UPDATED: October 25, 2024
Athletes are often prescribed medication delivered by inhalers, but for athletes subject to anti-doping rules and drug testing, it’s critical to understand how to use inhaled medications within the rules.
There are many brands of asthma inhalers with different active ingredients, delivery mechanisms, and dosages. Therefore, USADA strongly recommends all athletes check the permitted or prohibited status of their inhalers on GlobalDRO.com before use, taking special note of any guidance in the “Conditions/Warnings” section of the search results page. While this article provides some helpful insight into anti-doping rules around inhalers, it cannot describe all possible scenarios or combinations of inhalers on the market.
Below are frequently asked questions about inhalers in sport, along with answers that will help athletes determine how they can and can’t use inhalers under the World Anti-Doping Agency (WADA) rules.
Can I use my asthma inhaler in sport?
You may need a Therapeutic Use Exemption (TUE) before using your inhaler depending on the active ingredients in the inhaler, other medications you are taking, and your competition level. A doctor’s prescription alone is not enough to permit the use of a prohibited substance or method in sport.
In general, remember that:
- Inhalers prescribed by a doctor for therapeutic use that contain ONLY glucocorticoids are permitted at all times. Common examples are:
- Budesonide: Brand name Pulmicort Flexhaler
- Fluticasone: Brand names Flovent HFA and Arnuity Ellipta
- Mometasone: Brand name Asmanex Twisthaler
- Beclomethasone: Brand name Qvar RediHaler
- Ciclesonide: Brand name Alvesco
- Use of inhalers containing stimulants, like epinephrine and levmetamfetamine (e.g., Primatene Mist or various over-the-counter vapor inhalers), are prohibited in-competition but permitted out-of-competition.
- All beta-2 agonists are prohibited at all times, by all routes of administration (e.g., oral/syrups, inhaled by metered dose inhalers or nebulizers), except for four beta-2 agonists that have permitted uses when used therapeutically, by metered dose inhaler, and used within the dosage and schedule set forth by WADA, and not used with any medications in the class of diuretics and masking agents (see table).
The table below highlights the only four beta-2 agonists that have a permitted dosage where, if used in accordance with anti-doping rules, a Therapeutic Use Exemption is not required.
Four Beta-2 Agonists with Permitted Inhaled Dosage Thresholds | ||
Beta -2 Agonist | Permitted dosage- Metered dose inhaler only (nebulization prohibited) | Warnings/Conditions |
Albuterol (also called salbutamol) (e.g., ProAir, Proventil, Ventolin) (NOT levalbuterol (also called levosalbutamol) (e.g., Xopenex) which is prohibited at all times) | 600 micrograms/8 hours (maximum 1600 micrograms/24 hours) | No permitted dosage if you are on medication in class S5. Diuretics or Masking Agents. Please see FAQ on TUEs at bottom of article. Use of inhaler must be according to therapeutic guidelines in divided doses- can’t use all at once! |
Formoterol (NOT arformoterol (e.g., Brovana), which is prohibited at all times) | 36 micrograms/12 hours (maximum 54 micrograms/24 hours) | |
Salmeterol (e.g., Serevent) | 200 micrograms/24 hours | Use of inhaler must be according to therapeutic guidelines. |
Vilanterol (e.g., Anoro, Breo) | 25 micrograms/24 hours | |
Note: Common U.S. Brand names provided as an example only. Always consult Global DRO for a complete list of products and prohibited status.
What about respiratory emergencies?
If any prohibited emergency treatment is necessary, the athlete’s health is paramount, therefore do not withhold treatment. An emergency retroactive TUE application can be submitted after the treatment.
I am using one of the beta-2 agonists that has a permitted dosage. How many puffs I can use?
The best way to ensure you use your inhaler within anti-doping and therapeutic guidelines is to discuss these anti-doping rules and permitted dosages with a doctor or pharmacist.
But essentially, for inhalers that contain one of the four beta-2 agonists in the table above, look for the dosage on the inhaler itself or on the packaging and use that to calculate the number of puffs for permitted use. For example, one common dosage for inhaled albuterol is 90 micrograms (mcgs) per actuation (puff). Since the maximum permitted dose for inhaled albuterol is 600 mcgs per8 hours (starting from any point), 6 puffs X 90 mcgs per puff would be 540 mcgs. This is within the permitted range of use over 8 hours. However, 7 puffs of the same inhaler within an 8-hour time frame would deliver 630 mcgs, which is over the permitted threshold and would be an anti-doping rule violation.
Continuing through the day, another 6 puffs over the following 8 hours, along with 5 puffs in the final 8 hours (of 24) would also be permitted because the total is less than 1600 mcgs in 24 hours, and the inhaler was used within the permitted dosages in each 8-hour block of time (less than 600 mcgs).
Medical best practices recommend the use of metered-dose inhalers with spacer devices when possible, to optimize medication delivery.
If more inhalations are required to control asthma, a TUE may be needed. You can learn more about TUEs below.
What if I’m on a medication in the class of S5. Diuretics and Masking Agents?
Diuretics affect the way the body metabolizes and excretes beta-2 agonists. There are many medications that fall into this category including medications for altitude sickness, some blood pressure medications, water pills, acne pills or creams (spironolactone), medications to treat kidney disease, and others.
If you are on a diuretic medication (or on any other substance in the S5 category of the Prohibited List, including examples such as spironolactone and hydrochlorothiazide) for any reason and you are using an inhaler that contains salbutamol (albuterol) or formoterol, then you may need a TUE. You can learn more about TUEs below.
What if my doctor prescribes a syrup, tablet, or a nebulizer?
Use of an oral (swallowed) form of any beta-2 agonist, such as a tablet or syrup, or use of an albuterol or formoterol nebulizer is prohibited at all times, and may require a TUE. You can learn more about TUEs below.
Do I need a TUE for my inhaler?
Based on the anti-doping status of your inhaler and your competition level, you may need a TUE.
Athletes should submit a TUE Pre-Check Form to determine if a TUE is necessary.
More questions?
For questions about specific products, substances, and methods, contact USADA’s Drug Reference Line at drugreference@USADA.org or call (719) 785-2000, option 2.
All other beta-2 agonists, regardless of route of administration, are prohibited at all times and at all dosages!
For example, the threshold doses above do not apply to arformoterol or levalbuterol. Athletes using inhalers containing arformoterol or levalbuterol should see the Therapeutic Use Exemption (TUE) section below.
To find out whether your inhaler is permitted in sport, search for the brand or individual ingredients on GlobalDRO.com.
- If the status says “Not Prohibited,” then you can use your inhaler as prescribed.
- If the status says “Conditional,” it means there is a dosage threshold. The Additional Information section on your Global DRO search results will describe the permitted dose.
- If the status says “Prohibited,” then you should see the TUE section below.
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