted by the team doctor on the Doping Control Form, signed at the time of the test.
  • The substance was given in an ongoing treatment of Simon Yates’ documented asthma problems. However, in this case the team doctor made an administrative error by failing to apply for the TUE required for the use of this treatment. 

While asthma is a common illness, the use of its medication by athletes throws up a problem as it directly affects their ability to breathe and therefore perform. In light of the recent news, we recall a previous conversation [in 2015] with Dr. Jarrad van Zuydam, a team doctor at Team Dimension Data, to look at how asthma medication can be administered in the pro peloton.

Asthma has to be demonstrated in a test. We wouldn’t give these to a rider who said "I can’t breathe sometimes"

'There are a few guys who take asthma medication,' Van Zuydam says of his team [MTN-Qubeka at time of interview]. 'When signing a new rider, or if a [current] rider complains of symptoms of exercise induced asthma or asthma in general, they undergo an asthma provocation test. They will see a specialist pulmonologist who does flow volume loop testing [volume of inspiratory and expiratory flows] first at rest, then they exercise and see if there is any demonstrable narrowing of the airways. If the pulmonologist reports that there is evidence of exercise induced asthma then certainly we would use the first bronchodilator as the first port of call, and if that’s not effective then we might move onto corticosteroids.'

We must point out that Orica-Greenedge is an entirely different team, and the same protocol may not be followed, but it is nonetheless interesting to see how a fellow World Tour set up deals with asthma sufferers.

'This is treatment of a medical condition and it has to be demonstrated in a test. We wouldn’t be giving these to a rider who said "Look I can’t breathe sometimes, just give me some asthma medication.",' he continues. 'That’s not how it works. It has to be tested, we get reports, and if it were proven that this athlete has some degree of asthma then we would put them on the medications.'

The prescription

This medication can fall into one of two categories, which either cure immediate attacks, or prevent future ones, as Van Zuydam explains. 'The corticosteroids prevent further episodes of asthma while the bronchiodilators are for when you do become wheezy. If you feel that there’s an attack coming on, then you would use the Ventolin [a bronchiodilator]. The steroids are something you would take on an ongoing basis every single day, just as you would take something for diabetes or any other chronic illness.'

Terbutaline, which Yates was administering via an inhaler, is a bronchiodilator, essentially a curing, as opposed to a preventative, substance, which opens airwaves in the event of their contraction.

'They are both beta agonists,' says a GP we spoke to, who wished to remain anonymous, of terbutaline and its more commonly used equivalent, salbutamol, otherwise known as Ventolin. 'They both work on the same pathways, on the same receptors, and do the same thing. They are asthma relievers, causing the airways to relax and expand. 

'If you're wheezy, and take a puff of ventolin [salbutamol], you'll be "not wheezy" within a few minutes. That effect can last for hours. An athlete competing in freezing cold air might have a puff of ventolin before exercise to relax their airwaves and stop them wheezing.' Accuweather.com lists temperatures of 9 degrees in Maurepas, Paris, where the Paris-Nice prologue was held on Yates' test date of 6th March.

WADA (World Anti Doping Agency) lists all beta-2 agonists as substances banned in competition, apart from inhaled salbutamol if less than 1600 micrograms over a 24 hours period. That equates to roughly 16 puffs on an inhaler (more than 10 in a four hour period would normally result in a hospital admission).

Why, then, would Yates have been using a banned substance, when an apparently very similar drug could be used to the same effect legally? 

'Some patients shake [with tremors] quite a lot on salbutamol if they use it regularly,' our GP suggests. 'If they did, we'd put them on terbutaline instead.'

So there's no way that terbutaline may be in some way more potent or beneficial than salbutamol?

'It's not as far as I'm aware. From a GP's point of view, you'd just use one or the other based on current guidelines.'

If salbutamol is banned when used over a certain amount, perhaps it is just simply easier and less stressful to obtain a TUE for the equivalent drug, terbutaline, and use it at will, rather than risk using excessive amounts of salbutamol? That is, of course, providing one gets the TUE.

But on the contrary, a study 'to investigate the effect of high-dose inhaled terbutaline on muscle strength, maximal sprinting, and time-trial performance in trained men,' conducted at the University of Copenhagen, found: 'High-dose inhaled terbutaline elicits a systemic response that enhances muscle strength and sprint performance. High-dose terbutaline should therefore continue to be restricted in competitive sport.'

The quandary 

Regardless of whether or not a substance has secondary performance enhancing benefits, could it be that athletes are out to gain an asthma diagnosis to get an edge, when regularly their illness wouldn't be an issue?

'There’s quite a lot of research that says that asthma is more common in athletes than the general population,' says Van Zuyem. 'But maybe that’s just because they exercise and bring on those symptoms more. I think in our team we have four or five riders on asthma meds [2015]. It's one of the more common chronic illnesses that we see.'

Owain Doull, one of Yates' peers, was quick to voice his support for his compatriot and former teammate in confirming his condition. 'I'm not naive, I just know and trust the lad I raced and lived with for years and have seen first hand how he has struggled with asthma,' Doull said on Twitter.

Could there any benefit for non-asthma sufferers in taking asthma-related substances to improve their performance though?

'There’s a trial showing that [sabutamol] doesn’t [make you faster] unless you're asthmatic. I’m not sure - perhaps it [unnecessary use] does go on, but perhaps its pretty pointless and not beneficial.'

And what of terbutaline? The UCI will not be provisionally suspending Yates as 'such a substance does not entail imposition of a provisional suspension,' but the question marks over why he was using it will remain.

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