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amswimmer
October 18th, 2011, 07:20 PM
At our SCM meet this past weekend we had an out-of-state visitor swimming. She was a very serious swimmer, arrived a week early to acclimate, came with a bit of an entourage, and did some pretty amazing times (45-49). We also saw her taking frequent hits from a very large inhaler always just before her races as she was warming up and behind the blocks. Any thoughts?.

rxleakem
October 18th, 2011, 08:58 PM
We also saw her taking frequent hits from a very large inhaler always just before her races as she was warming up and behind the blocks. Any thoughts?.

I would think it was a fast-acting inhaler like Albuterol. I am not sure if that is a "legal" drug for competition; in addition to opening the airways, it can cause an increase in heartrate.

Rich Abrahams
October 18th, 2011, 10:26 PM
Definitely performance enhancing. I won't judge whether or not it is illegal by WADA standards. I think they may make some exceptions for diagnosed asthma. Interestingly, Phil Whitten told me that shortly after asthma inhalers were allowed with a medical diagnosis 100% of the British national team suddenly were diagnosed with having asthma.

P.S. you are swimming lights out Sergey.

Spock
October 18th, 2011, 10:32 PM
I remember a quote from Gary Hall Jr. saying Amy Van Dyken was puffing on her inhaler over and over at the Olympics ... far exceeding than the prescribed 2 puffs.

pendaluft
October 18th, 2011, 11:20 PM
I know a lot of athletes feel otherwise (and maybe perception is the most important thing), but if you don't have airway reactivity, the effect of albuterol on lung function is pretty minimal. There is some work on oral albuterol and improved strength that is really focused on reversing the effects of immobility. You would never a high enough dose by inhaling it anyways.

My opinion is that, if you don't have asthma, albuterol probably doesn't improve your athletic performance. The elevated heart rate and nervousness associated with the drug may make you feel like you are getting an enhancement but I doubt its a measurable one.

robertsrobson
October 19th, 2011, 07:09 AM
Definitely performance enhancing. I won't judge whether or not it is illegal by WADA standards. I think they may make some exceptions for diagnosed asthma. Interestingly, Phil Whitten told me that shortly after asthma inhalers were allowed with a medical diagnosis 100% of the British national team suddenly were diagnosed with having asthma.

Not to cast aspersions on anyone - don't believe everything you are told!

gaash
October 19th, 2011, 08:11 AM
Asthma medications are all quite strong performance enhancers (especially if used over the long term). They are thought to change the body composition to be more muscle and less fat ... plus the immediate pre race benefits of expanding airways etc. Do people really think it is a coincidence that so many olympic athletes 'have asthma'??

robertsrobson
October 19th, 2011, 08:37 AM
Asthma medications are all quite strong performance enhancers (especially if used over the long term). They are thought to change the body composition to be more muscle and less fat ... plus the immediate pre race benefits of expanding airways etc. Do people really think it is a coincidence that so many olympic athletes 'have asthma'??

Interestingly, many swimmers have taken up the sport as children on the advice that it will help them manage their asthma.

Let's not also forget that for some it is extremely debilitating. Joanne Jackson, who was a medallist in Beijing is just starting to get back to some kind of form after losing much of the last couple of years to asthma. If she wasn't an Olympic medallist she would have had to quit, as she has real difficulty training at all during the winter months and has to go abroad for warm weather.

The Fortress
October 19th, 2011, 10:08 AM
Definitely performance enhancing. I won't judge whether or not it is illegal by WADA standards. I think they may make some exceptions for diagnosed asthma. Interestingly, Phil Whitten told me that shortly after asthma inhalers were allowed with a medical diagnosis 100% of the British national team suddenly were diagnosed with having asthma.



I've heard that Ellen has "severe asthma." Perhaps the severity of the problem requires higher doses?

I've also heard other swimmers complain about the entourage and drama surrounding her swims.

knelson
October 19th, 2011, 10:44 AM
I've also heard other swimmers complain about the entourage and drama surrounding her swims.

Hey, I want an entourage, too! :)

pwb
October 19th, 2011, 10:59 AM
...as she has real difficulty training at all during the winter months and has to go abroad for warm weather.I, too, have real difficulty training during the cold winter months ... just haven't yet figured out how to afford to go abroad for warmer weather!

As for the subject of people using PEDs in Masters sports, I go back to this fundamental question: why? What's the upside? I get the incentives for pro athletes to use PEDs, but I just can't understand what's in it for a Masters athlete who is competing at a Masters level. Is the glory of winning really worth it?

robertsrobson
October 19th, 2011, 11:01 AM
I, too, have real difficulty training during the cold winter months ... just haven't yet figured out how to afford to go abroad for warmer weather!

As for the subject of people using PEDs in Masters sports, I go back to this fundamental question: why? What's the upside? I get the incentives for pro athletes to use PEDs, but I just can't understand what's in it for a Masters athlete who is competing at a Masters level. Is the glory of winning really worth it?

No.

And to be honest, I can't see why it is for an elite athlete either. I can see the financial side, but where's the glory?

pwb
October 19th, 2011, 11:20 AM
And to be honest, I can't see why it is for an elite athlete either. I can see the financial side, but where's the glory?Yes, when I was referring to incentives for pro athletes, I was thinking money alone.

no200fly
October 19th, 2011, 11:28 AM
I have had asthma since I was a kid. Swimming eliminated most of it.
I still have an occasional attack and sometimes have exercise induced asthma. I still keep a rescue inhaler around just in case.
Maybe I have not had access to the good stuff – or maybe using an inhaler only when you need it eliminates the benefit - but I have never felt any kind of benefit from using an inhaler.

Rich Abrahams
October 19th, 2011, 11:29 AM
Not to cast aspersions on anyone - don't believe everything you are told!

I don't believe everything I'm told, but when the source is Phil Whitten, perhaps the most knowlegeable person in the world on swimming and ped's, I tend to trust the source. You may recall that, when Phil was the editor of Swimming World magazine, he was the first to publicly question the Chinese women re doping. He is currently writing a series of articles on ped's in masters swimming. One installment has already been published in Swimmer magazine and I believe the second installment will be specifically on asthma medications.

Chris Stevenson
October 19th, 2011, 11:47 AM
As for the subject of people using PEDs in Masters sports, I go back to this fundamental question: why? What's the upside? I get the incentives for pro athletes to use PEDs, but I just can't understand what's in it for a Masters athlete who is competing at a Masters level. Is the glory of winning really worth it?

I'll go even further than that. The stakes are indeed low, so why should anyone else care? And in this particular case opinions about the potential benefits seem divided anyway.

I get that many get an ego boost from winning and breaking records, but IMO taking PEDs is an action that carries its own punishment.

I also get most don't want USMS events to be high-pressure affairs, and so behavior like that described can leave a sour taste for those who want a more relaxed atmosphere. Just ignore it; different people derive different motivation and enjoyment from these events. To the extent that it promotes a healthy and balanced lifestyle, it's all good.

no200fly
October 19th, 2011, 12:14 PM
I also get most don't want USMS events to be high-pressure affairs, and so behavior like that described can leave a sour taste for those who want a more relaxed atmosphere. Just ignore it; different people derive different motivation and enjoyment from these events. To the extent that it promotes a healthy and balanced lifestyle, it's all good.

I agree

ourswimmer
October 19th, 2011, 12:16 PM
At our SCM meet this past weekend we had an out-of-state visitor swimming. . . . Any thoughts?.

My thought is that using a "question" to start unkind rumors about someone is gross.

fastback
October 19th, 2011, 01:05 PM
Seems like this is a legitimate question. Given the responses is appears that there is no policy on this issue or if so, it's not widely known. It would be good to have it clarified. I don't think the question was meant to start a rumor.

gaash
October 19th, 2011, 03:03 PM
Interestingly, many swimmers have taken up the sport as children on the advice that it will help them manage their asthma.

Let's not also forget that for some it is extremely debilitating. Joanne Jackson, who was a medallist in Beijing is just starting to get back to some kind of form after losing much of the last couple of years to asthma. If she wasn't an Olympic medallist she would have had to quit, as she has real difficulty training at all during the winter months and has to go abroad for warm weather.

Except, it's usage is big in many sports not just swimming...

lefty
October 19th, 2011, 05:09 PM
We also saw her taking frequent hits from a very large inhaler always just before her races as she was warming up and behind the blocks. Any thoughts?.

A few years ago, chlorofluorocarbon-propellant albuterol inhalers were replaced by HFA-propellant inhalers (it was claimed this was for environmetal reasons, but reality is that there is patent protection on HFA Inhalers so no generics exist.).

The new inhalers, in a word, suck. If I am having an airway obstruction I take 10 puffs if not more (which means, in addition to being more expensive, I have to buy them more often). So from personal experience, I wouldn't judge anyone who "over-medicates" on the new inhaler. They just dont work as well.

I will add that all inhalers are the same size. It might have appeared larger because she was using a spacer (which makes the delivery of the medicine more effective).

pendaluft
October 20th, 2011, 08:01 AM
A few years ago, chlorofluorocarbon-propellant albuterol inhalers were replaced by HFA-propellant inhalers (it was claimed this was for environmetal reasons, but reality is that there is patent protection on HFA Inhalers so no generics exist.).

The new inhalers, in a word, suck. If I am having an airway obstruction I take 10 puffs if not more (which means, in addition to being more expensive, I have to buy them more often). So from personal experience, I wouldn't judge anyone who "over-medicates" on the new inhaler. They just dont work as well.

I will add that all inhalers are the same size. It might have appeared larger because she was using a spacer (which makes the delivery of the medicine more effective).

The pulmonary deposition of most HFA inhalers is superior to their CFC predecessors. Most studies show improved efficacy with the newer inhalers. With less deposition in the mouth, some people feel that they are getting less but the reality appears to be the opposite.

The switch from CFC was almost 10 years in the making and was motivated by the environmental concerns. Unfortunately, only one of the manufacturers of generic albuterol was prepared to switch to HFA. When they realize that they were the only one, they decided to price themselves like a brand name and drug. This looks as if it will change in the future.

Fresnoid
October 20th, 2011, 10:12 AM
At our SCM meet this past weekend we had an out-of-state visitor swimming. She was a very serious swimmer, arrived a week early to acclimate, came with a bit of an entourage, and did some pretty amazing times (45-49). We also saw her taking frequent hits from a very large inhaler always just before her races as she was warming up and behind the blocks. Any thoughts?.

Maybe she had friends/relatives to visit in the area, thus the early arrival. Perhaps socializing with her local contacts continued at the meet, giving the appearance of an entourage.

EJB190
October 20th, 2011, 11:20 AM
I too would assume this woman is taking albuterol or some form of it, as it is the most commonly prescribed inhaler. So is albuterol (or some other bronchodilator) performance enhancing?

I honestly don't think it would make that big of a difference if you did not have a breathing problem to start off with.

Just because you're taking it doesn't mean you're cheating. For all we know, she could have a legitimate breathing problem. I don't think they could ever outlaw taking legal medicine for legitimate health concerns or deny the swimmer over usage of the medicine. It is well known that swimmers have an increased rate of asthma due to irruption caused by the chlorine in the air.

Usually inhalers are instructed to be taken as needed. Additionally, the effects of Albuterol are very short lived, I would say at best 15 minutes. I also remember reading something that said whether you take a relatively normal breath or HUGE breath doesn't significantly improve the amount of oxygen you receive and the duration you can hold your breath (this was in reference to shallow water blackout).

Psychologically, I might see how having the feeling of easier breathing might make you more confident. I don't know. I don't think you can make accusations if you don't know her medical history and statistics (peak flow, etc), but if she is a healthy individual, I don't think albuterol would be a real performance enhancer.

- 3rd Year Pharm.D student

EJB190
October 20th, 2011, 11:25 AM
A few years ago, chlorofluorocarbon-propellant albuterol inhalers were replaced by HFA-propellant inhalers (it was claimed this was for environmetal reasons, but reality is that there is patent protection on HFA Inhalers so no generics exist.).

....

I will add that all inhalers are the same size. It might have appeared larger because she was using a spacer (which makes the delivery of the medicine more effective).

These are also very good points. The new HFA inhalers are universally believed to be not as effective. Many doctors also prescribe spacers to increase the efficacy of the drug delivery. Furthermore, the thread starter said she was taking "big hits" or something to that effect. That just means she was actually using the medicine correctly. Most people do not breath in hard enough to get the medicine where it's supposed to go.

Additionally, repeated doses can also be caused by a dirty inhaler. Most people don't know that your inhaler should be cleaned after every use. Failure to clean the device decreases its output.

__steve__
October 20th, 2011, 11:41 AM
I thought asthma targeted inhalers provide no advantage to athletic performance, just lessens performance harming effects caused by a medical condition

pendaluft
October 20th, 2011, 11:54 AM
These are also very good points. The new HFA inhalers are universally believed to be not as effective. .

This is just not true. The pulmonary deposition is as good or better with HFA than compared to CFCs (depending on which med you use) and all physiology efficacy studies have shown them to be the same. In addition, every respiratory specialist that I know --and I know a lot -- feel that they are equivalent. I can't imagine what you mean by "universally."

In addition, everyone should use a spacer when taking albuterol -- it increases the pulmonary deposition of the albuterol by a factor of three or more. You have more side-effects without it as well.

aztimm
October 20th, 2011, 04:02 PM
In addition, everyone should use a spacer when taking albuterol -- it increases the pulmonary deposition of the albuterol by a factor of three or more. You have more side-effects without it as well.

I've been taking Albuterol for about 25 years, and rarely (maybe 5-10 times) have used a spacer. I didn't even know about them until about 10 years ago, and it just doesn't seem as effective for me when I do.
But I can't even remember the last time I used mine as a rescue inhaler. I've been taking Asmanax for 5-8 years 2x a day. I'll use Albuterol to clear my lungs and the Asmanax seems much more effective.

All that said, yes I do feel like it helps my performance, especially in cooler water like an open-water swim, and also for longer pool swims (the 800/1500). I haven't really noticed any difference in shorter events. I definitely feel a difference in running too, especially in cooler air and/or when pollution is high.

EJB190
October 20th, 2011, 04:44 PM
This is just not true. The pulmonary deposition is as good or better with HFA than compared to CFCs (depending on which med you use) and all physiology efficacy studies have shown them to be the same. In addition, every respiratory specialist that I know --and I know a lot -- feel that they are equivalent. I can't imagine what you mean by "universally."


That's interesting, I will have to look into that. I know numerous people- patients, pharmacists, physicians, teachers, who find the new CFC's to be not as effective. Physiological efficacy studies should show them to be the same, otherwise they probably wouldn't be on the market.

Tim R
October 20th, 2011, 05:33 PM
I have had asthma since I was a kid. Swimming eliminated most of it.
I still have an occasional attack and sometimes have exercise induced asthma. I still keep a rescue inhaler around just in case.
Maybe I have not had access to the good stuff or maybe using an inhaler only when you need it eliminates the benefit - but I have never felt any kind of benefit from using an inhaler.

I have had asthma since i was a kid and thought it was exercize induced until i went for allergy testing 10 years ago ( damn cat ), and they tested my breathing and said i had the lung power of a 70 yr old ( i was 40 at the time ). I think i just got used to being short of breath when i wasnt exercizing and took ventolin before a workout.
I now take advair twice a day and nothing else.

EJB190
October 20th, 2011, 08:16 PM
We should remember though, you always have to remember with clinical trials. Especially if the drug company chooses who gets to be in it. Results can be skewed.

For example, antidepressant studies never used very depressed people for fear of suicide. Therefore, the people they are using are people who may not really be depressed and people who may become healthy again with a short amount of time. Similarly, if they are using "healthy" patients, patients without severe conditions, the efficacy of the drug is in question. The inhalers are fast acting. If a pt with severe respiratory problems was to have a severe problem that the new inhaler does not adequately treat, that puts the patient at risk. Therefore, unhealthy test subjects aren't used.

pendaluft
October 21st, 2011, 07:58 AM
Please see extensive reference list from this review:

Expert Rev Respir Med. 2008 Apr;2(2):149-59.
Albuterol HFA for the management of obstructive airway disease.
Colice GL.


Clinical efficacy

From the preclinical formulation work, it was expected that albuterol HFA MDI would be as effective a bronchodilator, on a puff-per-puff basis, as albuterol CFC MDI. This expectation was confirmed in dose-response studies in patients with asthma [73,74] . One puff of albuterol HFA MDI improved FEV1 significantly more than placebo, but the bronchodilator effect was less than with two puffs. The bronchodilator effects of two puffs from an albuterol HFA MDI were comparable to those of two puffs from an albuterol CFC MDI. In a pivotal Phase III study, adult patients with asthma were randomized in a blinded fashion to self-administer two puffs of either albuterol HFA MDI, albuterol CFC MDI or an HFA placebo MDI four-times per day for 12 weeks. At week 12, the bronchodilator effects of albuterol HFA MDI were significantly greater than placebo and comparable to the group randomized to treatment with albuterol CFC MDI [75] . The bronchodilator effects from both albuterol products decreased from baseline after 4 weeks of dosing (i.e., tachyphylaxis), with repetitive albuterol exposure occurring. Studies in children with asthma confirmed that the bronchodilator effects of two puffs of albuterol HFA MDI were comparable to those achieved with two puffs of albuterol CFC MDI after regular dosing for 2-4 weeks [76,77] .

Asthma patients who had been stabilized on regular treatment with albuterol CFC MDI were studied after being switched to regular treatment with albuterol HFA MDI [78,79] . No evidence of loss of asthma control was found and serial spirometry confirmed that albuterol HFA MDI provided comparable improvements in FEV 1 as were previously seen with albuterol CFC MDI. Two large postapproval studies, using diary card-recorded measures of peak expiratory flow and asthma symptoms, showed that patients randomized to albuterol HFA MDI treatment had comparable asthma control as those receiving albuterol CFC MDI [80,81] . In adults [82,83] and children [84] with asthma and exercise-induced bronchospasm, treatment with albuterol HFA MDI prior to exercise was significantly better than placebo and comparable to albuterol CFC MDI in preventing postexercise falls in FEV1 .
-----
(excerpted below):
73 Dockhorn R, Vanden Burgt J, Ekholm BP et al. Clinical equivalence of a novel non-chlorofluorocarbon-containing salbutamol sulfate metered-dose inhaler and a conventional chlorofluorocarbon inhaler in patients with asthma. J. Allergy Clin. Immunol. 96, 50-56 (1995).

74 Langley SJ, Sykes AP, Batty EP et al. A comparison of the efficacy and tolerability of single doses of HFA 134a albuterol and CFC albuterol in mild-to-moderate asthmatic patients. Ann. Allergy Asthma Immunol. 88, 488-493 (2002).

75 Bleecker ER, Tinkelman DG, Ramsdell J et al. Proventil HFA provides bronchodilation comparable to ventolin over 12 weeks of regular use in asthmatics. Chest 113, 283-289 (1998).

* Pivotal Phase III study comparing regular use of albuterol HFA MDIs with albuterol CFC MDIs over 12 weeks.

76 Shapiro GS, Klinger NM, Ekholm BP, Colice GL. Comparable bronchodilation with hydrofluoroalkane-134a (HFA) albuterol and chlorofluorcarbons-11/12 (CFC) albuterol in children with asthma. J. Asthma 37, 667-675 (2000).

77 Shapiro G, Bronsky E, Murray A et al. Clinical comparability of ventolin formulated with hydrofluoroalkane or conventional chlorofluorocarbon propellants in children with asthma. Arch. Ped. Adolescent Med. 154, 1219-1225 (2000).

Stevepowell
October 21st, 2011, 08:30 AM
If there is a noticable difference between the delivery methods, than the subjects know which they are getting. Reference 75 mentioned some time to onset variable that needed talked around.

EJB190
October 21st, 2011, 11:37 AM
I found this excerpt although I cannot verify the source or the exact procedures of the experiment, but I will look for it.


There was other evidence that the HFA formulation delivers a lower/less effective dose on a per acutation basis than the CFC product. In the single dose, dose ranging study in adults, and in the single dose methacholine challenge study in adults one and two acutations of albuterol CFC were statistically indistinguishable in terms of effect, whereas significant differences were seen between one and two acutations of albuterol HFA. Finally, the combined adolescent/adult studies showed that the HFA formulation had a longer median time to onset of effect(4.2-9.6 minutes versus 3.6-4.2 minutes), had a shorter duration of effect(1.55-3.30 hours versus 2.29 - 3.69 hours), and was associated with more albuterol 'back up' use than the CFC formulation.

Methacholine is a drug that will induce bronchioconstriction in individuals with bronchiohyperactivity (asthma, COPD) when inhaled. So a methacholine challenge is when a subject inhales methacholine.

lefty
October 21st, 2011, 02:50 PM
This is just not true. The pulmonary deposition is as good or better with HFA than compared to CFCs (depending on which med you use) and all physiology efficacy studies have shown them to be the same. In addition, every respiratory specialist that I know --and I know a lot -- feel that they are equivalent.

Do you really stand by this statement, or did you perhaps exaggerate a little bit? "all studies" and "every respiratory specialist" you know?!? Really? So the news that there are people who claim that HFA inhalers suck must have come as a real surprise to you. Hmm, yet you were so ready to respond. Strange.

The conspiracy isn't that a few people who stood to make Billions got CFC inhalers banned. It was that hundreds of thousands of patients got together and simultaneously claim that the new inhalers don't work as well.

pendaluft
October 21st, 2011, 05:16 PM
I absolutely stand by that statement and I don't believe I exaggerated at all.

There was no conspiracy to ban these meds. This was carefully planned and studied. In the case of some inhalers, the drug deposition actually improved. For most patients the difference is minimal. They do taste different -- and people who don't use a spacer are aware of that.

I was ready to respond only because treating airway obstruction is what I do -- I have a lot of information and experience. Recent political reports have suggested that the CFC ban is a recent change, part of some over arching conspiracy and likely to harm people. That's not true.

But you don't have to believe me -- I may be too naive to see these dark conspiracies. The generics are in the pipeline anyways so I guess they'll have to ban HFA next.

EJB190
October 21st, 2011, 11:50 PM
Do you really stand by this statement, or did you perhaps exaggerate a little bit? "all studies" and "every respiratory specialist" you know?!? Really? So the news that there are people who claim that HFA inhalers suck must have come as a real surprise to you. Hmm, yet you were so ready to respond. Strange.

The conspiracy isn't that a few people who stood to make Billions got CFC inhalers banned. It was that hundreds of thousands of patients got together and simultaneously claim that the new inhalers don't work as well.

I admit that my "universal" statement was a bit exaggerated, but I've worked in 3 different retail pharmacies at the time of the switch and I can honestly say dozens upon dozens of patients complained that that drug was not effective as it previous was. I've heard many other pharmacists agree with this. I've had teachers at my school verify these statements as well.

I am going to call up one of the most brilliant guys I know on the pharmaceutical world and see what his take is. He is literally one of the top pharmacists in the world and has done a lot to advance some aspects of drug delivery and IV protocol. He's been a clinical pharmacist at some of the top hospitals in the world and has lead many pharmaceutical organizations. I know he prefers the CFC to the HFA but I'll see what info I can get out of him. Aside from our main argument here, I do know, however, that there is a lot of information that suggests that HFA's are not as safe as CF'C's, having more adverse effects.

There definitely is a financial incentive for the switch from CFC's to HFA's. The pharmaceutical industry is probably one of the most corrupt entities in history. If you work in pharmacy, follow drug prices, follow the products on the market, you can easily see corruption and drug companies taking advantage of patients. Almost all the top FDA executives have ties to drug companies. It's a really messed up world and its no wonder health care is becoming exponentially expensive.

If the US made a law that drug companies could only sell drugs at the same price that they do in other countries, we would save billions. Drugs in America cost 2-10x as much as they do in other countries. Additionally, drug prices in America have doubled, tripled, and even quadrupled in the past 10 years. Drugs that have been around for years price's have skyrocketed. I had a pt that was in the donut hole and could not afford his $700/month Seroquel. We sent him to a Turkish pharmacy that used the exact same medicine and packaging and it cost him $350 for 2 months (175/month). It's incredible. Fluticisone (Flonaze) used to cost around $7-8, not it costs $20 in the door. The list is endless.

Drug companies have a huge incentive to take one the top prescribed drugs, albuterol (probably within the top 20, maybe 30 drugs prescribed), delete the ~$5-$10 generic option, and replace it with a brand name inhaler like Ventolin or Proventil and charge $40-$60. It's not a conspiracy. It's how the drug company works. And what better time, at the height of environmentalism, to sound the alarm that people's inhalers are going to destroy the ozone layer. The whole ozone layer hype occurred literally 15 years ago. In reality, the fair option would have been would be to replace the HFA with the CFC's and incur no price change in the drug. After all, its just albuterol which has been around for ages. Why should a new propellent allow the insurance companies to escalate the price significantly?