Your inhaler has a number on it, and fight week is the worst time to ignore it

Most fighters think of an inhaler as medicine, and of medicine as safe. The Prohibited List thinks of it as a beta-2 agonist with a number attached, and the number is not printed on the box.

This is one of the few subjects where a fighter can do everything honestly, treat a real condition with a prescribed drug, and still produce an adverse finding.

The rule in plain numbers

Beta-2 agonists are prohibited as a class. Four inhaled ones are carved out, with limits, on the current Prohibited List.

Stay inside those and no therapeutic use exemption is required.

There is also a urine threshold. Salbutamol above 1000 nanograms per millilitre, or formoterol above 40, is treated as inconsistent with therapeutic use and reported as an adverse analytical finding, unless the athlete proves through a controlled pharmacokinetic study that a permitted inhaled dose produced it. In practice laboratories report salbutamol above a decision limit of 1200 nanograms per millilitre, which builds in an allowance for measurement uncertainty.

Read the exemption clause again. The burden sits on you, and discharging it means a formal pharmacokinetic study rather than an explanation.

The trap inside the numbers

The daily figure is the one everybody remembers. The shorter window is the one that catches people.

A common salbutamol inhaler delivers 100 micrograms per puff. Six puffs is 600, which is the 8-hour ceiling. Six more after 8 hours is another 600.

That leaves four puffs, 400 micrograms, for the final block of the day.

Sixteen puffs across 24 hours, but never more than six in any 8-hour window, and the window runs from any dose rather than from midnight.

A fighter having a hard session, taking four puffs before and four after because it felt necessary, has gone over the 8-hour limit while sitting comfortably under the daily one. Nothing about that day felt like cheating.

The arithmetic does not care how it felt.

Why fight week is the dangerous window

Now the part that belongs to this sport, and that I have not seen written for fighters anywhere.

The salbutamol threshold is a concentration. Nanograms per millilitre of urine. Concentration depends on two things: how much drug is present, and how much water it is dissolved in.

A fighter in the final days of a cut is deliberately reducing the second one.

This is not my speculation. WADA has funded research specifically examining the effect of dehydration on the urine pharmacokinetics of inhaled salbutamol, alongside dietary flavonoid intake and consecutive days of inhalation. The question is being investigated because the answer matters, and the same programme notes that high urine concentrations relative to the dose inhaled can occur, meaning the risk of adverse findings may be greater than previously assumed.

So the week when an asthmatic fighter is most likely to reach for the inhaler, because of hard sessions, heat work and the general misery of a cut, is also the week the sample is most concentrated.

The second trap, and it is worse

This is the one that should stop any fighter reading this page.

Those dose thresholds do not apply if a prohibited diuretic or masking agent is found alongside the beta-2 agonist. In that situation any level of the beta-2 agonist is treated as an adverse finding, and an exemption is required for both substances, not one.

Diuretics are the classic weight-cut drug. They are prohibited at all times and they turn up in weight-class sport for reasons everyone understands.

So an asthmatic fighter who uses a diuretic to make weight has not committed one violation. He has committed the diuretic violation, and simultaneously destroyed the protection that made his legitimate inhaler use permissible.

Some blood pressure medications are diuretics as well. A fighter taking one on prescription without checking arrives in the same position without ever intending anything.

The alternative that has no allowance at all

Terbutaline is prescribed as an alternative to salbutamol often enough that it deserves naming.

It is prohibited outright. Every dose, every route, no carve-out, no threshold. It requires an exemption applied for in advance.

A fighter who runs out of salbutamol and is handed terbutaline by a pharmacist or a well-meaning doctor has swapped a permitted drug for a prohibited one, and the packaging gives no hint of the difference.

The counting problem when you travel

One more piece of small print that catches people crossing borders.

The Prohibited List refers to the delivered dose for formoterol and the metered dose for salbutamol, salmeterol and vilanterol, because labelling conventions differ between countries. The same drug at the same apparent strength on the box can be labelled on a different basis depending on where the inhaler was dispensed.

A fighter who buys a replacement inhaler abroad, or takes one from a local doctor during an away camp, may be counting in a different currency from the one he counted in at home.

Read the literature for the device in your hand, not the one you had last month.

One thing that is simpler than people fear

Inhaled glucocorticoids, which often come in the same device as the beta-2 agonist in a combination inhaler, are permitted. The prohibition on glucocorticoids in competition applies to injectable, oral and rectal routes.

So the steroid half of a combination inhaler is not the problem. The beta-2 half, and the number attached to it, is.

What I tell fighters to do

• Check the exact product on Global DRO, in the country you are in rather than the country you are from.
• Know your two numbers, the daily and the shorter window, and count puffs rather than estimating. If you have taken enough to need the arithmetic, write down the times.
• Declare the inhaler on every doping control form. It costs nothing and it is the difference between documented therapeutic use and an unexplained finding.
• Tell your doctor you are a tested athlete before any respiratory prescription, and get the diagnosis properly rather than borrowing an inhaler because your chest feels tight in camp. An undiagnosed athlete on a prescription drug has no medical file behind him when a question arrives.
• If a doctor wants to prescribe outside these four substances or above these doses, that is an exemption applied for in advance, not explained afterwards.

The point underneath all of it

Anti-doping catches very few people who set out to cheat. It catches a lot of people who did something ordinary without checking.

An inhaler is the most ordinary object in this article. It sits in a gym bag next to the tape and the mouthguard, and nobody thinks about it until a form asks which medications have been used in the past 7 days.

Know the number before somebody asks you for it.