Table 2.

Medical treatment of seasonal allergic diseases related to athletes

Drug	Mode of action	Use	Comments	WADA statusa
Antihistamines	Histamine antagonist at H1 receptor site	Allergic rhinitis and conjunctivitis, urticaria, allergic asthma	First-line therapy for mild to moderate symptoms	Not prohibited
Oral first-generation			Often combined with oral decongestant
Oral second-generation			Very effective for symptoms of rhinorrhea, sneezing, and nasal and ocular itch
Intranasal			First-generation formulations have significant CNS adverse effects, second-generation preferred
Topical (optical)
Corticosteroids	Antiinflammatory	Treatment of many allergic diseases: allergic rhinitis and conjunctivitis, asthma, urticaria, and atopic dermatitis	Potent antiinflammatory	Systemicb uses are prohibitedc; inhaled and intranasal only require abbreviated TUEd; topical are not prohibited
Oral			intranasal — first-line therapy for moderate to severe symptoms of rhinitis
Inhaled			oral — severe exacerbations of asthma, urticaria
Intranasal
Topical (skin)
Decongestants	α-adrenergic agonist	Rhinitis	Reduces nasal congestion	Ephedrine is prohibitede, phenylephrine, phenylpropanolamine, pseudoephedrine, and synephrine are on monitoring listf
Oral	Causes nasal vasoconstriction		May cause insomnia, loss of appetite, and nervousness
Intranasal			Intranasal may cause rebound nasal congestion (rhinitis medicamentosa)
Cromolyn/nedocromil sodium	Mast cell stabilizer	Asthma, allergic rhinitis	Nonsteroidal antiinflammatory	Not prohibited
Oral	Inhibits degranulation		Minimal adverse effects
Inhaled			Requires multiple daily dosing
Intranasal
Anticholinergic	Muscarinic receptor antagonist	Asthma, rhinitis	Effectively reduce rhinorrhea	Not prohibited
Inhaled			Role in acute bronchospasm
Intranasal
Leukotriene inhibitors	Inhibit phospholipid metabolism	Asthma	Nonsteroidal antiinflammatory	Not prohibited
Oral			Very effective in preventing EIA
			Steroid sparing controller
Allergen immunotherapy	Th2 response suppression	Allergic rhinitis and conjunctivitis, asthma	Very effective for allergic rhinitis	Not prohibited
	Th1 response stimulated
Anti-IgE antibody	Reduces serum IgE	Severe asthma, possibly allergic rhinitis	Approved for severe asthma	Not prohibited
IM injection			Requires multiple IM injections
			Expensive
β2 agonist	Bind β2 adrenergic receptor, ↑cAMP, relaxes bronchial smooth muscle	Asthma	First-line therapy in preventing EIA	Prohibited in general, some formulations with specific clinical indications require only an abbreviated TUEg
Inhaled
Short-acting
Long-acting
Theophylline	Inhibits phosphodiesterase, causing bronchodilation	Asthma	Long-term controller	Not prohibited
Oral			Required serum level monitoring
Inhaled
Epinephrine	α- and β-adrenergic agonist	Anaphylaxis	Universally recommended drug of choice for acute anaphylaxis	During competition requires a TUE
			Adult dose: SQ or IM, 0.2–0.5 ml of 1/1000 (wt/vol) dilution

Abbreviations: cAMP, cyclic adenosine monophosphate; EIA, exercise-induced asthma; IM, intramuscularly; SQ, subcutaneously; TUE, therapeutic use exemption.

^aBased on the WADA 2005 Prohibited List International Standard, see www.wada.com for current updated information.

^bOrally, rectally, IV, or IM.

^cIn competition only. Any substance or method that is on the Prohibited List must be granted a Therapeutic Use Exemption (TUE) for use.

^dnonsystemic routes require the completion of an abbreviated TUE application. Dermatological preparations are not prohibited.

^eProhibited when its concentration in urine is >5 mcg/mL.

^fThese stimulants are no longer on the Prohibited List, but are on the 2005 monitoring program “in order to detect patterns of misuse in sports.”

^gAll β₂-agonists including their D- and L-isomers are currently (2005) prohibited in and out of competition and require a TUE for use. Formoterol, salbutamol, salmeterol, and terbutaline are permitted by inhalation to prevent and or/treat asthma and exercise-induced asthma/bronchoconstriction, with the completion of abbreviated TUE application.