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. 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 rules.
Can I use my asthma inhaler in sport?
Inhalers that contain glucocorticoids are permitted.
However, ALL inhaled beta-2 agonists are either prohibited, or only allowed under a certain dose.
There are four inhaled beta-2 agonists that are permitted by inhalation under a certain dose:
Inhaled albuterol (also called salbutamol): maximum 1,600 micrograms over 24 hours in divided doses, not to exceed 800 micrograms over 12 hours starting from any dose, as long as it is not used in conjunction with a diuretic or masking agent
**Effective January 1, 2022, the daily dosing time interval for albuterol (salbutamol) will be reduced to 600 micrograms over 8 hours (the maximum daily limit remains 1,600 micrograms).
Inhaled formoterol: maximum delivered dose of 54 micrograms over 24 hours, as long as it is not used in conjunction with a diuretic or masking agent
Inhaled salmeterol: maximum 200 micrograms over 24 hours
Inhaled vilanterol: maximum 25 micrograms over 24 hours
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.
How do I figure out the dosage per puff on my inhaler?
Your inhaler will show the dosage of each active ingredient in milligrams (mg) or micrograms (mcgs). You can use the dosage per puff, and the permitted dose, to calculate how many puffs you can have per day in sport.
For example, for an albuterol (salbutamol) inhaler that delivers 90 micrograms/puff:
90 micrograms per puff X 6 puffs = 540 micrograms
From the WADA Prohibited List, the maximum permitted dosage of an albuterol (salbutamol) inhaler is 1,600 micrograms over 24 hours in divided doses, not to exceed 600 micrograms over 8 hours
Takeaway: You could take 6 puffs of the albuterol inhaler in an 8-hour period without incurring an anti-doping rule violation, but 7 puffs would exceed the maximum dosage allowed over an 8-hour period
An athlete could take 6 puffs in the first 8 hours, 6 puffs in the following 8 hours, but only 5 puffs in the remaining 8 hours of the day without the need for a TUE.
Some inhaled products contain a combination of a glucocorticooid and a beta-2 agonist. There is no limit to how much glucocorticoid you can inhale, but the four permitted inhaled beta-2 agonists (vilanterol, formoterol, albuterol, and salmeterol) have maximum daily limits to calculate.
For example, Symbicort is a combination inhaled product that contains budesonide and formoterol. It is common to see the dosages (prescription dependent) listed in this format: 160/4.5. One number is the dosage of the budesonide and the other number is the dosage of the formoterol. If you read the packaging carefully, it will state exactly how much of each ingredient is in each “actuation” (puff, or inhalation).