Doping

I want to know how much of David Millar has died this time?

puff adder

If we had #rep, that would have earned some.

I'm going to guess he smashed his inhaler after a stage. Did a wee test and it's higher than it should be.

This seems like a fairly plausible explanation. If he smashed his inhaler during the stage then there would be plenty of video/pictures to show this. Salbutamol is short acting and drops off quite quickly within a few hours so it couldn't be blamed before the start of the stage.

Taking more than 2-4 puffs during the last hour of racing would be pretty pointless as he wouldn't bronchodilate any more. It would only serve to make him tachycardic which would be detrimental.

Not enough.

Taking more than 2-4 puffs during the last hour of racing would be pretty pointless as he wouldn't bronchodilate any more. It would only serve to make him tachycardic which would be detrimental.

Depends when he took the previous dose and, by inference, how bronchoconstricted he was by then. Tachycardia is unlikely with normal inhaled doses, that's why we use them in preference to the old (i.e. my school days) 4mg tablets - faster action, reduced (pretty much eliminated, for most people) side effects.

Oh please don't assume ignorance. Frankly I have got to the point of not caring. At least with Wiggins they did it by the book, this is just sloppy.

Oh please don't assume ignorance.

What would you like me to take from the proposition that another doping story materially affects your interest in the sport? I'd have thought anybody over 10 was long past the point where another one made any difference.

At least with Wiggins they did it by the book

Which book? This one?

Froome's AAF is consistent with taking permitted doses of a substance for which there is scant evidence of performance enhancement when taken in the quantities and route of administration he probably used. Wiggin's TUE is consistent with shopping his medical condition around until he could find a doctor who would put his name to the idea that the PED Wiggin's wanted to use was the best and, for his patient, only suitable treatment. There are alternative explanations available in either case, but in the Froome case the alternatives look improbable, while in the Wiggins case they only change the nature of the wrongdoing.

I havent read all the way through the thread, so apologies if anyone else has already pointed this out.

As @mdcc_tester points out, the evidence for salbutamol​ being performance enhancing in endurance athletes is questionable at best. Even in inhaled form it regularly causes tachycardia and can also precipitate hypokalemia, both of which are not desirable. In fact, we can give salbutamol to treat hyperkalemia in a hospital setting.

However, nobody should be requiring that amount of salbutamol to control their asthma. The British thoracic society has a very clear set of recommendations for this, including long acting beta2 agonists and inhaled steroids etc. The steroid drugs would presumably require a TUE, which after Wiggins, Sky may be keen to avoid, but there are certainly other more effective therapies for asthma that don't require industrial quantities of salbutamol.

It doesn't all quite add up. Anyone with a medical degree would not be treating Froome with all that salbutamol, so either Sky needs a better doctor or something else is going on.

The steroid drugs would presumably require a TUE

The first line steroid for asthma in the UK is beclomethasone, which doesn't require a TUE for inhalation in normal doses. The WADA code doesn't define normal, but NICE says up to 1600μg a day. We don't know whether Froome is using that too, but there's no reason to suppose that he isn't.

there are certainly other more effective therapies for asthma that don't require industrial quantities of salbutamol

It's normal, AFAIK, for people with exercise induced asthma (alongside other triggers) to have good control of symptoms with beclomethasone (or alternative steroids) alone as long as they are more or less sedentary, but to require significant amounts of salbutamol (or other β2 agonists) if they engage in intensive exercise, especially if aggravating factors like pollen, dust or unhelpful temperature or humidity are also present. Not everybody gets good results from the long acting β2 agonists like salmeterol (a friend told me). Given the uncertainty over the pharmacokinetics, we don't really know whether Froome was taking "industrial quantities" or just normal amounts. My idea of industrial quantities would be those which require machinery to deliver, like 10-20mg a day via a nebuliser. I don't suppose your excretion rate would ever drop below 1000ng/ml if you were hooked up to one of these four times a day, but then the only time I've done that I was in hospital with the broken ends of four ribs poking into one of my lungs, so I wasn't going to be climbing any Spanish mountains at the same time :)

Even in inhaled form it regularly causes tachycardia

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Any numbers to go with that assertion? Prevalence and severity of tachycardia for inhaled salbutamol in the usual 2×100μg every 3-6 hours regime? The best I could find was a blanket <10%, which covers a multitude of sins. Since the reported number was only 3% for tablets (typically 4mg) and AFAIK systemic side effects are both more common with oral administration and dose dependent, I'd be a bit surprised if your "regularly" had the meaning understood by laymen.

I think enjoyment of a sport is more nuanced than that, you can't tell me to continue to enjoy it as much as before as some fresh scandal emerges because it has happened before and will happen again. This remains disappointing to me for reasons I can't necessarily articulate.

I mean I watch rugby knowing pretty much everyone on the pitch has taken PEDs, and I have sort of made my peace with it. If anything I believe in cycling more because at least it has been forced to tackle drugs very directly in ways where other, richer sports get a free pass. And so perhaps the disappointment comes from an opportunity denied, progress stalled, cycling's cleaner era postponed for a while.

And so you shrug and carry on, and compromise in your mind again, knowing there is a huge dissonance from what you want, clean sport, and what you actually get. I've made my peace with it, so these days I don't get angry, I'm just disappointed.

Fair enough. I think this is an issue of semantics. Based on my anectodal evidence of patients I have prescribed it for (admittedly hospital inpatients and not men cycling up spanish mountains), ~10% sounds about right, and that's the number GSK quote too. I would consider that significant enough to counsel patients about before prescribing though. Having said that, it's a bit of a throwaway comment because I dont know if that tachycardia is physiologically significant during maximal exercise

I am not a specialist respiratory physician but it's my understanding that patients with poorly controlled asthma (of which, exercise-induced asthma is a usually a sign of) tend to respond to a combination of the other drugs available (of which there are several beyond inhaled steroids and salmeterol), eventually escalating to oral steroids (or an excuse to get some triamcinolone) . I find it somewhat difficult to believe that Froome's asthma is severe enough to warrant any of this as this population of patient are more likely to be seen in ICU or the mortuary than in the red jersey.

It's also now thought that asthma in elite athletes mighht be a different pathology to asthma in the general population, so the optimum management strategies might be different. But there's evidence to suggest that long term salbutamol use induces tolerance and reduces its effectiveness in exercise induced asthma, so simply increasing his dose is probably not best practice.

Having said all that, I do take your point re pharmocokineticsI'm sure we'll be seeing "The effects of altitude and dehydration on salbutamol pharmocokinetics in elite cyclists: a single case report" Brailsford et al. 2017, soon enough...

Having said that, I do take your point re pharmocokinetics. I'm sure we'll be seeing "The effects of altitude and dehydration on salbutamol pharmocokinetics in elite cyclists: a single case report" Brailsford et al. 2017, soon enough.

Hopefully it'll be published alongside their study into the blood values of altitude natives and the biological passport.

#repped lol

Froome’s supposed defence strategy here (in Italian);

http://www.corriere.it/sport/17_dicembre_15/ciclismo-doping-ecco-dossier-sky-48aec066-e112-11e7-acec-8b1cf54b0d3e.shtml?refresh_ce-cp

Given the apparently high prevalence of asthma in the pro peleton, and the lack of regular positives, then you could argue that the (very) arbitrary limit is more or less set to the right level.

If you were Froome's doctor, surely you would have reviewed the above studies and worked out the maximum permitted doses that he could take, and be at 0% risk of ever reaching the limit, even when dehydrated, up a mountain, etc.

I would have thought that a team doctor must balance three things, the riders health, the riders performance and their ability to pass all required doping tests and rules.

Given the apparently high prevalence of asthma in the pro peleton, and the lack of regular positives, then you could argue that the (very) arbitrary limit is more or less set to the right level.

We don’t know if there are many other cases like this though, as the process for an AAF is to give the athlete a chance to explain how it happened. There could be dozens of cases like this where the explanation has been accepted and no further action taken. We just don’t know.

Maybe if he'd just used a TUE for Triamcinilone none of this unfortunate event would have ever happened... it's not like it's illegal or anything. hum.

Given it's status was allegedly changed as an apparent money saving exercise, having to investigate lots of cases would be counter intuative and would surely lead to a change in threshold level.

You’d think so, yes. But the limit isn’t set by the UCI, it’s a WADA specified level, which makes changing it more onerous.

I see Nibali wading in with how many puffs on the inhaler

I can't see how changing the threshold can be any more onerous than changing its classification. Especially if as you have stated the threshold is so arbitrary.

I agree, if there were dozens of cases a year, all with the same defence, all of which involve the rider winning, the threshold would be changed.

It's also now thought that asthma in elite athletes mighht be a different pathology to asthma in the general population

As we go down the track of individualised medicine, we'll probably stop talking about asthma and start discussing asthmas. The range of triggers, the interactions between them and the variation in individuals from one day or decade to the next all point to asthma being a symptom of a suite of pathologies.

having to investigate lots of cases would be counter intuative and would surely lead to a change in threshold level

The trouble with changing the threshold level would be that dopers using 8mg a day orally for the anabolic effects might not get caught. If the urine test for people using permitted doses ranges from <300 to >3000ng/ml (>10:1 ratio), you can probably see why raising it significantly would cause problems when you're trying to catch people doping with only 5 times the permitted daily dose.