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Therapeutic use exemption drugs and their place in performance medicine

Over the last couple of years the ‘Therapeutic Use Exemption’ (TUE) system in elite sport has been subject to much media speculation, in particular the drugs Kenalog, Thyroxine and Meldonium. Dr Leon Creaney, a consultant in sport & exercise medicine debates their uses and place in performance medicine

Over the last couple of years the ‘Therapeutic Use Exemption’ (TUE) system in elite sport has been subject to much media speculation. The purpose of TUEs is to allow athletes with legitimate medical problems to use drugs that are potentially performance enhancing, on the grounds that they are being used for legitimate medical reasons.

What is a Therapeutic Use Exemption?

The Doctrine of double effects states that an action can be morally justifiable for its good effects, even if it has bad effects, provided the bad effects were not intended. It may even remain justifiable if the bad effects were foreseen or expected.

This form of reasoning has been used in medicine for centuries to justify morally questionable actions. The most stark example is with opiates (Morphine). Let’s suppose a patient has terminal cancer and is in a lot of pain. They want to die, but euthanasia is illegal. The doctor gives them Morphine to relieve pain, but it causes respiratory depression. The patient stops breathing and dies. Did the doctor give the morphine to relieve pain or end a life? What was the true intention?

The Doctrine has much resonance with the current TUE debate. Three drugs in particular, Kenalog, Thyroxine and Meldonium have been in the headlines.

Kenalog (Triamcinolone) is a potent anti-inflammatory steroid. It has wide ranging effects, and can certainly help with the symptoms of asthma. It also has other well known effects on mobilising glucose and fat metabolism and certainly improves endurance. So an athlete with asthma can take it, knowing full well that it will improve their endurance performance too.

Thyroxine is used in people with an under-active thyroid. Problems exist in defining what constitutes an under-active thyroid. There is no universal agreement on the level of TSH or Thyroid hormone in the blood that necessitates treatment. Some doctors will treat levels that would be considered completely normal by others. Furthermore the symptoms of hypothyroidism are vague and subjective.

Thyroxine is perceived by athletes to be performance-enhancing, so there is an incentive to be diagnosed with hypothyroidism and receive Thyroxine.

Meldonium is a drug used to treat people with coronary artery disease. There is really no justifiable reason for healthy athletes to use it, but again it is perceived to be performance enhancing. Prior to it being banned, use of Meldonium was rife in elite sport, as evidenced by the Baku study.

Finally testosterone replacement therapy is worth mentioning. It is now marketed for the ‘male menopause’. Debate continues in medicine about whether this is a real medical condition. It is diagnosed on the basis of low-for-age serum testosterone levels and typical symptoms such as fatigue or lack of libido. It represents an attractive means of legitimising the use of anabolic steroids. 

So are these athletes cheating? No. The system allows it. Is it ethical and within the spirit of sport? That is another question. The TUE system is open to abuse and probably needs reviewing. Until then athletes will keep on searching for those marginal gains.

All of the above falls into the realm of what is becoming known as ‘Performance Medicine’. On the simplest level performance medicine is the branch of sports medicine devoted to keeping athletes healthy and optimised for training, recovery and competitive performance. However the darker side of performance medicine asks questions around how an athlete's physiology can be manipulated with medicine in order to maximise performance gains. The line between genuine medical care and the deliberate prescription of drugs to improve performance then becomes very blurred.

Some doctors, physiologists, coaches and athletes will always want to push at the boundaries, others will want run a mile from any suggestion of cheating. Nevertheless performance medicine is here to stay. The demand is there, so the supply will continue. The IOC, WADA and international sporting bodies will need to collectively draw a line in the sand, and decide what is acceptable practice, and what is recognised as a deliberate attempt to gain an unfair advantage.

Dr Leon Creaney


Consultant in Sport & Exercise Medicine


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