What’s the future for therapeutic use exemptions (TUEs)?

Spotlight shines on the system of therapeutic use exemptions after one of its biggest critics, Andrew Starykowicz, tests positive for oxygen-boosting drug says Tim Heming

What's the future for therapeutic use exemptions (TUES)?

With Andrew Starykowicz we’ve seen the brio. The brash, entertaining, staunch anti-doping advocate, with enough strength in his quads to power a small town in Texas. Now we have the Breo, a prescription medicine typically used to treat chronic obstructive pulmonary disease, that a year and several thousand dollars later, even he might admit was a mistake. The short take is ‘Starky’ failed a drugs test and is banned until the end of 2020. The wider perspective is that this case asks as many questions as it answers, and portrays either a flawed (Starykowicz says “broken”) system or a hypocritical man.


The story can be picked up with Starykowicz giving an interview at the Ironman Worlds in Kona last year where he declared that taking therapeutic use exemptions (TUEs) is doping. “If you have asthma that’s so bad you need a steroid inhaler just to breathe, you shouldn’t be racing. We need to do away with TUEs.”

On race morning in Kona, Starykowicz posted a DNS and a picture of his sink containing what appeared to be the contents of his lungs. He was back racing to finish runner-up in Ironman 70.3 Waco a fortnight later and third in Ironman Florida the following week. Then, like much of the racing world, he went quiet. Except while others were resting in lockdown, Starykowicz was fighting his corner.

On the advice of his doctor, he’d taken Breo for his Hawaiian flu and submitted a TUE saying if better by Waco, he planned to race. There were admin delays and, by the time of the race, the TUE wasn’t approved. He raced anyway, detailed his medication and tested positive for the beta-2 agonist. US Anti-Doping Agency (USADA) then declined the TUE, saying he should’ve taken alternative medication. Ironman pushed for a four-year penalty; Starykowicz pointed out others have received just public warnings for taking Breo and appealed to the Court of Arbitration for Sport, costing $75,000. He lost and was suspended for 13 months. Shortly after, WADA removed Breo from the prohibited substance list.

Some argue it’s deserved comeuppance for his hubris; an expensive and ironic lesson learnt over flippant comments regarding a TUE system he then had to use. Why not use alternative medication and why, no matter however frustrated at the system, race without the green light from USADA? Others contest that health comes first. Starykowicz followed doctor’s orders when sick; USADA dragged its feet; Ironman victimised an outspoken triathlete to make themselves look tough on cheats.

The reality is nuanced. Starykowicz has merit in his point about TUEs being abused by athletes and should be commended for speaking up. But he’s then tried – and failed – to play the system. Even before Kona he said, “I’m more focused in having a better race in Florida than I am here. In Florida, I can truly race an Ironman.” It’s a race he’s won before on a course he’s suited to. He may never admit it, but perhaps, after the frustration of sitting out Hawaii, the pull of getting back to racing proved just too great.


Illustration by Daniel Seex