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SAMJ: South African Medical Journal

On-line version ISSN 2078-5135
Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.109 n.7 Pretoria Jul. 2019




Therapeutic use exemptions - serving athlete patients



To the Editor: As members of the Therapeutic Use Exemption Committee (TUEC) of the South African Institute for Drug-Free Sport (SAIDS), we thank colleagues throughout the country for supporting athletes in their applications for a therapeutic use exemption (TUE). It is our intention to shed light on what might at times appear a cumbersome and inscrutable process for those not involved in anti-doping.

The management of athlete patients obligated to the World Anti-Doping Code (WADC)[1] presents some unique challenges for physicians. Whenever such management requires the use of substances that are on the annually updated World Anti-Doping Agency (WADA) Prohibited List,[2] South African (SA) athletes have to apply for a TUE to the SAIDS. A TUE allows an athlete to use a prohibited substance at a specified dosage and frequency for a limited amount of time.

The SAIDS is a signatory to the WADC and has to follow all of its provisions.[3] With regard to TUEs, these provisions ensure an unequivocal entitlement to appropriate medical care while monitoring the possibility that prohibited substances could be misused for performance enhancement.

The WADC obliges the SAIDS to define and publish the process by which athletes may apply for a TUE and to establish a TUEC consisting of at least three physicians with experience in the field. The TUEC itself has to meet the requirements of the WADA International Standard for Therapeutic Use Exemptions[4] in all its various aspects.

We regard athletes subjected to the WADC as no different to other patients in occupations that demand a unique approach to their clinical management (e.g. airline pilots, professional scuba divers). By accepting the clinical care of an athlete patient, the physician also becomes bound by the WADC, which entails a number of professional obligations such as providing a complete medical file to support a TUE application.

When considering a TUE application, the TUEC looks for answers to the following questions:

Has evidence of appropriate investigations been provided to support the clinical diagnosis?

Has this been endorsed by an appropriate medical specialist?

Would denial of this application jeopardise the health of the patient?

Are there non-prohibited, alternative medications that could have been used instead?

If so, is there supportive evidence that their use was ineffective?

Could this clinical condition be the result of the prior use of a prohibited substance?

It is of crucial importance to understand that the requirements for the medical file supporting a TUE application are not at the discretion of the SAIDS TUEC, but follow defined international standards.[5] The sole purpose of any TUE application review is to establish whether these standards are met; it must never be perceived as questioning a colleague's expertise or patient management.

The ultimate goal of the TUE system is to create a level playing field for athlete patients worldwide. If SAIDS's TUEs do not meet international standards, SA athletes may not be able to compete at world elite level because their TUEs will not be recognised by international sports bodies.

Katharina Grimm, Lervasen Pillay, Carl Tabane; South African Institute for Drug-Free Sport Therapeutic Use Exemption Committee

South African Institute for Drug-Free Sport, Cape Town, South Africa.



1. World Anti-Doping Agency. World Anti-doping Code 2015 with amendments 2018. (accessed 30 April 2019).         [ Links ]

2. World Anti-Doping Agency. International Standard Prohibited List January 2019. (accessed 28 September 2018).         [ Links ]

3. South African Institute for Drug Free Sport. South African Institute for Drug Free Sport AntiDoping Rules 2016. (accessed 30 November 2018).         [ Links ]

4. World Anti-Doping Agency. International Standard for Therapeutic Use Exemptions. January 2016. (accessed 4 December 2018).         [ Links ]

5. World Anti-Doping Agency. TUEC Guidelines (previously Medical information to support the decisions of TECs). Updated annually. (accessed 30 April 2019).         [ Links ]

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