The World Anti-Doping Code International Standard Prohibited List (Prohibited List) specifies substances and methods that are prohibited in sport, including substances and methods that are prohibited In-Competition only, as well as those that are prohibited at all times.

Below is important information about the use of Methylphenidate (e.g. sold under the brand names Ritalin, Neucon, Concerta, etc.), and Beta-2 Agonists which are found in many inhaled medications (e.g. Relvar) – what it involves, and the required protocol to follow when the medication is legitimately required.

WORLD ANTI-DOPING CODE PROHIBITED LIST – 2024

• Methylphenidate is categorised under S6 – STIMULANTS [S6.B: SPECIFIED STIMULANTS], and is PROHIBITED IN-COMPETITION only.
• Beta-2 Agonists is categorised under S3 – BETA-2 AGONISTS, and is PROHIBITED AT ALL TIMES (IN- AND OUT-OF-COMPETITION).

BACKGROUND

Asthma, Attention-Deficit Hyperactivity Disorder (ADHD) and Attention-Deficient Disorder (ADD) are medical conditions that may necessitate medication to optimise and maintain an individual’s health. However, medications used for these conditions contain substances that are prohibited in sport by the World Anti-Doping Agency (WADA). For athletes subject to Anti-Doping Rules (ADR) and drug testing, it is essential to understand how to use some of these medications in order to comply with ADR as outlined in the Prohibited List.

This advisory aims to inform Athletes and Athlete Support Personnel (ASP) about the implications of misusing such medications in sport, and the process to follow when required to obtain a Therapeutic Use Exemption (TUE) for authorised use. Athletes can continue using the prescribed medications while competing, providing they apply for, and receive an approved TUE. The sport, as well as the level that you compete in, in that sport, determines whether you need to apply for a TUE in advance, or retroactively. Please see “Annexure A – Who Needs to Apply for a TUE in Advance” to determine what you are required to do.

ADVISORY ON METHYLPHENIDATE-CONTAINING MEDICATION FOR CHILDREN AND ADULTS DIAGNOSED WITH ADHD AND ADD

ADHD and ADD are mental health disorders. Their presence and severity may necessitate the use of stimulant medications containing Methylphenidate and Phenethylamine found in brands such as Ritalin, Neucon, Concerta, etc. In the majority of sport codes, improved attention or focus has the potential to increase an athlete’s performance. As such, the use of stimulant-containing medication prescribed as treatment for a lack of attention or focus after an ADHD or ADD diagnosis, requires an extremely high level of scrutiny in accordance with best clinical practice, to avoid such medications being abused in sport. Where required and as per Annexure A, athletes with ADHD and ADD must apply for a TUE to use such medications.

Where do I start?

Before applying for a TUE for ADHD or ADD medication, athletes must demonstrate that the medication is necessary to treat a diagnosed condition, supported by medical documentation, in order for the athlete to return to normal health. Evaluation and diagnosis of ADHD or ADD must be made by a paediatrician, psychiatrist, and/or another specialised physician, and a second opinion from a licenced medical practitioner is recommended. The medical documentation should also show the prohibited medication is necessary because there are no other reasonable treatment alternatives.

A checklist for TUE applications specific to ADHD can be found at:
https://www.wada-ama.org/sites/default/files/2023-12/tue_checklist_adhd_-_version_7.1_-_october_2023.pdf

ADVISORY ON INHALED ASTHMA MEDICATION USE IN SPORT

Asthma or chronic respiratory conditions (e.g. Chronic Obstructive Pulmonary Disease), often requires the use of inhalers containing substances classified as Beta-2 Agonists, and which are prohibited in sport at all times. Under these conditions, athletes may be able to compete once they have obtained an approved TUE where required, and as per Annexure A.

Note that certain inhaled Beta-2 Agonists can be used up to certain concentrations without a TUE, as listed below. Please inform your medical doctor that you are an athlete subject to drug testing and show him/her this table below so that he/she prescribes your dosage and use in accordance with these levels.

• Inhaled Salbutamol: permitted up to a maximum dose of 1600 micrograms over 24 hours in divided doses, and not to exceed 600 micrograms over 8 hours starting from any dose.
• Inhaled Formoterol: permitted up to a maximum delivered dose of 54 micrograms over 24 hours.
• Inhaled Salmeterol: permitted up to a maximum dose of 200 micrograms over 24 hours.
• Inhaled Vilanterol: permitted up to a maximum dose of 25 micrograms over 24 hours.

ADVISORY ON THERAPEUTIC USE EXEMPTIONS

At any time that an athlete requires the use of prohibited substances, such as those outlined above, and which are on the annually updated WADC Prohibited List, South African athletes have to apply for a Therapeutic Use Exemption (TUE) to the South African Institute for Drug-Free Sport (SAIDS) where required, and as per Annexure A. A TUE allows an athlete to use a prohibited substance at a specified dosage and frequency, and for a defined period, without facing a possible Anti-Doping Rule Violation should there be an Adverse Analytical Finding after being tested. Applications for TUEs are evaluated by a panel of physicians, and approval is subject to specific criteria, as outlined in the International Standard for Therapeutic Use Exemptions (ISTUE), which is a policy that harmonises the process of
granting TUEs across all sports and all countries. TUEs ensure an unequivocal entitlement to appropriate medical care, while monitoring the possibility that prohibited substances could be misused for performance enhancement.

When considering a TUE application, the Therapeutic Use Exemption Committee looks for answers to the following questions:

• Has evidence of appropriate investigations been provided to support the clinical diagnosis?
• Has this been endorsed by an appropriate medical specialist?
• Would denial of this application jeopardise the health of the patient?
• Are there non-prohibited, alternative medications that can be used instead?
• If so, is there supportive evidence that their use was ineffective?
• Could this clinical condition be the result of the prior use of a prohibited substance?

Process for applying for a TUE:

• Check the WADC Prohibited List and SAIDS Medication Check tool to determine if the medication/method which the athlete intends to use, is prohibited or not.
• Inform your physician of your athlete status and competitive Level, and explore non-prohibited alternatives if available.
• National-Level athletes must apply for a TUE in advance, while other athletes may apply retroactively after being tested by SAIDS or another Anti-Doping Organisation, and they produce an Adverse Analytical Finding. Please refer to Annexure A to check your status and whether you need to apply for a TUE in advance or retroactively.
• TUE applications for In-Competition Prohibited Substances require submission at least 30 days before the next competition.

The ultimate goal of the TUE system is to create a level playing field for athletes worldwide. For further information, please refer to https://drugfreesport.org.za/tue/.

WHAT CAN INDIVIDUALS DO WHO SUSPECT THAT ANY MEDICATION IS BEING ABUSED OR MISUSED IN SPORT?

SAIDS is aware that asthma, and ADHD and ADD medications are potentially being misused in sport, and which can lead to serious consequences for an athlete’s health and career. Athletes and their ASP are urged to familiarise themselves with the WADC regulations, utilise non-prohibited alternatives where possible, and apply for TUEs when and where necessary.

Note: If you are aware that a parent, athlete, coach, manager, doctor, Athlete Support Personnel, and/or any other individual may be using, providing, or prescribing the above medications without the required approval, authority, or legitimate prescription, please contact SAIDS, including as much specific and detailed information as possible (who, where, what, based on what, how do you know, which sport/discipline, future events), on the “Report Doping” link at http://drugfreesport.org.za/contact-us/, or contact SAIDS at info@saids.org.za. All information is kept confidential.

Further information and assistance, resources, and a link to the 2024 Prohibited List are available on the SAIDS website, www.drugfreesport.org.za.