INTRODUCTION K-H. Carlsen*, J. Cummiskey#, L. Delgado}, S. Del Giaccoz *Voksentoppen BKL, Rikshospitalet University Clinic, University of Oslo, Oslo, Norway. # Blackrock Clinic, Blackrock, County Dublin, Ireland. } Servic ¸o de Imunologia, Faculdade de Medicina, da Universidade do Porto, Hospital S. Joa ˜o, Porto, Portugal. z Dipartimento di Medicina 2, University of Cagliari, Cagliari, Italy. Asthma and allergy represent increasing problems for the actively competing athlete. The prevalence of exercise-induced asthma (EIA) has increased over the last two decades, especially amongst elite endurance athletes [1–3] it has been reported that high-level endurance training in particular may increase bronchial hyperresponsiveness (BHR) [4] and cause inflammation in the airways [5]. Intensive endurance training and competition, together with environmental influences, are thought to be causative factors. For winter sports, inhaled cold air represents such an environmental factor moreover, exposure of competing swimmers to organic chlorine products released from indoor swimming pools is another example of a harsh environment. Furthermore, the increased amount of training and increased level of physical fitness and maximum oxygen uptake reached by present-day elite athletes may, in some cases, make it difficult to discriminate between limitations to maximum exercise set by normal airways and EIA. This underlines the need for developing good diagnostic criteria for EIA and BHR in relation to sports. It has become a concern that the use of inhaled asthma drugs, especially inhaled b2- agonists, has become increasingly wide-spread amongst elite athletes and that high-level endurance training in particular may increase BHR [4] and cause inflammation in the airways [5]. In 1993, the Medical Commission of the International Olympic Committee (MC-IOC) restricted the use of inhaled b2-agonists, even in asthmatic athletes, and only allowed inhalation of the short-acting b2-agonists (SABA) salbutamol and terbutaline for use in relation to sports by asthmatic athletes. All drugs should be prescribed by a doctor with confirmation of an asthma diagnosis. Several studies were performed on the effect on performance of both inhaled SABA and long-acting b2-agonists (LABA), regarding endurance performance and maximal strength, speed and power functions however, none of these studies could confirm any improvement in performance. Thus, from 1996, the MC-IOC also allowed the use of salmeterol, a LABA, by inhalation later (2001), inhaled formoterol was allowed by both the MC-IOC and the newly formed World Anti-Doping Agency (WADA) in relationship to participation in sports by asthmatic athletes. However, due to the frequent use of both SABA and LABA by inhalation, and the fear that b2-agonsts in high systemic doses might increase muscle mass, as indicated by some animal studies [6, 7], further regulations were introduced by the MC-IOC in December 2001, shortly before the Winter Olympic Games in Salt Lake City (UT, USA) 2002. In order to be allowed to use inhaled b2-agonists, the team doctor had to make a prior application to the commission, together with documentation of increased reversibility to bronchodilators, bronchial hyperresponsiveness and/or exercise-induced broncho- constriction (EIB). Anderson et al. [8], who suggested these regulations, described their experiences during the Winter Olympics in 2002. Many respiratory physicians caring for top athletes felt that the regulations were too strict and the procedures required for documentation were too demanding on resources, Eur Respir Mon, 2005, 33, vii–ix. Printed in UK - all rights reserved. Copyright ERS Journals Ltd 2005 European Respiratory Monograph ISSN 1025-448x. ISBN 1-904097-22-7. vii
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