dopingbroschure2_e_55959

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Erythropoietin Blood Doping


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Introduction to Erythropoiesis

Erythropoiesis is part of a large process of haematopoiesis

that involves the production of mature cells found inthe blood and lymphoid organs. Haematopoiesis iscontinuously required because of normal turnover incell populations of blood and lymphoid organs. In thenormal adult human, the daily turnover of erythrocytesexceeds 1011 cells. ln periods of increased erythrocyteloss due to haemolysis or haemorrhage, the productionof erythrocytes increases rapidly and markedly. However,an overproduction of erythrocytes does not occur evenafter the most severe loss of erythrocytes.

ln haematopoiesis, a few rare haematopoietic stem cellsin the bone marrow proliferate and differentiate to giverise to all the cellular components of the blood and thelymphoid system. During this process, an individualhaematopoietic cell undergoes an apparent randomprocess called commitment. When a cell undergoescommitment, its proliferation becomes limited and itspotential to develop into multiple types of mature cellsis restricted. Thus, these haematopoietic cells are referredto as committed, lineage-specific progenitor cells.

The major stages of differentiation in mammalianerythropoiesis are:

The most immature stage of committed erythroidprogenitors is the burst-forming unit-erythroid(BFU-E).

The next major stage of erythroid progenitor cell

development is the colony-forming unit-erythroid(CFU-E).

A continuum of erythroid progenitor stages existsbetween the BFU-E and CFU-E, with decreasingproliferative potential as the progenitors approach theCFU-E stage.

The descendant cells of the CFU-E are termederythroid precursor cells.

The erythroid precursors are proerythroblasts,basophilic erythroblasts, polychromatophilicerythroblasts and orthochromatic erythroblasts. Theorthochromatic erythroblasts do not divide but theyenucleate, forming the nascent erythrocyte called thereticulocyte.

Production of Erythropoietin

EPO is a 30,400 molecular weight (MW) glycoproteinhormone produced mainly in the kidney, in the liver(


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the IOC Medical Commission decided to ban this drugin 1990 even though all forms of blood doping werealready officially banned since 1984. Two philosophieswere developed for the detection of rhEPO abuse in

sports. The first was based on the detection of indirectblood markers and the second was based on the directdetection of rhEPO in urine. The promotion ofsecondary blood markers was based mainly on the factthat they could be used to detect rhEPO injectionsperformed a long time ago (more than a week) andalso that they could be used to detect all kinds oferythropoietic stimulators such as erythropoietin , ,, , darbepoitin and mimetic peptides. Furthermore,secondary blood markers could eventually be usedto detect athletes who ceased using rhEPO or othererythropoietic stimulators. In the meantime, scientistswere working on the direct detection of rhEPO in bloodor urine. This latter detecting method had the advantageof identifying the drug itself (or metabolites), but hadthe disadvantage of being expensive, of low sensitivityand delicate to perform.

Indirect Methods

With the introduct ion of s ophistica ted haema tologicalanalysers in 1993, some scientists proposed a modelimplicating the analysis of the percentage of redblood cells having a mean corpuscular haemoglobinconcentration below 28 pg (MCH) and a meancorpuscular volume above 128 fl (MCV). These redblood cells are called macrocytic hypochromaticerythrocytes. This test had the advantage of being fastand cheap (as long as the laboratory was equippedwith this special analyser) and was very selective.Unfortunately, the test was limited by a relatively poorsensitivity, as 50% of the rhEPO samples were notdetected.

Anot her indir ect test was devel oped in 19 96 f or thedetection of rhEPO abuse, based on the determinationof the sTFR(serum transferin receptor)/ferritin ratio.The results obtained during a trial involving healthysubjects demonstrated that regular rhEPO injectionssignificantly increased the sTFR concentration.Ferritin was used as a denominator mainly to controlhydration level variations. Unfortunately, during thistrial, the ferritin level collapsed, because the subjectsdid not receive any iron supplies. Knowing that ironsupplementation was common practice among athletes(especially intravenous iron injections), the sTFR/ferritin ratio was modified into a new ratio taking into

account possible exercise induced haemoconcentration,the sTFR/total protein.

The lack of sensitivity of some of the secondary blood

markers as well as the lack of specificity of some othersencouraged scientists to put them together in orderto obtain a multiple-marker mathematical model todistinguish rhEPO abusers from healthy sportsmen.Following a double blind study with regular rhEPOinjections (continuous treatment), the AustralianInstitute of Sport together with the Australian SportsDrug Testing Laboratory designed an anti-doping testusing multiple secondary blood markers such as thehaematocrit level, the reticulocyte haematocrit, serumsTFR and EPO concentrations and the percentageof macrocytic cells. Different mathematical modelsallowing the identification of sportsmen under rhEPOtreatment (ON-model) and those who took rhEPO inrecent days (OFF-model) were developed.

In August 2000, the IOC Medical Commissionapproved the ON-model for use during the Sydney2000 Olympic Games. As the direct method capableof discriminating endogenous EPO from rhEPO waspublished in spring 2000, the ON-model was only usedas a screening test to determine which urine samples hadto be collected to perform the urinary test.

At th e sam e ti me as th e st ud y was per for med inAus tra lia , the LAD (La bor ato ire Sui sse dA nal ysedu Dopage) conducted a very similar controlledrandomised double blind trial, with the exception thatiron supplementation was much more important andgiven intravenously to be the most efficient and as closeas possible to the procedure in cycling. Therefore, thebehaviour of secondary blood markers was differentduring continuous treatment. In contrast to theAustral ian stu dy, the Sw iss demon strate d that some ofthe secondary blood markers (haematocrit, haemoglobin

and reticulocyte count) could be used as part of ascreening test, but in no case could be used for anti-doping purposes.

Direct Methods

Endogenous EPO and rhEPO are slightly different andthese differences come from glycosilation of rhEPO,which takes place in Chinese hamster ovary (CHO) cellsrather than in human cells. Indeed, the post-translationalmodifications are species- and tissue-dependant and alsodepend on the cell culture conditions. Therefore, it is

possible to separate the endogenous from the exogenousEPO isoforms thanks to the different charges of thedifferent sugar structures. The technique developed byWide (2002) allo wed t he s epar atio n of the diffe rent

isoforms thanks to the differences of charges on thedifferent structures of sugars. This technique was veryreliable in urine and in blood as long as the biologicalsamples were collected within 24 hours after the lastrhEPO injection. Unfortunately, once the rhEPOtreatment was ceased for more than three days, less than50% of the treated subjects could be declared positive.Seven days after the last rhEPO injection, no sampleshowed any traces of rhEPO.

A few months before the Su mmer Ol ympic G ames inSydney, the French anti-doping laboratory in Parispublished in Nature a novel test based on the isoelectricfocusing patterning and a double blotting protocol.The exogenous isoforms of rhEPO are less acidicthan the endogenous EPO, making it possible to findthe convenient protocol to separate them using theisoelectric focusing method. This test was designed toseparate , and rhEPO (see Figure 1).

Targeting rhEPO Abusers

The LAD and selected federations made the decisionto launch the blood screening test based on thedetermination of the haematocrit, the haemoglobin andthe reticulocyte count. It was introduced during the2001 cycling season at the Tour des Flandres. The bloodtest quickly demonstrated its ability to detect rhEPO

abusers. Since then, more sport federations have decidedto introduce the screening test set up in Lausanne. Withtime, this test has shown to be even more efficient in thefollow-up of athletes (blood profile). Variations abovenormal were excellent indicators of blood manipulation.

F-MARC DOPING UPDATE 2006 | ERYTHROPOIETIN BLOOD DOPINGERYTHROPOIETIN BLOOD DOPING | F-MARC DOPING UPDATE 2006

Figure 1:Anti-doping urine analysis demonstrating the presence of rhEPOin urine (see lane 4). 1. rhEPO standard, 2. Positive urine (control),3. Negati ve urine (control), 4. Sample declared positive,5. Darbepoeitin (Aranesp standard)

Acidic

Basic

+1 2 3 4 5


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Abnormal Blood Profiles

For approximately two years, abnormal blood profileshave been noticed without any traces of rhEPO in

urines. This meant that athletes were either dopingwith undetectable compounds or had returned toancient doping techniques such as blood transfusion.In the 1970s, blood transfusion was a common practicefor enhancing oxygen transport from the increase ofred blood cell mass. This method of doping virtuallydisappeared with the arrival of rhEPO on the market atthe end of the 1980s because the use of the hormoneis much easier (to store and to use) and cheaper. Thelaunching of the direct detection test of rhEPO in urinesamples in 2000 had an unwanted side-effect: a returnto blood transfusion. The regular follow-up of someblood parameters such as haematocrit, haemoglobinand reticulocyte count suddenly showed that someathletes who demonstrated abnormal blood parametersalthough rhEPO could not be detected in urine. Thisclearly indicated a return to blood transfusion practices.With the possibility of analysi ng specific red blood cellmembrane proteins defining the different blood groupsand sub groups, the LAD decided to perform anti-doping tests in blood for the first time (summer 2004).The specific labeling of some red blood cell membraneproteins in combination with flow cytometry detectionproved that abnormal blood profiles were due tohomologous blood transfusion. Federations that haveintroduced blood testing now have a powerful tool tofollow all athletes potentially abusing rhEPO or bloodtransfusion. Therefore, they need to focus their anti-doping tests on those demonstrating abnormal bloodprofiles.

This targeting aid enables the federations to determinethe prevalence of doping methods before any validatedanti-doping test is on the market. For example, it waspossible to determine that HBOC (Haemoglobin

Based Oxygen Carrier) abuse was not a major problembecause none of the sportsmen tested had abnormalhaematological indices.

Conclusion

It i s likely that all cases of blood doping and rh-EPO abuse will be identified in the near future. Thenecessity to take blood samples in order to screen andtest for this type of doping habits has become obviousfor sports authorities. In this field, there is st ill a needfor more research and coordination with anti-dopingpanels to target the use of blood manipulation better.Haematological follow-up of the sportsmen is certainlyone of the solutions for this targeting. Besides, newbiochemical investigations should allow the scientiststo improve the tools for direct detection of this sort ofdoping.

ERYTHROPOIETIN BLOOD DOPING | F-MARC DOPING UPDATE 2006 F-MARC DOPING UPDATE 2006 | ERYTHROPOIETIN BLOOD DOPING

References

Berglund B, Wide LErythropoietin concentrations and isoforms in urine of anonymous

Olympic athletes during the Nagano Olympic Games.Scand J Med Sci Sports 2002; 12: 354-7.

Lasne F, De Ceaurriz JRecombinant erythropoietin in urine.

Nature 2000; 405: 635.

Nelson M, Ashenden M, Langshaw M & Popp H Detection of homologous blood transfusion by flow cytometry:a deterrent against blood doping.

Haematologica 2002; 87: 881-882.

Parisotto R et al. A novel method utilising markers of altered erythropoiesis for thedetection of recombinant human erythropoietin abuse in athletes.

Haematologica 2000; 85: 564-572.

Robinson N, Saugy M, Buclin T, Gremion G, Mangin P The interpretation of secondary blood markers can get hazardousin case of a discontinuous rhEPO treatment.Haematologica 2000; 87(6). ETL 28.

Mixed population with a majority expressing (3) or non expressing (4)

Contributing Authors:

Neil Robinson, PhD

Christophe Saudan, PhD

Norbert Baume, PhD

Lida Mateus-Avois, PhD

Martial Saugy, PhD

It is likely that all cases of blood

doping and rh-EPO abuse will be

identified in the near future

Single population without expression (1) or with expression (2)

Fig 2: Anti-doping blood analysis demonstrating the presence of a single (1-2) or mixed (3-4) red blood cell population


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Human Growth Hormone


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Introduction

Growth hormone (GH) is a naturally occurring peptide

hormone secreted by the pituitary gland. Even thoughthe hormone in the body is rat her heterogeneous, themajor component is made of 191 amino acids, stabilisedby two disulfide bonds and reaching the molecularweight of 22 KDa. Previously, the only source of human

GH (hGH) was human cadavers, but contaminationby Kreutzfeldt-Jacobs disease made this form

of treatment obsolete. Since the late 1980s,recombinant human GH (rhGH) has beendeveloped through genetic engineering and

is used clinically with good results in thetreatment of hGH-deficient patients toallow bone growth and impact on thepatients final stature. This form of hGH

has an identical sequence to the naturallyoccurring 22 KDa hormone. Its abuse was

suspected in sport because of i ts anabolicproperties. It was claimed by athletes and body-

builders that hGH increased lean body mass anddecreased fat mass.

The use of hGH in sport today is not only based on itsanabolic properties, but on its effect on the metabolismof carbohydrate and fat. Recombinant hGH has beenfound in swimming and also during the Tour de Francein 1998. International federations and the IOC havehad hGH on the list of forbidden compounds since1989, when it became obvious that the development ofbiotechnology products based on the recombination ofDNA made it much easier to obtain the product on theregular and black markets.

It is on of the 2006 FIFA list of prohibited substancesin class S2 of hormones and related substances. EPO(erythropoietin) and ACTH (corticotropin) as well

as IGF-1 and insulin belong to the same category ofpeptide hormones.

Growth Hormone and Exercise

The effect of acute exercise on growth hormoneproduction in the body has been widely described inliterature. The hGH concentration in blood increases

HUMAN GROWTH HORMONE | F-MARC DOPING UPDATE 2006

Human Growth Hormone

F-MARC DOPING UPDATE 2006 | HUMAN GROWTH HORMONE

with time for a given work intensity and can increase10-fold during prolonged moderate exercise. Duringmore intensive exercise (with accumulation of lactateat 70% VO2-max for a short term period like 1020

min) the increase of HGH will increase 5-10 fold.Furthermore, it appears that hGH response is moreclosely related to the peak intensity of exercise than thetotal work output.

Apart from exercise-r elated increase, hGH secretion canbe increased by hypoglycemia, increased temperatureand stress. It is decreased by obesity, a carbohydrate-rich diet and B2-adrenergic agonists. Thus, it is hard todifferentiate between the physiological increase in hGHlevels seen in exercise and what can be observed fromexternal hGH administration (as in doping).

Pharmaceutical Action of hGH

Human GH is secreted by somatotrope cells in theanterior pituitary. Its secretion is pulsatile and is

regulated by two hypothalamic peptides,growth hormone releasing hormone

(GHRH) that s t imulate s hGHsecretion and somatostatin, whichinhibits hGH secretion by back-

regulation. hGH applies its biological effects on targetcells by binding to specific receptors present throughoutthe whole body.

Secretion by women is slightly higher than by men,with the highest levels observed at puberty. There is adecrease in hGH secretion with age of around 14% perdecade. Moreover, hGH secretion varies with normalphysiological and pathological conditions. hGH levelsare higher during slow-wave sleep and are increased byexercise, stress, fever and fasting with some amino acids(leucine and arginine). Some specific drugs such asclonidine, L-dopa and GHB (gamma-hydroxybutyrate)increase its secretion, as androgens and estrogens do.

Therapeutic Use of hGH

hGH is prescribed for both childhood and adulthoodhGH deficiency and for chi ldren with TurnersSyndrome. High doses of hGH are used for relief fromexcessive burns or other thermal injuries. hGH-deficient

children have been treated since the end of the 1950swith hGH extracted from cadaveric pituitaries. Recently,due to the better availability of recombinant growthhormone, hGH deficiency in adults has been recognisedas a clinical syndrome and studied through clinical

The effectiveness of rhGH in the

improvement of sport performance is

still under debate among users.


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trials. The major studies of hGH t herapy in hGH-deficient adults have demonstrated that rhGH treatmentfor a period of 4 to 6 months shows favourable effectson body composition, exercise aptitude, renal and

cardiac functions, and in general, an improvement ofthe quality of life. In long-term experiments, an increasein bone mass and persistence of the positive effects ofhGH therapy has been observed.

The positive effects on body composition are essentiallydue the anabolic, lipolytic and anti-natriuretic properties.An inc rease in th e body cell mass ( muscle s) an d tot albody water will be observed. The hGH dose in adults isgenerally individualised, but the typical dose is 1-2 IU/day applied subcutaneous every evening. With therapeuticdoses, no adverse side-effects have been observed.

hGH as Doping Agent

Growth hormone has been considered as an ergogenicdrug since the late 1980s. Since that time, official

and non-official sources report that abuse in sport hasincreased steadily. The popularity of the product isbased on the popular knowledge that it is efficient, hardto detect and without major side-effects if well dosed.

The frequency of use and the dosage are hard toevaluate, but underground information suggests thatthe athletes abusing hGH are taking 10-25 IU/ day 3to 4 times a week to increase their lean body mass. Wetend to think that mean doses are about 4 IU/day incombination with other doping agents such as anabolicsteroids in power sports or EPO in endurance sport.

The treatment is often applied in cycles of 4 to 6 weeksas is the case for anabolic steroids in bodybuilding. Inendurance sport, very little is known on the optimumutilisation of hGH doping in combination with other

products. It is very individual and empirically based.

The effectiveness of rhGH in the improvement of sportperformance is still under debate among users. Thepositive effects described with hGH-deficient adultsare not so clear for athletes. Although many of theseunderground reports indicate some positive effect onmuscle mass, it is difficult to determine the benefitsobtained when hGH is taken in combination withanabolic steroids or even if the hGH used was a lesseffective product.

The use of hGH as an anabolic agent still seems to bewidespread, but it is difficult to investigate the extent of

the phenomenon. It has been reported that 5% of maleAmerican high-school students use or have used hGH asan anabolic agent. It is unknown how popular hGH isamong female athletes, but some use has been reported

because of the low risk of androgenic side-effects seenwith anabolic steroids. Not only is the anabolic effectof hGH favoured by high-power output athletes, butits use is also gaining acceptance in endurance sportin combination with methods for enhancing oxygentransport.

Whi le the re are anec dot al rep ort s o n t he so- cal leddramatic increases in muscle mass and strength afterlarge doses of hGH (especially among bodybuilders),their effectiveness under controlled conditions isgenerally less impressive. Since the results of controlledstudies are generally not in agreement with subjectiveunderground reports by abusers, it is difficult to drawany definite conclusions regarding the effects of excessivehGH administration on skeletal muscle function. Itmust be stressed that the habits of hGH users in sportare designed to reach purposes other than just an increase

in their muscle mass. The doses involved are certainlyspecific to the discipline, its training model and to theregime of other ergogenic substances used concurrently.

Adverse Effects of hGH

The long-term risks due to utilisation of hGH are notwell known since epidemiological data regarding thattype of treatment in healthy sportsmen are unavailable.Acro mega ly, a p ath olo gica l i ncre ase in e ndog enou sproduction, is often cited as one of the major risksassociated with excessive use of hGH. The majorsymptoms are swelling of the hands and feet, coarsenedfacial appearance, dentition problems, arthralgias,fluid retention and excessive sweating. Acromegalicpatients have an increased risk for diabetes mellitus

and hypertension leading to premature mortality fromcardiovascular diseases. It can be argued that long-termhGH doping with elevated dosage will probably resultin abusers suffering fluid retention symptoms andincreased risk of development of diabetes mellitus andhypertension. There is also a risk of cardiomyopathy,osteoporosis, menstrual irregularities and impotence.Some of these side-effects are reversible after withdrawalof the drug. Furthermore, hGH abuse can disturb thelipid profile with decreased HDL-cholesterol.

Since hGH is administered by injection, if syringesare non-sterile or contaminated, there is a risk of crossinfections such as HIV/AIDS and hepatitis. Even

though cadaveric GH is now rare in the black-market,its use is associated with a high risk of developingCreutzfeldt-Jacob disease, which is characterised byslowly progressive dementia.

Detection Of hGH Doping

Until the Olympic Games of Athens 2004, hGHdoping was considered undetectable. Growth hormoneis a peptide with a very short half-life in blood andlow concentration in urine. The peptidic nature of thesubstance forces analysts to investigate other methodsthan that used in the classical analyses for anabolicsteroids or stimulants with relatively low molecularweight. The amino acid sequence of the recombinantmolecule is identical to the major 22 KDa isoform,which is secreted by the pituitary gland. There is nopossibility to use a post-transcription modificationof the molecule to find the difference between therecombinant and the natural form.

Secretion of hGH by the pituitary gland is pulsatile,leading to highly fluctuating levels in the circulation.Moreover, hGH is considered as a stress hormoneregulated by factors such as sleep, nutritional status,exercise and emotion. Thus, the secretion of hGHis highly variable, both intra- and inter-individually.Quantifying the hormone itself is not sufficient to detectexogenous recombinant growth hormone. More stableserum parameters implied in the biological cascadeproduced by hGH secretion, or a doping application,may be the route of successful detection of hGH. Thegrowth factor (IGF-1), or some of its transport proteins(IGFBP-3), have been proposed as possible candidatesfor indirect detection of hGH doping. But the inter-individual variability is quite high and makes it hard toprecisely define a quantitative cut-off level.

Urine Strategy

Most of the anti-doping samples are takenfrom urine collected out of competitionor after effort. Because of its convenientavailability and the relatively unlimitedvolume, some attempts to use urine forpeptide detection have been conducted.For example, urine could be used forsuccessful detection of EPO because of theglycosylated form of this hormone. However,the only way to detect hGH in urine is toapply an extremely sensitive immuno-test to

quantify the total amount of the hormone in urine. Theaverage urine concentration of hGH is between 100to 1,000 times less than in blood, but the idea was todevelop a screening test for out-of-competition testingin order to benefit from a relatively longer detectiontime window. The limitations of that test have been

clearly demonstrated because of the large influence ofrenal excretion process on the concentration measuredin urine. The lack of discrimination and specificity ofthe answer made the urinary test less promising than ablood test.

The Indirect and Direct Approaches in Blood

Two main strategies are currently being followed todetect hGH doping using blood.

Indirect Approach

The increasing knowledge about the naturally occurringvariability of several hGH-dependent parameters (i.e.

growth factor IGF-1, different IGF binding proteins(IGFBPs), or several markers of the bone turnover) may,individually or in combination, provide a database for

establishing normal ranges for theconcentration of these parameters.This may lead to an establishment ofcut-off levels and describe so-calledabnormal values outside of the

normal constellation of parameters.

Thi s approach, proposed in themid-1990s, was investigated by aninternational panel of endocrinologists,but did not lead to a solution for

F-MARC DOPING UPDATE 2006 | HUMAN GROWTH HORMONEHUMAN GROWTH HORMONE | F-MARC DOPING UPDATE 2006

Table 1:Relative abundance of hGH molecular forms in circulation (adaptedfrom Bidlingmaier et al), the percentages are approximate

Isoforms: %

22 KDa monomer 48

20 KDa monomer 9

Modified hGH (dimers and oligomers) 30

Acidic hGH (desaminated and acy lated forms) 7

Fragmented hGH (17, 12, 5, 30 KDa) variable


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hGH-doping detection. One of the elements from allthese investigations is that the indirect approach canbe used for screening and targeting purposes. HGH,IGF-1 and IGFBP-3 in the hGH biological cascade aswell as selected peptides involved in bone metabolism(for example the N-terminal peptide from pro-collagennamed PIIIP) or osteocalcin can play a role in the

definition of individual normal ranges in athletes. Basedon these observations, samples for sensitive and specificcharacterisation of doping offences can be collected inorder to apply a direct detection of hGH abuse.

Direct Approach

The Strasburger-Bidlingmaier group in Munich hasdeveloped a so-called direct method for the detectionof hGH doping. Two specific immunoassays have beendeveloped in order to quantify several types of hGHisoforms. Recombinant hGH is exclusively representedby the native 22 KDa form, whereas the circulating

hGH in the human blood is present in several forms(Table 1). When the recombinant form is injected intothe body, this will increase, for a period of time, the ratioof the 22 KDa in comparison to all other circulatingforms. Moreover, with long-term treatment, the classicalback-regulation on the endogenous secretion of naturalhGH will occur and the proportion will favour the

major 22 KDa sequence.

The proposed test was used during the Olympics inAthens. In order to fulfill the requirements of the WorldAnti-Dop ing Code and th e stand ards fo r labo ratori es,two double tests were applied to serum samples: thefirst test quantified specifically the 22 KDa and thesecond test was a comprehensive assay measuring allforms present in the serum (Figure 1). The ratio wasestablished and a cut-off defined to differentiate thenormal subjects (negative samples) from those having asignificant higher proportion of 22KDa hGH (positivesamples). A second double sample test was used for

confirmation purposes. The detection window for thesetests is between 24 to 36 hours after the last injection,depending on the dosage used. It is supposed thathGH doping, to be efficient, needs multiple injection

treatments. It has also been shown that the direct testis not influenced by environmental parameters such asexercise or stress. If applied in out-of-competition tests,direct tests should be a deterrent.

References

Bidlingmaier M, Strasburger CJ2000. Baillieres Clin. Endocr. Metab. 14:99-109.

Ehrborg C, Bengtsson BA, Rosen T

2000. Growth hormone abuse. Baillres Clin. Endocr. Metab. 14:71-77.

Saugy M, Cardis C, Schweizer C, et al.1996. Detection of growth hormone doping in urine. J.

Chromatography B, Biomed. Appl. 687, 201-211.

HUMAN GROWTH HORMONE | F-MARC DOPING UPDATE 2006 F-MARC DOPING UPDATE 2006 | HUMAN GROWTH HORMONE


Martial Saugy, PhD

Neil Robinson, PhD

Christophe Saudan, PhDNorbert Baume, PhD

Lidia Mateus-Avois, PhD

Figure 1:Molecular basis of direct detection of hGH abuse by differential immunoassay. A ratio isthen calculated between the signal given by the Assay 1 to the signal given by the Assay2. Two of these double tests must be applied in case of positive serum sample in order toconfirm the diagnosis (adapted from Bidlingmaier et al).

20 KDa

hGH

Acidic

hGH

Modified

hGH

Fragmented

hGH

ASSAY 1(22 KDa or Recombinant hGH)

ASSAY 2(permissive hGH assay)

22 KDa

hGH

A new direct blood test is able to detect

doping with human growth hormone


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Therapeutic Use Exemption


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Football players who suffer from acute or chronicdisease or physical symptoms and signs following injurymay need a disease- or injury-specific medication fortreatment which might be on the prohibited list.

Acc ord ing to the cli nic al sit uat ion , a Th era peu ticUse Exemption (TUE) may be granted to a player,permitting the use of a prohibited substance or methodcontained in the prohibited list. An exemption will begranted only in strict accordance with the followingcriteria (FIFA Doping Control Regulations 2006, WorldAnti-Doping Code (WADC)):

The player shall submit an application for TUE noless than 21 days before participating in an event.

The player would experience a significant impairmentto health if the prohibited substance or method wereto be withheld in the course of treating an acute orchronic medical condition.

The therapeutic use of the prohibited substance or

method would produce no additional enhancementof performance other than that which might beanticipated by a return to a state of normal healthfollowing the treatment of a legitimate medicalcondition. The use of any prohibited substanceor method to increase low-normal levels of anyendogenous hormone is not considered as anacceptable therapeutic intervention.

There is no reasonable therapeutic alternative to theuse of the otherwise prohibited substance or method.

The necessity for the otherwise prohibited substanceor method cannot be a consequence, wholly or inpart, of prior non-therapeutic use of any substancefrom the prohibited list.

The TUE will be cancelled by the granting body, ifa. The player does not promptly comply with any

requirements or conditions imposed by the FIFADoping Control Sub-Committee granting theexemption.

b. The t erm for which the TUE was granted hasexpired.

c. The player is advised that the TUE has beenwithdrawn by the FIFA Doping Control Sub-Committee.

An application for a TUE will not be considered forretroactive approval except in cases where:a. Emergency treatment or treatment of an acute

medical condition was necessary, orb. Due to exceptional circumstances, th ere was

insufficient time or opportunity for an applicant

to submit, or the granting body to consider, anapplication prior to doping control.

Confidentiality of information: The applicant shallprovide written consent for the transmission of allinformation pertaining to the application to membersof the FIFA granting body and, as required, otherindependent medical or relevant scientific experts.If the assistance of external, independent expertsis required, all details of the application will becirculated without identifying the player involved in

THERAPEUTIC USE EXEMPTION | F-MARC DOPING UPDATE 2006

Therapeutic Use Exemption

F-MARC DOPING UPDATE 2006 | THERAPEUTIC USE EXEMPTION

the doctors care. The applicant shall also give writtenconsent for the decisions of the FIFA granting bodyto be distributed to the involved medical personnelof other relevant anti-doping organisations under the

provisions of the FIFA Doping Control Regulations.The members of the granting body involved shallrespect the Hippocratic Oath and the medical legaland ethical rules of confidentiality. FIFA proposesusing the standard application forms for TUEapplications, which are listed in the WADC underInternational Standard for TUE Appendix 1, or theFIFA Forms (Appendix 2).

As a result of the agree ment between WADA and FIFAregarding implementing the requirements of the World

Ant i-D opi ng Cod e, in Mar ch 200 4 F IFA and theconfederations immediately introduced a therapeuticuse exemption process for all national and internationalplayers participating in competitions. The WADA TUECommittee is informed about any approval and rejection(very rare) and FIFA will disclose any information to themedical staff of WADA on request.

In agreement with FIFA and according to article 4.4 of theWADC, the TUE applicatio ns proced ure has been putinto operation for football players according to Table 1.

In order to avoid misunderstandings, players and teamdoctors were told that a TUE request may be submittedto only one body at a time. The same TUE request mayNOT be submitted to several bodies.

To deal with these TUE requests, FIFA and theconfederations have created, according to the WADAInternational Standard, their own panel of independentdoctors called the Therapeutic Use ExemptionCommittee (TUEC). This committee reviews eachrequest and analyses the medical evidence beforegranting a TUE.

WADA has e stablishe d two d ifferent TUE forms to beselected and used according to the treatment which hasto be administrated to the player (Table 2).

Table 1: Therapeutical Use Exemptions procedure

For TUE application to be addressed to Request made by

National players participating in domestic

competitions only.

(This includes friendly matches abroad)

FIFA member association, national anti-dop-

ing organisation (NADO) or competent public

authority, association.

Player and club doctor

International players called up to participate in

international team competitions and interna-

tional friendly matches.

FIFA/confederations Player and national team doctor

International players participating in club com-

petitions

FIFA/confederations Player and club doctor

International players called up by member asso-

ciation in FIFA competitions (i.e. 2006 World

Cup qualifiers).

FIFA Player and national team doctor

Abbreviated TUE Standard TUE

Only for glucocorticosteroids

by non-systemic routes (applied

locally) and for beta-2 agonists

(formoterol, sulbutamol,salmeterol and terbutaline)

by inhalation. Dermatological

glucocorticosteroids NO LONGER

require a TUE.

For any treatment involving a

substance or method on the

prohibited list that is not admis-

sible for an abbreviated TUE.

Use the abbreviated TUE form. Use the standard TUE form.

Granted automatically upon

receipt of the completed applica-

tion by the relevant organisation.

(Check by the TUEC may be

carried out at any time during

the duration of the TUE)

Will be examined by the TUEC.

Table 2: Requirements for abbreviated and standard TUE


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74 75

Abbreviated TUE

Abbrev iated TUE r equest s are valid as s oon a s FI FA,the confederations or the member associations TUE

Committee has received a request and therefore thetreatment may start immediately after this is received.However, the TUE Committee has the right to askfor additional information should the indication forapplication of glucocorticosteroids or beta-2 agonistsappear doubtful. FIFA has also decided that for a TUE

for beta-2 agonists following the clinical diagnosis ofexercise-induced or allergic asthma, functional lung-test

results must also be supplied to substantiate the clinicaldiagnosis. With this request, the FIFA Sports MedicalCommittee has clearly stressed the importance of soundclinical diagnosis following state-of-the-art assessmentto avoid abuse of beta-2 agonists without a clear clinicaldiagnosis. In this respect, FIFA endorses the statementmade by the IOC medical committee workshop onasthma and beta-2 agonists in May 2001.

Standard TUE

In cases of standard TUE where specialised expertiseis required, the TUE Committee appoints externalindependent experts to seek a second opinion to justifythe decision.

Standard TUE requests are valid as soon as FIFA or aconfederation has sent the player a certificate of approval(except in rare cases of an acute life-threatening condition,for which retroactive approval may be considered).

Results of Current Procedure

The process of Therapeutical Use Exemption hasbeen systematically introduced in the FIFA member

associations and the confederations since 2003 afterthe presentation of the World Anti-Doping Code.FIFA receives applications for TUEs from playersparticipating in international competitions such asqualifying matches for the World Cup (male andfemale) and various age-category competitions, as wellas for the final competition of the World Cups. UEFA,on the other hand, receives requests for confederationcompetitions such as EURO 2004 and internationalclub competitions such as the Champions League.The total amount of abbreviated and standard TUEsapproved by FIFA and UEFA is summarised in Table 3.

The application process has been introduced insuch a way so that there is a mutual recognition ofthe approvals by member association, confederationand FIFA. However, FIFA, if informed, checks theapplication and decision of member associations and

has the right of appeal. Once TUE-approved, theconfidential medical information is filed at FIFA and acopy of the approval is supplied to WADA according tothe World Anti-Doping Codes international standardfor therapeutic use exemption.

References

FIFA Doping Control Regulationshttp://www.fifa.com/en/regulations/regulation/0,1584,9,00.html

http://www.fifa.com/

World Anti-Doping Code 2003http://www.wada-ama.org/en/dynamic.ch2?pageCategory.id=250,http://www.wada-ama.org/

THERAPEUTIC USE EXEMPTION | F-MARC DOPING UPDATE 2006 F-MARC DOPING UPDATE 2006 | THERAPEUTIC USE EXEMPTION

For a TUE for beta-2 agonists following

the clinical diagnosis of exercise-induced

or allergic asthma, functional lung-test

results must also be supplied


Prof. Jiri Dvorak

Don Kirkendall, PhD

and Marc Vouillamoz

Year Abbreviated TUEs Standard TUEs

UEFA FIFA UEFA FIFA

2004 251 140 14 23

2005 299 101 20 11

Table 3: Documentation of approved TUEs in FIFA and UEFA


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Beta-2 Agonists and Asthma


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78 79

Asth ma is one o f th e mos t fr equent chron ic di seases .Hippocrates already described it in classical antiquity.An inf lam mat ion and hyp er- res pon siv enes s o f t heairways to different stimuli occurs. This results in a

variable and reversible bronchoconstriction. Althoughthe adult population frequency amounts to approx. 5%,a frequency of 10-15% is assumed in athletes. Pollutantssuch as nitrogen oxides, ozone and dust in the air arethe main causes of the worldwide increase in observedasthma. There is a genetic predisposition. Asthma isfrequently hereditary with typical cases of onset duringinfancy. However, non-allergic asthma usually arisesduring adulthood. The factors inducing an asthma attackare numerous: pollen, dust, contact with animals orchemicals at the workplace, medicines (e.g. acetylsalicylicacid, non-steroidal anti-inflammatory drugs), viralinfections, cold air, psychological and physical strains.

Exercise-induced asthma is the term given to asthmawhich only occurs during physical strain. The inhalationof large volumes of cold dry air with the subsequentdevelopment of a bronchial mucous membrane edema

seems to play a substantial role. The symptoms arenormally pronounced towards the end of strenuousphysical loads, so that complaints during games ofsport usually arise during the intervals. Breathlessness,rhonchus and coughing are typical symptoms. Athletesparticipating in winter sports are more frequently affectedthan those in summer sports. Endurance athletes alsosuffer more frequently from asthmatic complaints thanother sportsmen. Despite favourable humid conditionsapparent in swimming, the frequency of exercise-inducedasthma is particularly large. Competitive swimmers whotrain several hours a day inhale substantial quantities ofchlorine gas, which can cause asthma attacks.

Asthma Diagnosis

Respiratory symptoms may have many causes. Aphysiologically occurring shortness of breath (e.g.wheezing) is often associated with high-intensityexercise in poorly conditioned individuals, thus leadingto a misdiagnosis of asthma. For a reliable diagnosis,lung function tests are necessary. In pronounced cases,a simple spirometry test with measurement of forcedexpiratory volume for one second (FEV1) is sufficient.This can otherwise be termed as the air volume thatcan be exhaled after maximum inhalation within thefirst second (Figure 1). If the FEV1 is reduced and risesafter inhalation of a beta-2 agonist by at least 12%,asthma can be assumed. In most cases, particularly withexercise-induced asthma or a hyperreagible bronchial

system, provocation tests are necessary. These can beaccomplished using exercise tests in laboratory conditionson an ergometer or under sport-specific conditions withfield tests, measuring lung function before and after the

effort. The test is considered positive if the FEV1 dropsby more than 10% after exercise. Another lung functiontest involves the inhalation of test substances such asmethacholine, which induces a bronchoconstriction.When all erg y-in duc ed ast hma is sus pect ed, all ergydiagnostic tests are necessary.

Asthma Therapy

For the treatment of asthma, including exercise-inducedasthma, stage patterns exist. For the athletes, the goal oftherapy consists of being symptom-free and being able toexhibit normal lung function during all sports activities.When ast hma onl y o ccu rs rar ely or int ermi tte ntl y,short-acting inhaled beta-2 agonists (e.g. salbutamol orterbutaline) are sufficient. With just exercise-inducedasthma, the beta-2 agonist should be inhaled shortlybefore starting the exercise causing the asthmaticcomplaints. With persistent light asthma, i.e. whenasthma attacks occur once a day at t he most, a continuoustherapy with an inhaled beta-2 agonist, possibly alsowith long-acting substances (formoterol or salmeterol)in combination with inhaled glucocorticosteroids, isrecommended. Glucocorticosteroids are used because

of their anti-inflammatory effect and are not effectivefor the treatment of acute asthma attacks. Alternatively,or also in supplementation, leukotriene antagonistsand cromolyn compounds are possible for a preventiveapplication. Theophylline derivatives can be used foracute treatment, but are less suitable for athletes due totheir small therapeutic index.

Beta-2 Agonists and Doping

Of the drugs relevant for the treatment of asthma, beta-2 agonists and glucocorticosteroids appear on the listof prohibited substances for sport. For the prophylactic

BETA-2 AGONISTS AND ASTHMA | F-MARC DOPING UPDATE 2006

Beta-2 Agonists and Asthma

F-MARC DOPING UPDATE 2006 | BETA-2 AGONISTS AND ASTHMA

treatment of asthma and exercise-induced asthma,inhalational application is permitted. A TherapeuticUse Exemption (TUE) in this case an abbreviatedTUE is required by athletes to use these treatments

for exercise-induced asthma. Copies of lung functionand/or provocation tests (see asthma diagnostics) arerequired to be enclosed with the application for TUE.

In contrast to glucocorticosteroids, (see the respectivearticle) inhaled beta-2 agonists, or asthma sprays, arenot only banned for competition but also for training.Abbreviated TUEs are only possible for the beta-2 agonistsformoterol, salbutamol, salmeterol and terbutaline. Asalbutamol concentration in the urine of >1000 ng/mlis usually not reached by inhalational application andis therefore considered a positive doping test. Athletesseeking a competitive advantage, even after allowing forcommonly existing medical conditions, frequently abuseinhaled beta-2 agonists. But do asthma sprays actuallyaffect performance? Since 1983, numerous placebo-controlled studies have been published, which havelooked at the effect of inhaled beta-2 agonists (including

the four mentioned above) on the aerobic and anaerobicperformance as well as muscle strength on highly trainedathletes. Most studies did not show any increase inperformance. In contrast to inhaled beta-2-agonists, oraladministration of salbutamol and clenbuterol can induceergogenic effects, most of the relevant findings, however,originate from animal experiments, with only a few testresults coming from those on humans. Overdoses maycause side-effects such as heart palpitations, tachycardia,

tremor or rhythm disturbances. Altogether, on the basisof scientific evidence, inhaled beta-2 agonists do nothave a performance-enhancing effect in non-asthmaticcompetitive athletes: one does not have to be asthmatic in

order to succeed.

The administrative expenditure for acquiring specialpermission is substantial. The proof of an asthmaillness in need of treatment by means of lung functionand provocation tests requires a specialised medicalinvestigation in several athletes. This can causeconsiderable costs. Therefore, campaigns to clear up thesense and nonsense of asthma sprays would seem highlydesirable.

References

Kindermann WThe problem of doping and current doping list.

Dtsch Z Sportmed 55 (2004) 90-95

Larsson K, Ohlsen P, Larsson L, Malmberg P,Ryddtrom PO, Ulriksen HHigh prevalence of asthma in cross country skiers.

Br Med J 307 (1993) 1326-1329

Maiolo C, Fuso L, Todaro A, Anatra F, Boniello V,Basso S, DeLorenzo A, Pistelli R Prevalence of asthma and atopy in italian olympic athletes.

Int J Sports Med 25 (2004) 139-144

McKenzie DC, Stewart IB, Fitch KD The asthmatic athlete, inhaled beta agonists, and performance.Clin J Sport Med 12 (202) 225-228

Figure 1:Forced expiratory volume in 1 sec (FEV1): Normally, after maximalinspiration, at least 80% of the volume is expired again within 1 sec(black curve). With asthma and exercise-induced asthma the volumeexpired out in 1 sec is decreased (red curve).

100

90

80

70

60

50

40

30

20

10

0

Volumeofinspira

tion[%]

1 2

Time [sec]

FEV1

(normal)

FEV1(Asthma)

3


Prof. Wilfried Kindermann


14/28

Glucocorticosteroids


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82 83

Hormones are produced in the adrenal cortex, whichare described as corticosteroids. Glucocorticosteroidsrepresent a sub-group whose name indicates their maineffect: carbohydrate metabolism. This leads to sugar orglucose formation, i.e. from protein and their amino acidconstituents. This procedure is called gluconeogenesis.The most physiologically significant glucocorticosteroidis cortisol. Synthetic glucocorticosteroids are often calledcortisones.

Effects

Cortisone affects metabolism and glucose is formedfrom proteins. Due to their proteolytic effect,glucocorticosteroids belong to the catabolic hormones.In addition, fat metabolism is affected, which leadsto an increased formation of free fatty acids. The mostimportant effects on the electrolyte balance consist of thefact that sodium together with water in the body is heldback and potassium is increasingly eliminated. After all,the glucocorticosteroids are of crucial importance for the

life-saving stress reaction of the organism.

The broad therapeutic use of cortisone (Table 1) resultsfrom the anti-inflammatory characteristics on cells andtissues. Early (edema) and late (e.g. growth of connectivetissue cells) inflammatory reactions are inhibited. During

sport injuries and symptoms of overuse, inflammatoryreactions arise causing pain. Local cortisone injectionsinhibit inflammation resulting in a pain-relieving effect.For some internal and general medical illnesses, cortisone

GLUCOCORTICOSTEROIDS | F-MARC DOPING UPDATE 2006

Glucocorticosteroids

F-MARC DOPING UPDATE 2006 | GLUCOCORTICOSTEROIDS

belongs to the necessary drug therapy. With competitiveand top-class athletes, a cortisone treatment can, forexample, be indicated with allergies, asthma, intestinaldiseases or diseases of the skin and eyes (Table 1). Withasthmatic diseases, inhalational cortisone treatmentbelongs to basic therapy.

Side-Effects

The frequency of unwanted effects correlates withthe duration and dose of the treatment. Table 2 listsimportant side-effects, particularly in view of sport. It is,however, a selection and is therefore not complete.

The production and release of glucocorticosteroids iscontrolled by the brain (hypothalamic-pituitary axis).Aft er cor tiso ne t reat ment , e ndog enic prod ucti on isdecreased due to the inhibition of this automatic controlloop system. This leads to temporary adrenocorticalinsufficiency. Conditions of exhaustion to the point ofcollapse in stressful situations can occur after suddencessation of the cortisone treatment. Furthermore,withdrawal symptoms can develop, accompanied byfever, joint and muscular pains and a general feeling ofsickness. Cushings Syndrome is assumed if the cortisonetherapy leads to symptoms of acne, weight gain, waterstorage and high blood pressure.

The influence of cortisone on metabolism can also

lead to practically relevant side-effects. Due to the newformation of glucose, diabetes mellitus can develop oran existing diabetes can get worse. The protein balanceis also adversely affected. The presence of protein isreduced, particularly in the musculature, bone and skin.The myopathy occurring in some cases can be the cause

With asthmatic diseases,

inhalational cortisone treatment

belongs to basic therapy.

S ys te mi c A pp li ca ti on L oc al Ap pl ic at io n

Rheumatic and other in

flammatory diseases

Traumatic, inflammatory and

degenerative joint diseases

(Injection into the joint)

Tendines

(e.g. musculo-tendinous

insertion pain, tendosynovitis)

Spinal diseases

Allergic diseases

(e.g. allergic reactions to medi-

cine, anaphylactic reaction)

Skin diseases

(incl. allergic reactions)

Asthma disea ses Asthma dis ease s ( inhala tive)

Intestinal diseases

(e.g. Crohns disease,

ulcerative colitis)

Malignant diseases

Diseases of nervous system

Diseases of the eyes, nose

and ears

Table 1: Indications for glucocorticosteroids selected examples

Adrenocortical insufficiency

Cortisone withdrawal symptoms

Cushings disease

Diabetes mellitus

Myopathy (muscle weakness)

Osteoporosis

Wound-healing disorders

Loss of potassium

Risk of infection

Gastric and duodenal ulcers

Psychic disturbances

Overuse injuries

Skin damage

Table 2: Side-effects of glucocorticosteroids


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84 85

of muscle weakness, in particular of the upper arms andthighs as well as the shoulder girdle and pelvic area.In addition, osteoporotic changes of the bone, i.e. areduction of the bone mass which can lead, for example,to compression fractures of the vertebral bodies, arecaused by proteolytic metabolism. Furthermore, theincreased calciuria induced by cortisol seems to play apart in the osteoporosis. Back pains, for example, canbe a consequence of cortisone therapy. Disturbancesof wound healing as well as an atrophy of the skin areprimarily the result of an inhibition of the connectivetissue fibroblasts. A possible resulting loss of potassiumwould primarily affect the intracellular potassiumcontent and is not always identifiable in measuredpotassium values in the blood. The anti-inflammatoryeffect and the weakening of the immune systemcause an increased risk of infection during cortisonetreatment. Inflammatory reactions need to belong to afunctional immune system. Cortisone also inhibits partsof cellular immunity. The lymphocytes, including theirsubpopulations in particular, are attenuated.

Gastric and duodenal ulcers are primary side-effectsin the digestive tract. Bleedings and perforations areparticularly feared, these complications commonlydevelop insidiously. A decreased protection of themucosa is usually considered as the main cause.Ulcers occurring during cortisone treatment shouldbe taken seriously. After all, cortisone can also lead todifferent psychological disturbances: nervousness, sleepdisturbances, listlessness, euphoria and psychoses. The

same unwanted effects as with a systemic treatmentcan in principle occur with a local cortisone therapy.The risk of infections always exists with intra-articularapplication (injection into the joints), in particular whentaking immune system impairment through cortisoneinto account. Complications such as tendon rupturescan occur when repetitive, local pain injections areadministered after sports injuries and repetitive stressreactions. The local administration e.g. as ointment orcream can also cause damage to the eyes and skin. Alongwith the above-mentioned skin atrophy, the occurrenceof acne is also common.

Treatment with Cortisone Preparations

Many cortisone preparations are available. They can beapplied in different ways: as injections, tablets, drops,solutions, suppositories, sprays, ointments and/orcreams. In principle, even with local use, an absorptioninto the circulation and therefore into the blood must betaken into account. This leads to systemic reactions as

well the occurrence of the whole spectrum of side-effects.Inhalation treatment, such as that for asthma, seemsto produce few systemic effects. Substantial qualitativedifferences in effect do not exist between the individualpreparations. There are, however, quantitative differences,i.e. different efficacy. The biological half-life, or how fastan active substance is broken down or excreted from thebody, is of considerable importance. There are substantialdifferences, particularly in the necessary treatment

of athletes subject to doping controls, where this issignificant. Between short and long-acting medication,all gradations exist, whereby the latter can still be tracedseveral weeks after the last application. Precise data arenot usually possible. In German high-performance sport,the active substa nces Triamcinolone and Dexamethasoneare frequently used with orthopaedic indications.

Cortisone and Doping

All gl ucocort icostero ids are prohibit ed in co mpetitio nwhen administered orally, rectally, intravenously orintramuscularly. Their use requires a Therapeutic UseExemption (TUE) approval. There exists, however, afrequent, particularly orthopedic, indication for theiruse. For non-systemic application (e.g. injections into thejoints or at tendinous insertions) a simplified procedurecorresponding to a de facto message (notification) atthe time of application exists, but in each case beforecompetition. This notification requires an abbreviatedTherapeutic Use Exemption. Non-systemic applications

(topical preparations) when used for dermatological (e.g. ointments and creams), aural/otic, nasal, buccal cavityand ophthalmologic disorders are not prohibited and donot require any form of Therapeutic Use Exemption.The way in which the active substance was administeredcannot be differentiated by urine analysis. Therefore,it cannot be distinguished between systemic and non-systemic application.

The different detection times of different preparationsare problematic. In order to protect the athletes, itwould therefore be necessary to start the applicationprocedure if the local injection of glucocorticosteroidsalready took place weeks before the next match althoughusage is not prohibited out of competition. This formalprocedure would only be redundant if one is sure thatthe administered cortisone was no longer traceable aftera few days and cannot be detected in the urine at the dayof the match.

Performance-enhancing effects of glucocorticosteroidsare disputed and have not been proven by scientificdata as yet. The euphoric effect is being discussed as apossible mechanism for influencing achievement, but thecatabolic effects of long-term use can be unfavourable toperformance.


Prof. Wilfried Kindermann

GLUCOCORTICOSTEROIDS | F-MARC DOPING UPDATE 2006 F-MARC DOPING UPDATE 2006 | GLUCOCORTICOSTEROIDS

Performance-enhancing effects of

glucocorticosteroids are disputed and have not

been proven by scientific data as yet.


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Medical Legal Aspects


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88 89

Historical Background

Ancient Gr eek athl etes ar e known t o have used spe cialdiets and stimulating potions to fortify themselves.Strychnine, caffeine, cocaine, and alcohol were oftenused by cyclists and other endurance athletes in the19th century. Thomas Hicks ran to victoryin the Olympic marathon of 1904 in SaintLouis with the help of raw egg, injectionsof strychnine, and doses of brandyadministered to him during the race. Bythe 1920s it had become evident thatrestrictions regarding drug use in sportswere necessary.

In 1928 the International AmateurAt hl et ic Fed er at ion (IA AF ) bec amethe first international sport federationto b a n th e u s e o f d o p i n g ( u s e o f stimulating substances). Many otherinternational federations followed suit, butrestrictions remained ineffective as no tests

were performed. The death of Danishcyclist Knud Enemark Jensen duringcompetition at the Olympic Games inRome 1960 the autopsy revealed tracesof amphetamine increased the pressure forsports authorities to introduce drug tests.

In 1966 the International Cycling Union (UCI) andin 1970 the Fdration Internationale de FootballAssocia tion (F IFA) were among t he firs t inte rnation alsports federations to introduce doping tests in theirrespective World Championships. In the following yearthe International Olympic Committee (IOC) institutedits Medical Commission and set up its first list ofprohibited substances. Drug tests were first introducedat the Olympic Winter Games in Grenoble and at theOlympic Summer Games in Mexico in 1968 after the

urgency of anti-doping work had been highlightedby another tragic death, that of cyclist Tom Simpsonduring the Tour de France 1967.

A rel iable test method to de tect anabol ic ste roids wasfinally introduced in 1974 and the IOC added anabolicsteroids to its list of prohibited substances in 1976. Thisresulted in a marked increase in the number of drugdisqualifications in the late 1970s, notably in strength-related sports such as throwing events and weightlifting.

Blood boosting or blood doping which involvesremoval and subsequent re-infusion of the athletesblood in order to increase the level of oxygen-carryinghaemoglobin, has been practiced since the 1970s. TheIOC banned blood doping as a method in 1986.

Anti -dop ing w ork was compl icat ed i n t he1970s and 1980s by suspicions of state-

sponsored doping practiced in somecountries. The most famous doping caseof the 1980s concerned Ben Johnson,the 100-metre runner who tested positivefor stanozolol (anabolic steroid) at theOlympic Games in Seoul, 1988. Johnsonscase focused the worlds attention to thedoping problem to an unprecedented

degree.

In 1998 a large number of prohibitedmedical substances were found by the

police in a raid during the Tour de France.

The scandal led to a major reappraisalof the role of public authorities in anti-doping affairs. As early as 1963, Francehad been the first country to enact anti-

doping legislation. Other countries followedsuit, but international cooperation in anti-dopingaffairs was long restricted to the Council of Europe. Inthe 1980s there was a marked increase in cooperationbetween international sports authorities and variousgovernmental agencies. Before 1998 debate was stilltaking place in several discrete forums (IOC, SportsFederations, individual governments), resulting indiffering definitions, policies, and sanctions. One resultof this confusion was that doping sanctions were oftendisputed and sometimes overruled in civil courts.

The Tour de France scandal highlighted the need for

an independent international agency, which would setunified standards for anti-doping work and coordinatethe efforts of sports organizations and public authorities.The IOC took the initiative and convened the WorldConference on Doping in Sport in Lausanne in February1999. Following the proposal of the Conference, theWorld An ti-Dopi ng Agenc y (WADA) was es tablis hedon 10 November 1999.

MEDICAL LEGAL ASPECTS | F-MARC DOPING UPDATE 2006

Medical Legal Aspects of Doping in Football

F-MARC DOPING UPDATE 2006 | MEDICAL LEGAL ASPECTS

On March 5, 2003, at the second World Conferenceon Doping in Sport, some 1200 delegates representing80 governments, the IOC, the International ParalympicCommittee (IPC), all Olympic sports, nationalOlympic and Paralympic committees, athletes, nationalanti-doping organizations, and international agenciessuported the World Anti-Doping Code as the basis forthe fight against doping in sport. The Code entered intoforce on January 1st, 2004.

On October 19, 2005, the World Anti-Doping Codewas adopted as the 1st International Conventionagainst Doping in Sport by the General Conference ofUNESCO at its plenary session. Some 184 countrieshave signed the Copenhagen Declaration on Anti-Doping in Sport, the political document through whichgovernments show their intention to implement theWorld Anti -Dop ing Code by the rati fica tion of theUNESCO Convention.

Doping Control in Football

FIFA introduced an anti-doping program in 1970at the World Championships, being one of the firstinternational sports federations to do so.The fundamentalaims as stipulated in the FIFA Doping ControlRegulations (2006) are quite similar to the purpose ofthe World Anti-Doping Code Program set out below.

Definitions

The word doping is probably derived from the oldDutch word dop, which was the name of an alcoholicbeverage made of grape skins used by Zulu warriorsin order to enhance their prowess in battle. The termprogressed into mainstream use in the early 20thcentury, originally referring to drugging of racehorses.

The practice of enhancing performance through foreignsubstances or other artificial means, however, is as old ascompetitive sport itself.

According to the definition of doping in the World Anti-Doping Code, doping is defined as the occurrence ofone or more of the following violations:

The presence of a prohibited substance or i tsmetabolites or markers in an athletes bodily specimen(strict liability rule)

Possession by an athlete at any time or place of asubstance that is prohibited in out-of-competitiontesting or a prohibited method, unless the athleteestablishes that possession is pursuant to a therapeuticuse exemption granted in accordance with theFIFA Doping Control Regulations regarding thetherapeutical use of forbidden substances or otheracceptable justification.

Possession of a substance that is prohibited in out-of-competition testing or prohibited method by athletesupport personnel in connection with an athlete,competition or training, unless the athlete supportpersonnel establishes that the possession is pursuant toa Therapeutic Use Exemption as descr ibed previously.

Trafficking in any prohibited substance or prohibitedmethod is sti ll a violation of the anti-dopingregulations and in most legal systems an illegal actagainst the medical preparations law.

Administration or the attempted administration

of a prohibited method to any athlete, or assisting,encouraging, aiding, abetting or covering up as well asany other type of complicity involving an anti-dopingrule violation or any attempted violation.

As set fo rth in t he preamble o f the World Ant i-DopingCode, the purposes of the World Anti-Doping Programare:

To protect the athletes fundamental right toparticipate in doping-free sport and thus promotehealth, fairness, and equality for Athletes worldwide;and

To ensure harmonized, coordinated, and effectiveanti-doping programs at the international andnational level with regard to detection, deterrence,

and prevention of doping.

Prohibited substances in the context of these regulationsare regularly published in the:

WADA (World Anti Doping Agency) l i s t o f prohibited substances (http://www.wada-ama.org)and

are included as Appendix A of the FIFA DopingControl Regulations (www.FIFA.com)


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Medical Legal Implications

Strict Liability Rule

The reason for the strict liabi li ty rule has beencomprehensively stated by the Court of Arbitration forSport (CAS), Lausanne in certain cases e.g. the case ofQuigley v. International Shooting Union (UIT) in 1995:

It is true that a strict liability test is likely in somesense to be unfair in an individual case, such as that ofQuigley, where the athlete may have taken medication asthe result of mislabelling or faulty advice for which he orshe is not responsible particularly in the circumstancesof sudden illness in a foreign country. But it is also insome sense unfair for an athlete to get food poisoning onthe eve of an important competition be altered to undounfairness. Just as the competition will not be postponedto await the athletes recovery, so the prohibition ofbanned substances will not be lifted in recognition of itsaccidental absorption. The vicissitudes of competition,

like those of life generally, may create many types ofunfairness, whether by accident or the negligence ofunaccountable persons, which the law cannot repair.

Furthermore, it appears to be a laudable policy objectivenot to repair an accidental unfairness to an individual bycreating an intentional unfairness to the whole body ofother competitors. This is what would happen if bannedperformance-enhancing substances were tolerated whenabsorbed inadvertently. Moreover, it is likely that evenintentional abuse would in many cases escape sanctionfor lack of proof of guilty intent. And it is certain that arequirement if intent would invite costly litigation thatmay well cripple federations particularly those run onmodest budgets in their fight against doping.

The Whereabouts Rule

Apart from such special cases, effect ive doping cont rolsare bonded to out-of-competition tests. Without

accurate athlete location information such controls maybe inefficient and sometimes impossible. This so calledwhereabouts rule requires athletes and/or teams thathave been identified for out-of-competition control tobe responsible for providing and updating informationon their whereabouts so that they can be located forNo Advance Notice out-of-competition control. Theapplicable requirements are set by the responsible sportfederation or National Anti-Doping Organisation(NADO) in order to allow flexibility based uponvarying circumstances encountered in different sportsand countries. A violation of this rule may be based oneither intentional or negligent conduct by the athlete,but it is known that the whereabouts rule may not berealistic in international team sports, if players arenormally playing for a club far from their home nation.

Separation of Power

An imp ort ant leg al pri nci ple is th e sep ara tio n o fpower between the anti-doping executive authorities

and the disciplinary committee responsible for theadministration of anti-doping sanctions. This is tominimise any accusations of bias or conflict of interestin the application of the Code.

Under FIFA regulations, this principle is applied ina practical sense by having the Doping Control Sub-Committee (representing medical, pharmacologicaland medical legal expertise) dealing with the medicaland biochemical aspects of the alleged doping eventand, once this issue has been determined, a separateDisciplinary Committee which awards the appropriate

sanction in view of the individual circumstances of theathlete concerned. The exact procedure is describedbelow.

Medical Legal Aspects of Doping Control Procedures

The full details of the FIFA doping control procedure areset out in the annually updated FIFA Doping ControlRegulations (http://www.fifa.com/en/regulations/regulation/0,1584,9,00.html)

Regarding the medical legal aspects of doping controlprocedures, the process is as follows:

Once an A sample has tested positive, then the FIFADoping Control Sub-Committee investigates thedocumentation of the case and prepares a reportfor the FIFA Chief Doping Control Officer. TheFIFA Chief Doping Control Officer has to verifythat the correct doping control procedures havebeen completed according to the doping control

regulations. This process usually involves contactingthe testing laboratory as well as the original dopingcontrol co-ordinator where the athlete was tested.

If the anal ysis of specimen A is confirmed as positiveby the FIFA Doping Control Sub-Committeesreport, the FIFA General Secretary shall at onceconfidentially notify the chairman of the DisciplinaryCommittee, the Sports Medical Committee and thenational association of the player concerned, whichshall have the right to request a second analysis usingspecimen B within 24 hours of being notified.

F-MARC DOPING UPDATE 2006 | MEDICAL LEGAL ASPECTSMEDICAL LEGAL ASPECTS | F-MARC DOPING UPDATE 2006

Individual case management and

the principle of fault are integral parts of

FIFAs approach to doping control


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If a second analysis i s requested, FIFA shallcommunicate this request immediately to the head ofthe laboratory where the specimen B is being kept. Ananalysis of specimen B shall be carried out as soon aspossible, by personnel who were not directly involvedwith the analysis of specimen A. The associationconcerned shall have the right to have a representativepresent, in addition to the player concerned. Theresults of the analysis of specimen B shall be sentimmediately to the FIFA Chief Doping ControlOfficer responsible, by fax or e-mail. If no request fora second test is made, the laboratory shall dispose ofspecimen B after 30 days have elapsed.

In addition to the procedural roles above, the FIFAChief Medical Officer and the Doping Control Sub-Committee also have to estimate the seriousness ofthe individual case from a medical point of view asto whether the violation was intentional (partiallyautonomous but not fully self responsible), deliberate(fully autonomous) or negligent and examine whetherany exceptional circumstances may apply. Finally, a

written statement about the medical analysis of the caseincluding an estimation of the medical legal aspects hasto be submitted to the FIFA Disciplinary Committeefor consideration of sanctions.

In cases where FIFA is asked by a national federation or aconfederation to take over the sanction or decide about asanction for the international level, the same procedure iscarried out. The individual case management as outlinedabove and the principle of fault are integral parts ofFIFA`s approach to doping control and based on SwissSanction Law. This means that there must be evidencethat the player is personally guilty of the offence beingsanctioned and the unjustness of his behaviour has to beobvious to him. Thus, every sanction inevitably containsa distinctive individual component.

Problems that Remain to Be Solved

Wit h reg ard to the ong oin g d eve lo pme nt of newsubstances and laboratory methods, regular review ofstandards and regulations is necessary for appropriateanti-doping action in accordance with the scientificevidence and sport ethics.

T/E ratio

The lowering of the threshold for the ratio of testosterone(T) to epitestosterone (T) from 6 to 4 has led to intensediscussion with the accredited laboratories and raisedconcerns on behalf of FIFA. According to the FIFA

database 2005, none of the samples with elevated ratiosbetween 4 and 6 showed evidence of exogenous intake inthe GC-Isotope Ratio Mass Spectometry (GC-IRMS).In face of the logistic impact and additional costs, FIFAshould strongly advocate detailed statistical analysis ofthe WADA data, examining the incidence of exogenousintake of testosterone in samples with T/E ratios between4 and 6. Furthermore, legal difficulties arise in caseswhere the T/E ratio is between 4 and 6 but GC-IRMSdoes not verify exogenous intake.

Alpha-Reductase Inhibitors

The increasing use of alpha-reductase inhibitors fortreatment of male pattern baldness has led to positiveurine samples of athletes for finasteride, the mainmetabolite. Finasteride is a banned substance listedunder S5. Diuretics and masking agents in the dopingcontrol regulations. Only recently, a German footballplayer has been suspended by the supreme court ofthe German Soccer Federation for six months with

additional fine after a positive result for finasteride. Inthis case, the laboratory explicitly used more sensitiveanalytical methods which could not identify any tracesof anabolic steroids in the sample a finding that isnot covered by the World Anti-Doping Code. This caseillustrates several critical medical legal aspects which haveto be addressed, including the question if male patternbaldness represents a psychological disease and theeligibility for a Therapeutic Use Exemption.

Recreational Drugs

Recent years have shown a constant increase of positivetesting for recreational drugs. While this finding revealsrather a social than a doping problem, an importantlegal aspect has to be considered, too: The consumption

of marihuana presents a severe offence against the lawin some countries, especially in Africa and Asia, even ifconsumed abroad. Here, the publication of a positiveresult may lead to serious consequences for the respectiveplayer including a prison sentence. Anti-doping bodiesshould therefore carefully reconsider the unconditionedban of recreational drugs, preferably based on a juridicalexperts opinion.

Conclusion

While the Worl d Ant i-Doping Code a nd th e Dop ingControl Regulations of FIFA offer a comprehensivebasis for the fight against doping, the permanentprogress in the development of new substances andlaboratory methods calls for regular review and updateof the adopted policies. Whereas harmonization of thestrategies of national and international anti-dopingagencies is reinforced, the legislation and politics ofdifferent countries constitute a permanent obstacle.Any regulatio n concerning medical legal aspect s shouldtherefore be based on scientific evidence and juridicalexpertise and has to be supported by close collaborationof national and international bodies.

References

World Anti-Doping Code 2003,World Anti-Doping Agency, Montreal, Quebec, Canada, March 2003,

www.wada-ama.org

Blackshaw IS, Siekman RCR, Soek J The Court of Arbitration for Sport 1984-2004; decisions 1995; CAS

94/129, Asser press and Cambridge University Press 2006

Bundesgericht des Deutschen Fussballbundes DFBDecision Nr. 3/2005/2006


Prof. Toni Graf-Baumann

F-MARC DOPING UPDATE 2006 | MEDICAL LEGAL ASPECTSMEDICAL LEGAL ASPECTS | F-MARC DOPING UPDATE 2006

The permanent progress in the

development of new substances

and laboratory methods calls for

regular review and update of

the adopted policies.


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FIFAs Future Activities inthe Fight against Doping


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The fight against doping in sport receives considerablemedia interest and results in much speculation regardingthe ability of athletes to compete on a level playing field.Football was one of the sports that took early leadershipin this fight when FIFA introduced doping control infootball in 1970 as part of a wider strategy to ensurethat the results of representative matches were a fairreflection of the ability of those taking part.

As a result of the coll aborative effort between FIFA, theconfederations and their member associations and inconjunction with national anti-doping organisations,more than 20,000 doping controls are performedannually on football players. The overall incidenceof positive doping samples for prohibited substancesaccounts for 0.4% of all tests.

The majority of positive drug tests are due to cannabisand cocaine, so-called social drugs. Only a fewindividual cases (0.07% of positive tests in 2004) werepositive for anabolic steroids, such as nandrolone andtestosterone.

The majority of doping control tests have been carried outin competition. FIFA, UEFA and some of the nationalanti-doping organisations also perform unannounced,

out-of-competition controls at training venues during thefootball season. Prior to t he 2006 FIFA World Cup inGermany, unannounced doping controls were performedin friendly matches between nations as well as during thetraining camps prior to the opening match on 9 June2006. All tests to date have proved negative. UEFA,the European football confederation, also performedunannounced testing in the 2005-2006 football seasonon all of the teams participating in the UEFA Championsleague and UEFA Cup. Ten players were randomlyselected from each of the 38 top European professionalteams and subjected to testing. No prohibited substanceswere found in any of the 380 samples tested.

Since 1994, FIFA has followed a similar strategy ininternational competitions for both men and women.In these tests, two randomly selected players per teamare tested after each finals match and a total of 3,327tests have been performed in 32 tournaments to date.Only three samples have tested positive since testingcommenced: one for ephedrine, one for cannabis and onefor nandrolone. One sample tested positive for ephedrine

during the qualifying matches for the 2006 FIFA WorldCup Germany. The incidence of positive tests in FIFAcompetitions over the past 12 years is 0.1%.

FIFAS FUTURE ACTIVITIES | F-MARC DOPING UPDATE 2006

FIFAs Future Activities in the Fight Against Doping

F-MARC DOPING UPDATE 2006 | FIFAS FUTURE ACTIVITIES

During the Olympic Games in Sydney 2000 and inAthens 2004, none of the football players tested positivefor any prohibited substances. An internal survey amongall Olympic team sports federations revealed that noneof the team sports athletes tested positive for prohibitedsubstances.

It is currently not possible to compare positive drug testsamong the different sports as the World Anti-DopingAge ncy (WAD A) onl y pre sen ts adv ers e ana lyt ica lfindings in their published statistics rather than truepositive results. The statistics include therapeutic useexemptions as well as elevated (>4) T/E ratios that maybe seen in normal athletes. Football accounts for themajority of doping controls performed worldwide.

The current doping statistics demonstrate a very lowincidence of positive tests and justifies the assumptionthat there is no evidence for systematic doping infootball and most probably in any of the other Olympicteam sports.

Alth ough no cl ear d ata exist s fr om WADA about thedistribution of in- and out-of-competition drug testing,it can be assumed that the majority are in-competition.It has to be remembered that the professional footballseason in which the footballers are subject to randomtesting runs for 49 weeks a year in most football-playingnations.

There are several possible explanations for the lowincidence of positive findings of prohibited substancesamong football players.

The stringent drug-testing programme occurs duringthe entire football season in most countries.

Football players worldwide understand that prohibitedsubstances in sport will neither improve their physicalperformance nor their football skills and hence theyare reluctant to use agents that are not effective andsubject to possible sanctions.

As a result of ongoing education campaigns by FIFAto doctors, administrators, officials and players, adrug-free culture is encouraged in football.

It is also possible that both in- and out-of-competitiontesting is insufficient to detect drug use. However,this is unlikely given the large number of in- and out-of-competition drug tests occurring at all levels ofprofessional sport over many years with relatively fewpositive results.

FIFA has also developed close collaboration withthe medical representatives of other Olympic teamsports federations, as well as with the InternationalRugby Board, over the past six years, realising that thedimension of abuse of prohibited substances is differentin comparison to individual Olympic sports. The medicalrepresentatives of these bodies expressed their collectiveopinion during a WADA meeting in Copenhagen in

Football was one of the sports that took

early leadership in the fight when FIFA

introduced doping controls in football in 1970


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March 2003, suggesting a possible revisionof the World Anti-Doping Code giventhe different needs of international team

sports federations and the lack of evidenceof systematic doping in those sports.

Furthermore, given that 20,000 doping controls areconducted on football players annually worldwide,it became obvious that a close collaboration had to bedeveloped with the accredited testing laboratories inorder to understand the different examination methodsand to keep abreast of new scientific developments. Theclose collaboration with the laboratories has resulted inthese laboratories being considered equal partners inthe global strategy against doping. It has also resultedin a number of research studies being performed oncontroversial issues such as nandrolone metabolism,analysis of testosterone/epitestosterone ratio and theinfluence of age and ethnic differences on testosteronemetabolism.

It seems likely that constantly increasing the number

of drug tests would not alter the incidence of positivefindings. Unannounced testing at training groundsfollowing the impressive example of UEFA withChampions League teams could be introduced in allconfederations to provide more information frompossible abuse of prohibited substances between officialmatches. The absence of any positive tests in the UEFAtesting to date makes it unlikely that this strategy wouldidentify a significant number of drug cheats who arecurrently not being detected.

Given these findings, the question is raised as to whetherthere is a need for fundamental change in the strategy tofight doping in football?

The FIFA Sports Medical Committee is of the opinionthat the educational process has to be intensified with thehelp of national associations and in particular, throughteam physicians. The team physicians play a centralrole in the educational programme as they have directinfluence over player behaviour and have the knowledgeto advise players, not only on the potential risks tohealth, but also the effect that sanctions may have on aplayers career if caught. The 32 team physicians of thefinalists have once again confirmed their unconditionalsupport of FIFA`s strategy by their joint declarationsigned prior to the 2006 FIFA World Cup Germany.The doping control officer at testing controls can alsoreinforce the educative aspect of the fight against doping.

Future Challenges in the Fight against Doping

In 2006, FIFA launched a new development programme,FUTURO III. The FIFA Sports Medical Committeeundertook to implement the mandate of FIFA PresidentJoseph S. Blat ter an d the FIFA Exec utive Committe e,i.e. to educate more than 3,000 physicians worldwidein football medicine over the next three years. Anti-doping education is an integral part of the instructionalcourses, which were launched in Oceania in February2006 followed by CONMEBOL (South America) inApril 2006. Active participation within the instr uctionalcourses will entitle the physicians to become membersof the worldwide network of FIFA medical officers, notonly to deal with optimal management and preventionof injuries, but also to act as FIFA doping controlofficers throughout the 207 member associationsof FIFA in collaboration with national anti-dopingorganisations.

In this respect, FIFA is of t he opinion that the dopingcontrol programmes have to be carried out by members

of the international sports federations and obligatory byphysicians. There is no need to delegate this importantwork to commercial companies. The experience of FIFAclearly indicates that employing physicians to performdoping controls is not only effective but can be done atlow cost, and most probably, it would reduce the riskof potential corruption as the physicians have to followtheir professional ethical and medical legal constraints.

Another challeng e is th e contin uous sea rch to identifynew performance-enhancing drugs being distributed onthe market via the internet and in this respect, medicalscience, in close collaboration with laboratory expertsand the Scientific Committee of the World Anti-DopingAgency, might help to identify p ossible n ew drugs andsanction their abuse accordingly.

Argu ably, the majo r c hal leng e f or the futu re lies ingenetic doping and its detection. There is no doubt thatwe cannot stop the development of medical science asthe development of altered genetic information seeks tohelp many patients suffering from incurable diseases andyet it could be claimed that this scientific advancementmight be abused for performance enhancement insport. In this regard, the education and cooperation ofteam doctors forms a crucial link in the chain to preventathletes adopting such strategies.

Conclusion

Following the leadership of FIFA, there is strongevidence that doping controls and sanctions of positivecases will only be sufficient if the problem of doping andrecreational drugsin sport is tackled over the long-termin a comprehensive manner. There are strong indicatorsthat the education of athletes, and in

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