Health, Human Performance, Pharmacological Medicine, and Competitive Sports

In 2000, Roumanian gymnast Andreea Raducan was stripped of an Olympic gold medal because she took a cold medication which was prescribed by her physician. The medication contained pseudoephedrine, a very common over-the-counter decongestant – which was (and is) prohibited by the World Anti-Doping Agency, which sets antidoping standards for international sports competitions.

This year, several 2008 Tour de France competitors were disqualified (and prosecuted under French criminal law) for the use of erythropoietin (EPO) stimulating agents (ESA) – medications used to boost red blood cell production. These agents have legitimate pharmaceutical use to treat anemias brought on by renal failure, cancer, and critically-ill trauma patients – however, they can also be used to increase oxygen availability to muscle cells, improving athletic performance.

Like all pharmaceuticals used to enhance athletic performance, ESA use is not without medical risks. For those who use or advocate the use of performance-enhancing agents – not just the athletes, but their trainers, doctors, and corporate sponsors – the rewards are worth the health risks (and apparently, the detection risks). I’m not presuming to either advocate or excoriate this practice – but a quick Wikipedia search on “EPO” sent me on another information-gathering excursion, with some interesting twists and turns to it.

According to Wikipedia, ESA use is detected because the erythropoietin produced under its influence is slightly different from one's own erythropoietin in exact molecular structure. This reminded me of some questions about analog insulins. Recently, Allie Beatty, Scott Strummello, and others have expressed concerns over the lack of control over, of knowledge of, the exact molecular structure of analog insulins -- and the deleterious effects this may have upon survival of any remaining beta cells, as well as the development of complications of diabetes (most particularly hypoglycemia awareness). In addition, current research on insulin resistance suggests that persons with "type 2" diabetes produce both correct (usable) pro-insulin and a structural variant pro-insulin that is not usable.

If we can detect structurally-variant EPO, then I have to wonder whether or not we can detect structurally-variant insulin… and whether or not that could be an issue for our world-class “Type 1” athletes. Remember, in 2000, it appeared that decongestants were considered performance-enhancing drugs – but these are drugs that have legitimate therapeutic uses. Diuretics – which also have legitimate therapeutic uses – are also banned. So… what about those T1 athletes?

I followed the links over to the WADA site and downloaded their list of prohibited drugs.

Now I was even more perplexed: among the list of prohibited drugs was (you guessed it) insulin!


And yet, there are World-class – even world-champion – T1 athletes. So… what’s the deal?

If one reads the list closely, it turns out that the WADA has made provisions for those athletes with medical conditions that either cause imbalances in their naturally-produced hormones that, in the absence of such a condition, indicate doping, or that require the use of an otherwise-prohibited substance in order to remain alive and healthy. These sorts of drugs include certain testosterones, diuretics, beta blockers, and (ta-DAH!) insulin. The “excuse note” is called a “Therapeutic Use Exception” or TUE.

The basic description of a TUE is that the request must be submitted at least 21 days before an event, with supporting medical information, and that the athlete must not be using the drug in question until the TUE is approved. (Incidentally, once the request has been submitted, it has to be farmed out to an approval board, each member of which has 30 days in which to respond to it, so the real waiting period can be significantly longer.) Moreover, TUEs are set to expire on relatively short notice (many are per-event).

Again, this is something that does not make sense where withholding the drug (in our case, insulin) could be fatal.

After digging through a few more documents on the WADA site, I finally found the appropriate information.

In the case of conditions that are generally considered to be lifelong conditions, the supporting medical data must include reasons why “approved” drug classes for the condition, where available (e.g., ACE inhibitors to treat hypertension instead of beta blockers), are not appropriate for the patient/athlete.

  • In the case of insulin-dependent diabetes, there is (obviously) no alternative treatment. It is also considered obvious that withholding insulin would be life-threatening, if not fatal. (Interestingly, there is no official option to not withhold insulin while the TUE request is being processed.)
  • The medical information guidelines state that our T1 athletes must reapply annually for TUEs, and that they will be constantly under medical review to keep their blood glucose levels in control.
  • The TUE request forms request specific statements of both brand name and generic name of each prohibited-list medication in use, the dosage, the "route of administration", and the frequency of administration.
  • While the medical information guidelines suggest that the athlete and his medical team are aware of his needs and able to adjust them on-the-fly, the format of the request form suggests that no variation in insulin use would be tolerated (e.g., no extra unit to cover the extra slice or two of bread or the oncoming cold) -- meaning, our T1 athletes must be even more vigilant about their health than other athletes, and other T1s, combined.
<*shaking head*>Whoa!

This research excursion has given me even more respect for our T1 athletes – having to run a veritable red-tape-and-medical steeplechase just to be able to step up to the starting line.

Interestingly, while insulin secretagogues are not specifically mentioned by class, they are provided for in the guidelines under the catch phrase, "and other substances with similar chemical structure or similar biological effect(s)". However, there are no TUE guidelines for T2 diabetes, suggesting that elite-class athletic, oral-antidiabetic-dependent T2s either must be treated only with non-secretagogue agents (i.e., biguanides), or must be handled on a case-by-case basis, and possibly be prohibited from competing. Some encouragement to get us T2s off the couch, eh? (Not!)
And on another not-so-side-note, the development of higher-performing prostheses for amputees is bringing these athletes back into elite (world-class) performance levels -- but these prostheses are coming under attack for perhaps posing "an unfair advantage". (See for more about the case of sprinter Oscar Pistorius.) When (not "if", but "when") we start having to question the performance enhancement of life-sustaining therapeutic drugs, prostheses, and other palliatives that bring us back to par with "normal, healthy" human beings, will our T1 and T2 athletes also be shunted off -- not to the Paralympics or the Special Olympics, but to a yet-to-be-developed Diabetolympics?
Side notes notwithstanding, hats-off and best wishes to our T1 athletes.