BRIEF REPORT Impact of Changes in Anti-doping Regulations (WADA Guidelines) on Asthma Care in Athletes Mariana Couto, MD,*† Luís Horta, MD, PhD,‡ Luís Delgado, MD, PhD,*† Miguel Capão-Filipe, MD,*§ and André Moreira, MD, PhD*† Objective: To investigate how changes to the World Anti-Doping Agency (WADA) guidelines on asthma medication requests have impacted the management of asthmatic athletes in Portugal. Design: Retrospective analysis of asthma medication requests submitted in 2008 to 2010. Setting: Portuguese Anti-Doping Authority database. Participants: Athletes requesting the use of inhaled corticosteroids and/or b 2 -agonists. Independent Variables: Demographic, therapeutic, and diag- nostic test data. Main Outcome Measures: Yearly changes in number of asthma medication requests and diagnostic procedures. Results: We analyzed 326 requests: 173 abbreviated Therapeutic Use Exemptions in 2008 (objective tests not required), 9 Declaration of Use (DoU) and 76 Therapeutic Use Exemptions (TUEs) in 2009, and 39 DoU and 29 TUEs in 2010. Spirometry was performed in 87% and 37% of athletes in 2009 and 2010, respectively; the corresponding figures for bronchoprovocation were 59% and 16%, almost all positive in both years. Conclusions: Applications for inhaler use have decreased by app- roximately half since objective asthma testing became mandatory. Our findings show that WADA guidelines have an impact on asth- matic athletes care: In 2009 a more rigorous screening was possible, leading to withdrawal of unnecessary medication. Constant changes, however, jeopardize this achievement and nowadays introduce safety issues stemming from the unsupervised use of inhaled b 2 -agonists. Key Words: asthma, airway hyperresponsiveness, anti-doping, bron- choconstriction, exercise, inhaled beta-2 agonists, sports, WADA (Clin J Sport Med 2012;0:1–3) INTRODUCTION Diagnosing asthma in athletes is challenging. Multiple phenotypes of asthma exist, and different underlying mech- anisms contribute to etiopathogenesis. 1,2 Also, alternative diagnoses must be considered, 3 and in athletes, symptoms are poor predictors of this condition. 4 Objective evidence (eg, positive bronchodilator or bronchoprovocation test), thus, is needed to confirm a diagnosis in this setting. 5 The recommendation of the International Olympic Committee Medical Commission (IOC-MC) for Olympic athletes to present objective evidence of asthma before allowing the use of inhaled b 2 -agonists (IBAs), in place since 2002, has facilitated the study of how asthma impacts differ- ent sports and has benefited athletes by ensuring better care. In 2009, the World Anti-Doping Agency (WADA) followed the IOC approach, extending it to all other athletes. 6 The WADA guidelines on asthma, however, have changed in recent years. Before 2009, an abbreviated Therapeutic Use Exemption (aTUE), which did not require objective evidence of asthma, accompanied by a physician’s report of asthma, was sufficient for requesting permission to use inhaled corti- costeroids (ICS) and inhaled formoterol, salbutamol, salme- terol, and terbutaline. In 2009, although, aTUEs were withdrawn and replaced by a Declaration of Use (DoU) for ICS and a full Therapeutic Use Exemption (TUE) requiring objective evidence for the same 4 IBAs. In 2010, the DoU was extended to salbutamol and salmeterol, but the other IBAs still required a TUE. The aim of this study was to assess the impact of WADA guideline changes on asthma medication requests by Portuguese athletes. METHODS We retrospectively analyzed asthma medication requests submitted to the Portuguese Anti-Doping Authority between 2008 and 2010. Athletes older than 16 years who requested permission to use ICS and/or IBAs for more than 3 months were included. Data on respiratory symptoms, medication requested, spirometry, and atopy (at least 1 positive skin prick test or positive specific IgE) were collected. A diagnosis of asthma was based on a positive bronchodilator test or broncho- provocation test. 5 Exhaled nitric oxide results were converted to personal predicted values using the FeNO Interpretation Aid tool (http://www.enovis.org) and considered increased if above 150% of predicted. Data were expressed as median and range, and categorical variables were compared using the x 2 or Fisher Submitted for publication January 08, 2012; accepted July 05, 2012. From the *Allergy, Asthma & Sports Unit, Immunoallergology Department, Centro Hospitalar São João E.P.E., Porto, Portugal; †Immunology Labo- ratory, Faculty of Medicine, University of Porto, Porto, Portugal; ‡Anti- Doping Authority of Portugal, Lisbon, Portugal; and §Internal Medicine Department, Baixo-Vouga Hospital Center, Aveiro, Portugal. The authors report no financial or conflicts of interest. Correspondence Author: Mariana Couto, MD, Serviço de Imunoalergologia, Centro Hospitalar São João, EPE, Alameda Prof. Hernâni Monteiro 4200-319 Porto, Portugal (marianafercouto@gmail.com). Copyright © 2012 by Lippincott Williams & Wilkins Clin J Sport Med  Volume 0, Number 0, Month 2012 www.cjsportmed.com | 1