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Therapeutic Use Exemptions (TUE) and Harm. The solution is obvious for Sportsmen and Doctors in Asthma and ADHD

Matt Dickinson , the chief sports writer in The Times, writes an excellent article today 16/9/16 regaring TUEs. Essentially the article reads that more athletes than ever are being granted TUEs and there is a healthy degree of scepticism as to the likelihood that a large proprotion are actually essential. All fair points. However the real debate is why is the medical evidence to support a TUE is not more solid? This is the clear missing factor.

As a doctor I would be looking at many illness features before offering an opinion or report. Firstly if an athlete is only requesting TUE rarely, why? The types of illness cited mostly here by Matt Dickinson are long term and in general terms stable over a few months, notably asthma and ADHD. It would be a hard hearted person to determine that an asthmatic, and most cases of asthma ( not all though) develop in childhood and early adolescence, cannot compete in sport due to the need for medication. It also needs to be said upfront that asthma does kill people annually and regularly, it can be a very serious illness. Stopping medication is rarely a safe nor sensible thing to do, so to be allowed to continue medication when in competition is essential and medically necessary. And this is the point. Medication usage is generally stable. So TUEs when granted should refect the regular need for a medication over months. Competition is intense sure, but also so is training. Exertion levels are not likely to vary enormously. A TUE should never for example allow a medication to be started just prior to competition. In simple terms, the asthma medication carries on as normal. To be convinced to start a new medication, steroid for example, there needs to be serious evidence of a deterioration in asthma that would not just have occurred overnight. Hence the intermittent usage of Kenalog (triamcinolone) for example could only be entertained on a strictly seasonal basis if hayfever symptoms had been  prominent annually at that time of the year. It requires some explanation why Bradley Wiggins took only 3 injections of Triamcinolone June 2011, June 2012 and April 2013, if these medical facts are indeed correct. They may not be. It would also be interesting to entertain the spcific pollens giving the allergy.

For ADHD it is much the same. The diagnosis of ADHD is made generally with a history of symptoms that have been present in certain well prescribed patterns for many years. Adults diagnosed with ADHD must have shown evidence of long standing symptoms present since before 12 years old. The need to treat ADHD generally does not differ markedly over a period of time, in that the likelihood that a treatment needs commencing immediatley prior to an event is minimal. Treatment needs tend to be stable. Stopping ADHD treatment is not a good thing either.

Lastly Matt Dickinson points out that ADHD is relatively common in adults, he cites 4-6% of the adult population, which is a little high, maybe 3-4% is probably correct using the updated DSM-5 diagnostic criteria. But his scepticism about Major League Baseball players having ADHD in 10% of cases might be unfounded. ADHD is more common in sportsmen as many of the illness facets tend to be helpful in sport provided they are harnessed appropriately. Thus 10% is not an unreasonable estimate, though no thorough research seems to have been done on this. Creativity, hyperactivity and hyperfocus are features of ADHD and as such gymnasts like Simone Biles as an example may do well despite having ADHD. They too however need treatment. Impulsivity is the one feature of ADHD that does often get sportsmen into trouble. Lastly an interesting recent medical finding is that asthma is far more common in those with ADHD than the general population. The reason is not clear.

So where should the scepticism come in? Firstly any sudden TUE prior to a competition needs a full investigation and critical analysis. Secondly any TUE where there is an unexpected and changed medication need, especially if intermittent, needs again careful analysis. If sportsmen are using TUEs as legal loopholes then it is the duty of doctors to stop this happening, and thats far easier than many imagine.