Athletes needing asthma drugs face extra hurdles

With better treatments, more asthmatics are becoming athletes, but they struggle with a sports mind-set and some International Olympic Committee rules not conducive to treatment compliance.

By Victoria Stagg Elliott, amednews staff. Sept. 24, 2001.

Jim Davis, the creator of the cartoon cat Garfield, credits his success to a childhood spent indoors drawing. He wasn't allowed to play outside because of his asthma.

This condition may have also been a factor that led other famous people -- Ludwig Van Beethoven, Robert Louis Stevenson, Charles Dickens, for instance -- to nurture their talent, because their lung function did not allow them to do more active things.

Olympic rules for asthmatics
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But the days in which asthmatics were relegated to quiet, indoor lifestyles are long past. Improved pharmaceutical options mean that asthma no longer automatically precludes a person from participating in sports.

Most asthmatics are now able to compete, and some do so at the highest level. Track and field athlete Jackie Joyner-Kersee, swimmer Amy Van Dyken and Washington Redskins fullback Donnell Bennett are all asthmatics and top-flight athletes. The list keeps growing. And even at the recreational level, people who use inhalers before and during competition are a regular sight.

"Even kids with severe asthma can be well-controlled and well-conditioned to participate in all age-appropriate physical activity," said Martin Hurwitz, MD, clinical associate professor in the pediatric pulmonology department at the University of Michigan Health System in Ann Arbor. "And they can play competitive sports, sometimes at extremely high levels where the limitations are only their own innate physical gifts."

Physicians complain, however, that the combination of a sports mindset that makes people think they are invincible, and an international sporting world obsessed with getting drugs out of sports -- even those needed to treat a medical condition -- is hampering treatment efforts.

"Compliance is the biggest problem we have," said John Weiler, MD, a professor of internal medicine with the University of Iowa College of Medicine in Iowa City. "The medications we have today are wonderful, but they don't do anything if they're not taken."

In August, Northwestern University football player Rashidi Wheeler died during a practice. His death is being blamed on asthma, and there are suggestions that he had not taken his medication. Doctors say such deaths are rare, but when they happen, they highlight the challenges and high stakes of treating asthmatics.

"This was a young man who needed his inhaler many, many, many times during practice," said Dr. Hurwitz. "That's a badly controlled asthmatic patient."

Controlling asthma usually requires a combination of quick-acting bronchial dilators and medications such as anti-inflammatories that provide long-term maintenance. But it is the latter category that has the poorest adherence, with most estimating 50% compliance populationwide.

"You don't get positive body feedback," Dr. Hurwitz said. "But it improves your pulmonary function and does prevent acute asthma attacks."

Physicians say medication is what allows asthmatics to compete as equals with non-asthmatics, but concerns that the treatments are sometimes viewed as performance enhancers is another wrinkle.

According to a study published in the Journal of Allergy and Clinical Immunology last year, use of asthma medications by American athletes at the 1998 Winter Olympics ranged from a high of 60% among cross-country skiers to a low of 3% for bobsledders. Because of high numbers like these that are not in line with populationwide estimates for the condition, the international sporting community has targeted asthma medications as part of the efforts to get performance-enhancing drugs out of sport.

"An awful lot of people are using asthma medications," Dr. Hurwitz said. "Nobody knows if they're really performance-enhancing, but a lot of the athletes think that it gives them an edge. Like anything else, it can be subject to abuse."

IOC skepticism trickles down

Last month, the International Olympic Committee announced their new list of prohibited and restricted substances, including tougher requirements to get permission to take asthma medications. Athletes must now submit clinical proof to a medical review panel and may be subject to an on-the-spot test to substantiate that they have asthma.

"I don't want to see athletes taking drugs they shouldn't," said Dr. Weiler, who authored the study. "But when they start making edicts that don't allow for the art of medicine and its just a bunch of numbers, that does not work. We make the diagnosis of asthma based on clinical presentation, but they're asking for tests that aren't commonly done. And they're probably not the right tests to be asking for."

While most experts feel that the intent of the efforts is noble, it sometimes means therapeutics are categorized with other drugs that give athletes an unfair edge.

"The IOC doesn't really believe asthma exists among athletes," Dr. Weiler said. "But it's a common problem and not any less common among athletes. Athletes also push themselves, and they can provoke pretty severe attacks."

Experts believe asthmatic athletes may forgo their medication because of the hassle, and that some, although diagnosed as asthmatic, may not pass the tests required by the IOC. "Every test we do has an opportunity to be falsely negative," Dr. Weiler said. "Then what do you do? You don't provide drugs to them? That's terrible."

And although the actions of the IOC appear to affect only elite athletes, physicians report that its approach does trickle down to recreational athletes.

"The message it sends to our kids and the athletes who participate at lower levels such as the NCAA, all the way down the line, is not a good one," said Dr. Weiler. "The message is: 'This really doesn't exist. These people are going for these drugs so they can improve their performance.' Indeed athletes have it at all levels. Let's treat them properly."

ADDITIONAL INFORMATION:

Olympic rules for asthmatics

Beta-2 agonists

Must submit clinical and laboratory evidence of asthma, including lung function tests, at least one week before competition.
This evidence will be reviewed and approved by a panel of medical and scientific experts.
If questionable, athlete will be required to submit to additional tests.

Salbutamol, salmeterol, terbutaline*

Classified as stimulants.
Permitted by inhaler only.

* Otherwise, same requirements as in place for beta-2 agonists.

Glucocorticosteroids

Regular oral, rectal and intravenous administration is banned.
Athlete can receive intermittent local injections as deemed medically necessary.

Weblink

Olympic Movement Anti-Doping Code (http://www.olympic.org/ioc/e/org/medcom/medcom_antidopage_e.html)

Article, Asthma in United States Olympic Athletes who Participated in the 1998 Olympic Winter Games, Journal of Allergy and Clinical Immunology, August 2000