Asthma Medications: Not a Clear Advantage

The New York Times By GINA KOLATA Published: July 22, 2008

In 1992, just after she had returned from winning a gold medal in the Barcelona Olympics, the swimmer Dara Torres was running with a friend on a hot, humid day in Gainesville, Fla. She was wheezing, she said, which was nothing new. She had always had breathing problems and thought nothing of it.

But her friend, a hand surgeon, told Torres that she sounded like someone who had asthma. Torres’s father has asthma, but it had never occurred to her that she might have it, too. She did, and as soon as she started taking asthma medication, she realized how much, and how needlessly, she had been suffering.

“I was always coughing,” she said in a telephone interview last week. “And my breathing was horrible. I really had a hard time.”

Now, at 41, Torres has returned to competitive swimming and earned a place on the United States Olympic team. And she is outraged by those who say that she only recently declared she had asthma and that taking asthma drugs was the secret to her astounding success. The drugs, it is often claimed, are performance enhancers.

That is not, however, what asthma and doping experts say. Inhaled asthma drugs, according to medical consensus, allow athletes with asthma to breathe normally but do not make them better than normal. And they do nothing for athletes who do not have asthma.

Elite-level athletes with documented proof that they have asthma are allowed to take certain inhaled corticosteroids, which prevent inflammation of airways and can hold asthma symptoms at bay.

And they are allowed to take other inhaled drugs, beta-2 agonists, which relax the smooth muscle cells of airways, relieving symptoms. A few of the beta-2 agonists can increase muscle and decrease body fat if they are injected or taken orally.

But when they are inhaled, in doses used to control asthma, beta-2 agonists do not improve performance, asthma and doping experts say. And neither do corticosteroids.

“A lot of people believe they are performance enhancers,” Dr. Gary I. Wadler said about inhaled asthma drugs. But, added Wadler, who is chairman of the World Anti-Doping Agency’s prohibited list and methods subcommittee, “there is no evidence for that at all.”

Dr. Kenneth Fitch, a member of the International Olympic Committee’s medical commission, has provided some of that evidence. A professor at the School of Sport, Exercise and Health at the University of Western Australia, he conducted three double-blind studies of asthma drugs and concluded that they did not enhance performance. In the studies, neither the participants nor the researchers knew who was receiving asthma drugs or who was receiving a dummy substance.

Some, like Paula Radcliffe, who has asthma, have heard other explanations for why the drugs are banned. Radcliffe is the women’s world record holder in the marathon. The drugs, she believes, are banned for those without the condition because they can mask the presence of other performance-enhancing drugs.

“That’s what I’ve been told,” Radcliffe said in a telephone interview from her home in Britain.

But that is not true, according to Dr. Patrick Schamasch, the medical and scientific director for the I.O.C.

Wadler explained that a drug “doesn’t have to work to be on the list” of the World Anti-Doping Agency’s prohibited substances.

To be banned, a drug has to meet two of three criteria: Taking it must enhance or potentially enhance performance, place an athlete’s health at risk, or violate the spirit of sport.

In a person who does not have asthma, the drugs have no benefits, only the risk of side effects that can place an athlete’s health at risk. An athlete taking them in an attempt to gain a competitive advantage would then be violating the spirit of sport. Therefore, Wadler said, inhaled asthma drugs can be banned.

Yet there is no doubt that many elite athletes have asthma, or that asthma symptoms can be brought on by intense exercise.

That is what happened to Radcliffe. She said she learned that she had asthma at 14, when she passed out while training because she could not breathe. Running, she said, and especially running when the air is cold or polluted, brings on her symptoms. It is hard for her to train without the drugs. She said that in order to receive permission to take asthma drugs in competition, she had to stop taking drugs for 10 days before being tested for asthma.

“I struggled,” Radcliffe said. “I wheezed and my voice got creaky. And I had a dry, tickly cough that lasted for five or six hours after hard workouts.”

One indication of the prevalence of asthma among elite athletes came when researchers tested every athlete in seven sports on the 1998 United States Winter Olympic team — biathlon, cross-country skiing, figure skating, ice hockey, Nordic combined, long-track speedskating and short-track speedskating. Nearly a quarter of the athletes, including half of the cross-country skiers, had asthma. In comparison, about 5 percent of the general population has asthma.

The percentage of all United States Olympians with asthma increased from 1996, when it was 12.4 percent, until 2000, when it was 18.9 percent, according to Fitch. But in 2002, when testing became more stringent, the percentage dropped to 12.9 percent. It was 9.1 percent in 2004 and 12.1 percent in 2006, Fitch said.

Asthma is especially prevalent in swimming, distance running, cycling and skiing. That may be because those athletes are exposed to pollutants and dry air, said Dr. Thomas Casale, the chief of allergy and immunology at Creighton University in Omaha. Those who are prone to asthma, he said, can have airways that are especially sensitive to irritants.

For swimmers, the irritants may be tricholoramines used to disinfect the water, said Kenneth Rundell, the director of the Human Performance Laboratory at Marywood University in Scranton, Pa. Ice skaters may be affected by pollutants released by ice-cleaning machines, which are often powered by natural gas or propane, he said. Skiers breathe Teflon when they go in and out of the wax room.

As for distance runners and cyclists, Rundell said, they can be affected by air pollution, especially fine and ultrafine particles, and by the drying effect of breathing rapidly for long periods of time.

Pollen can make symptoms even worse for those who are allergic to it, which includes the majority of athletes with asthma, as it turns out.

None of this bodes well for the Beijing Olympics, asthma researchers say. The Chinese government has said it will reduce the air pollution, but it also warned that the Olympics will be held during pollen season.

One approach the United States has taken has been to fly its athletes to Beijing to have them tested for asthma while they exercise there.

“Our concern is that many who are asymptomatic in a place like Colorado Springs run into problems in Beijing,” said Randall Wilber, a sports physiologist at the United States Olympic Training Center in Colorado Springs. Although he said he could not reveal how many athletes were now documented asthmatics, “that certainly is being considered by many athletes as a strategy.”

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