The Yates Case: Turmoil with Terbutaline and TUEs

simon yates dauphine 2015 orica greenedge COR VOS
Yates in action at the 2015 Critérium du Dauphiné

Thursday’s news of Simon Yates’ positive test for asthma drug Terbutaline capped a horrific week for British Cycling, with the various Shane Sutton-related scandals that also exploded this week still ongoing. Combined, the scandals have made for a disastrous run-in to the Tour de Yorkshire, one of the flagship events of the British racing calendar..

Others with more interest in track cycling and more knowledge of women’s cycling than I have analysed and picked apart the Sutton scandals better than I ever could (Anne-Marije Rook, Sarah Connolly, Helen Pidd), but the focus here will be on the Yates case.

The Basics

On Thursday British newspaper The Daily Mail teased the positive test of a British ‘track star’ who was gunning for an Olympic road race spot, adding that the test was recorded at a French race in March. Twitter detectives (me included) swiftly concluded that it was likely Simon Yates, an assumption which was soon confirmed by the paper.

The drug that the 23-year-old had tested positive for was Terbutaline, one of the few not yet familiar to cycling fans, doing so on stage six of Paris-Nice. His team, Orica-GreenEdge confirmed this via press release, noting that use of the substance was declared on the Doping Control Form when Yates took the test. The team goes on to say that they were informed on April 22nd and adding that the reason for the positive test was that “a team doctor made an administrative error by failing to apply for the TUE required.”

At the time of writing, there is much to unpack and Yates’ status is up in the air as he waits for the UCI to review his documentation before they rule on the case. As Terbutaline is not a specified substance (a substance more susceptible to a non-doping explanation), Yates is not provisionally suspended per the UCI’s Anti-doping rules, section 7.9.1.

The drug, and its legality

Before getting to the ins and outs of the case, what is Terbutaline? Put simply, it’s a bronchodilator, a substance which dilates bronchial passages, opening the airways and increasing airflow to the lungs.

When inhaled, it’s fast-acting and the effects can last for six hours – that’s slightly longer than the more common Salbutamol. Basically it’s an asthma medication, also used to delay preterm labour in pregnant women.

A beta2-agonist, the drug is prohibited for use in sports, per WADA’s Prohibited List. As opposed to similar asthma drugs Salbutamol, Formoterol and Salmeterol, which are allowed in some doses without a TUE, Terbutaline use is only allowed if the user has a TUE.

wada prohibited list beta2 agonists

The effects of this group of drugs on athletic performance are much debated, with a number of medical studies contradicting one another. For example, this 1996 study concludes that beta2-agonist do not increase physical performance in top athletes, and this 2011 study found no significant effects on healthy athletes from the drugs.

On the other hand, this 2000 study tells us that Salbutamol increases muscle strength and endurance in non-asthmatics, while this study from the same year notes that Salbutamol improves performance during sub-maximal exercise. Meanwhile, this 2004 study suggests benefits for endurance athletes. It should be noted though, that these studies used far greater quantities of the drug than a regular asthmatic would inhale.

However, those studies did not include Terbutaline. A 2013 study specifically dealing with the drug found that the substance aids anaerobic ability and muscle strength while endurance suffered due to the drug’s side-effects.

I spoke to Dr John Dickinson from the University of Kent, an expert on asthma in sport, and he confirmed this.

More recent studies suggested that Terbutaline can improve strength and power performance. Even to get those you’d need to take quite high doses of it. Linking back to the guy who is in the news today – it’s not really likely to improve endurance performance, as far as we know.

simon yates orica greenedge dauphine 2015 COR VOS
Yates donning the best young rider’s jersey at last year’s Critérium du Dauphiné

Asthma in pro cyclists – really?

Whenever a case related to asthma medication comes up, many people react with shock – how could so many athletes, these peak physical specimens, suffer from asthma?

Dr Dickinson, who conducted a study on this subject in 2014, says that this is not so strange after all. He found that 70% of swimmers from the British swim squad have some form of asthma, while a third of Team Sky riders were found to suffer from it. That’s against a national rate in the UK of 8-10%.

Rather than suffering from classic asthma (caused by genetics or environmental factors) though, this is exercise-induced asthma. The symptoms are similar but the condition is instead caused by the heavy, fast breathing induced by exercise. This form of asthma is what Team Sky’s Chris Froome claims to suffer from.

Dickinson reaffirmed his findings when I talked to him.

Exercise-induced asthma, on the spectrum of asthma, is on the milder end of it. Most elite athletes who do have it purely have exercise-induced asthma – they only get it when they’re at the top end of their high intensity exercise, which is increasing their exposure to things that trigger an asthma attack.

The majority of them would be mild to moderate cases. When they’re not training or competing they’re unlikely to suffer.

TUEs

Chris Froome claimed not to have one, the CIRC Report said they were abused, and Orica-GreenEdge forgot to apply for one at Paris-Nice. Therapeutic use exemptions have been in the news a lot over the years. They are, in effect, special permissions for athletes to use an otherwise prohibited substance in order to treat a legitimate medical condition.

In order to obtain a TUE for Terbutaline, WADA specifies that along with the request itself, an athlete must submit their full medical file (see below for what that entails).

medical information required for asthma tue - wada

After the CIRC Report found that the UCI’s TUE process was deficient, noting that Froome’s TUE at the 2014 Tour de Suisse was processed by one person. Since then, the UCI has put into place a TUE Committee, a six-person panel, three of which look at each TUE request before a final decision is made about the request.

There are several conditions that must be met before a TUE can be granted, and as a result of the introduction of these measures and the introduction of the TUE Committee, the number of TUEs granted annually by the UCI has decreased year on year (see below for both).

conditions for granting tue, tues annually granted - uci

So it’s pretty thorough, right? Seemingly so, but the system can still be gamed as we have seen in athletics with the coach of the Nike Oregon Project, Alberto Salazar.

After a doctor declined her medication in 2004 for the exercise-induced asthma she was experiencing, Salazar set up an appointment at the Nike Oregon Project with a doctor who had an established protocol. The athlete must go to the local track, run around it, work herself up to having an asthma attack, run down the street and up 12 flights of stairs to the office where the doctor “would be waiting to test you”. Fleshman did this, failed her health test, and was duly prescribed the Advair brand for the duration of the racing season when the pollen count was highest, as well as rescue inhaler Albuterol.

There have been no cases like that in cycling (that we know of anyway), but given the history of the sport it would hardly be a surprise.

With this in mind it seems inevitable that we will see questions arise in relation to Yates’ forgotten TUE (and presumed past TUEs). Is his need for Terbutaline legitimate? Or could a TUE be falsified, Salazar-esque, in a bid to obtain the perceived performance gains? It’s a question that can, and has been applied to every case like this in the past – this culture of suspicion is the norm in our sport.

The BBC’s Matt Slater confirmed via Twitter that Yates had not previously had a TUE for Terbutaline. This fact changes things; with no previous TUEs to point to it will be hard, even impossible, for Yates and the team to prove that his use of Terbutaline was in response to a legitimate medical need (presumably Yates was using Salbutamol previously).

As for the choice of Terbutaline over Salbutamol, Dickinson notes that the differences in effect between the two are negligible.

Sometimes athletes choose Terbutaline because they don’t get along with Salbutamol – either it’s not working well for them or they get more side-effects. There’s not really, from an asthma treatment point of view, that much difference. The effects can last a bit longer so that might be a reason for a cyclist to use it.

And if you’re wondering, as many are, why Terbutaline usage requires a TUE while other asthma drugs don’t; Dickinson has the answer for that too.

The reason Terbutaline needs a TUE and Salbutamol doesn’t is more down to the way the tests differentiate between oral and inhaled form. With Salbutamol it’s quite clear that if level in urine is above 1000ng/mL it’s likely that you’ve taken an oral dose. Whereas with Terbutaline it’s quite difficult to tell the difference between an oral and inhaled dose, so you can’t differentiate between the two.

Questions about Orica-GreenEdge

The Australian squad, who left the MPCC earlier this year, aren’t exactly known for a history of positive tests, unlike some other teams in the peloton, though this incident does bring the team and their staff into the limelight.

First though, lets consider the “administrative error” claim. Considering that TUE applications are not guaranteed to be accepted, it seems somewhat disingenuous to basically claim that the process was a done deal and that all that was missing was the application itself. Given the strict documentation guidelines laid out above, the granting of a TUE was not a given.

The grave error in communication is a worry – surely the priority is to get the TUE approved first before using the drug? Maybe Yates and other team staff assumed that it was granted, but this case just goes to show how important vigilance and double-checking are with regard to TUEs

Just as troubling has been the team’s employment of Spanish doctor Manuel Rodríguez Alonso. Having worked for ONCE and Mapei in the 1990s, he later worked at QuickStep, where Patrik Sinkewitz named him as a provider of cortisone, human growth hormone and EPO.

Alonso has been employed at the team for several years, though it is unknown whether he is still with the team as the website does not list staff members. Given his history though, the fact that Alonso has been associated with the team doesn’t look great.

Yates was World Champion in the points race at the 2013 Track WorldsYates was World Champion in the points race at the 2013 Track Worlds

Conclusion

Ultimately my thoughts were that this situation is the result of an honest mistake by the team, as they had claimed. However, the lack of a previous TUE for the drug does muddy the waters somewhat.

The fact that asthma medication does not have a great effect on athletic performance has not stopped cyclists from abusing them in the past. However, it makes no sense that a rider would risk purposely using Terbutaline without a TUE, given the certainty of being caught if tested.

Regardless, considering Yates’ lack of TUE history for the drug, the outlook for him isn’t great. A ban looks likely, though the length should be a matter of months rather than years. Past Terbutaline cases have included a cyclist (4 months), a swimmer (3 months) and a kayaker (2 months).

As ever, it will be some time before this case reaches its conclusion, but we can thank Orica-GreenEdge’s failure to apply for a TUE for bringing the issue to the forefront once again, letting us take another look at this problematic corner of the sport.

The MPCC just got even smaller

Tour of Qatar 2016 - Elite - Stage 5
Katusha at the Tour of Qatar earlier this season (Cor Vos)

Yet more teams leave the voluntary organisation

WorldTour teams Katusha and Orica-GreenEdge have become the latest teams to leave the Movement For Credible Cycling (MPCC) this week. It leaves the France-based organisation with just seven teams in the sport’s top tier, with seventeen remaining at ProContinental level.

The latest withdrawals continue the exodus of last year, when five teams left the group, with a variety of reasons cited.

Lampre-Merida (9 March 2015) – Quit after hiring Diego Ulissi, when MPCC rules stated they would have to wait another year to do so.

Bardiani-CSF (4 June 2015) – Left after a fallout over an unnamed rider who rode the Giro d’italia with low cortisol levels.

LottoNL-Jumbo (10 June 2015) – Fell out with the organisation after being forced to withdraw George Bennett from the Giro due to low cortisol levels.

Astana (4 September 2015) – Kicked out after letting Lars Boom start the Tour de France with low cortisol levels.

Southeast (20 June 2015) – Chose to leave rather than suspend itself from racing after Ramon Carretero’s EPO positive.

Meanwhile, Katusha have found a delightfully contrived reason to leave, and thus avoid the mandatory self-suspension had they stayed aboard. With the team cleared to race by the UCI Disciplinary Commission in the wake of Luca Paolini and Eduard Vorganov’s positive tests, they claim that they will fall foul of a mandatory participation rule should they self-suspend from racing.

“A suspension of Team KATUSHA during a WorldTour race based on the MPCC Rules would violate the UCI Regulations of mandatory participation and the Disciplinary Commission would then be obliged to sanction the Team.”

The remainder of the press release goes on to state how dismayed the team is with the MPCC for not bringing their team suspension rules (8 days for 2 positive B-Samples) into line with the UCI’s (15 days for 2 positive A-samples), before reaffirming their commitment to clean cycling.

However, we have already seen teams suspended from racing in similar situations, notably AG2R La Mondiale in 2013 – the French team missed the Critérium du Dauphiné and were not punished by the UCI.

Katusha meanwhile, have taken this nice opportunity to leave the group whose rules, considering the team’s past, are likely to cause them trouble at some point in the future, as well as preventing themselves from missing any important Spring races.

Santos Tour Down Under 2016 stage 4
Simon Gerrans at the Tour Down Under (Cor Vos)

Onto GreenEdge, and their exit is an interesting one, being as they are the only team so far that isn’t departing under a cloud of controversy. Their reasoning is altogether different to any given previously, too.

As general manager Shayne Bannan noted via press release, several initiatives put in place by the MPCC “have now become an integrated part of the rules of the sport.” So if many of the MPCC’s rules have already been incorporated into the UCI’s rulebook, teams see no reason to stay part of what they see as a now largely useless organisation.

The no-needle policy has been adopted by the UCI, as has the idea of team suspensions, while the CIRC Report reccomended that the cortisone rules also carry over. Meanwhile, UCI President Brian Cookson has already talked about a possible tramadol ban.

Hark back a handful of years and remember that both teams joined the organisation in order to look good. Katusha joined up while fighting the UCI in CAS for the right to stay in the WorldTour, while GreenEdge came aboard at a time when key staff members such as Matt White and Neil Stephens faced suspicions about their pasts.

Conclusion

The MPCC has, in many cases only been useful to teams for a PR boost – as we have seen in the past many find themselves leaving when they are inconvenienced by rules.

Still, it is hard to deny that the organisation is facing increased irrelevancy – yes, teams are jumping ship but the rules they had put in place have been adopted by the UCI. Only there are certainly more fronts to fight on in the war against doping, and no doubt more issues to highlight.

The MPCC’s strong relationship with the ASO is another wrinkle to this situation – Tour de France organiser has said in the past that members would be prioritised for Tour invites. Should the ASO vs UCI standoff remain in place, then the lineup of teams in future ASO races could get more interesting.

In spite of this, the prospect of teams flip-flopping in and out to please Prudhomme doesn’t seem too probable. And would he really refuse invitations to non-members such as Sky and Etixx-QuickStep? It’s unlikely.

Putting these hypotheticals aside, and despite its seemingly increasing redundancy, the MPCC remains an organisation that can make real differences in cycling. We have already seen that it can bring important issues to the fore, and should continue to do so, at least while it still has the power (via the members it holds on to) to have a voice.