Examination of the Medical Issues behind the Hollis Thomas Suspension

This is the first of 2 posts concerning the suspension of New Orleans’s DT Hollis Thomas (the other post is on confidentiality,Thomas, and drug testing). Steroid Nation will discuss the medical aspects of Thomas’ case.  Of the 3 option that may account for Thomas's + test -- lab cross-reactivity, clenbuterol, or another banned steroid -- you will read how Thomas most likely was using clenbuterol.

Like other famous doping stories this year, a multitude of conflicting information spewed after the Thomas suspension. Confusion ensues from the 'passive' nature of the stories.  Media reports come from secondary sources, or inside sources; almost never do American teams or leagues release information beyond the basic legal fact of a suspension (see the second post).

For purposes of sports doping, the medical treatment of asthma has relevance in 2 classes of drugs: anti-inflammatory medications: steroids, and broncodilators: theophylline and beta agonists. We will discuss the beta-agonists.

The steroids are corticosteroids, and may be inhaled or given by mouth (po). These are cousins to anabolic steroids, however the chemical structure contains important differences that enhance their anti-inflammatory action, and deemphasize their anabolic (muscle building) and androgenic (male) side effects.  The oral medications consist of prednisone and similar drugs. Inhaled steroids include medications like Singulair or Azmacort (triamcinolone). These drugs decrease inflammation, which opens airways.

The beta(adrenergic)-agonists, meanwhile work on ‘receptors’ in smooth muscle cells that cause the airways in the lungs to dilate. Obviously this is an advantage when asthmatic lungs are over-reactive, and want to close up (thus causing the shortness of breath). These medications include short-acting (inhaled) and long-acting (inhaled or oral) beta-agonists.

(Much much more after the jump)

Theophylline is an oral medication that will not be discussed here.

I am not an expert in management of asthma; however it often takes a combination of steroids, beta-agonists, and other medications to treat the symptoms.

Non-experts become confused because the names of beta-agonists (which are NOT steroids) sound like steroids: albuterol, and salmeterol. (These drugs sound like steroids: Winstrol, Dianabol).

A further layer of complexity occurs when there is a cross over drug like clenbuterol.  Clenbuterol (referred on the street as ‘Clan’) is also a long-acting beta-agonist that can be a bronchodilator. Seems these drugs can also increase muscle strength and endurance.

Clen has gained street credibility as an appetite-suppressor, and a muscle-builder, not exactly its ‘medical’ use as a bronchodilator. Clen may also give the user an energy boost. Thus, Clen is a non-steroid drug body-builders use. However, clenbuterol is legal only in one veterinary preparation in this country. There is no FDA approval, or marketing of Clen at legal US pharmacies; you cannot get a prescription for clen.

Because of abuse by body-builder and other athletes, clenbuterol is on WADA's (and other agencies) banned drug list. Clen is illegal, and it is banned from a sports anti-doping perspective. If you test positive for Clen, that’s a violation of the regulations.

Reports on Thomas contain conflicting elements. The intial report I saw stated that he was taking 2 steroid inhalers, which would be unusual, but possible. (likely he took a steroid and a beta-agonist inhaler; even more confusing is that he took a combination inhaler that has both a steroid and a beta-agonist).

The initial story made it appear that the steroids were detected in his tests, and that was the reason for the violation and suspension.

That would seem to be highly unlikely, as these drugs are not banned by the NFL, nor are they anabolic, nor are they confused with metabolites of anabolic steroids (like Winstrol). Further, one would expect an appeal to the NFL to be successful if these drugs were medically indicated.

ESPN even confuses the issue in this report:

The Saints suffered a big blow to their defense Tuesday when they found out defensive tackle Hollis Thomas, who is having a career year, is being suspended for four games because he violated the league's steroid policy due to asthma medication he takes.

Thomas has been challenging the positive steroid test and had the support of the Saints. Thomas is a 335-pound defensive tackle who has struggled to keep his weight down and doesn't have the body that normally would be linked to steroids.

During his appeal, John Amoss, who is the Saints' team doctor and an assistant professor at the LSU Health Science Center, sent a letter to the league in support of Thomas. Amoss said Thomas has severe asthma problems and requires a high dose of inhaled steroids to breathe. According to the doctor, Thomas needs a long acting beta agonist and a short acting beta agonist to control his asthma.

During his August drug test, the defensive tackle was taking an asthma product called Advair twice a day while also using an inhaler four times a day.

"Advair contains both the steroid fluticasone and the long acting beta agonist galmeterol," wrote Amoss, who thought the possibility of a false positive might have happened.

ESPN reported a violation of 'steroid policy' then discusses 'beta-agonists'.  If Thomas takes Advair, those compounds do not violate NFL policy.  There would be no NFL violation of the anabolic steroid policy.

However, other news agencies (New Orleans media) reported Thomas tested positive for clenbuterol. That’s an automatic violation of league policy. Even though it might be argued Clen is effective in asthma, it is clearly on the banned substance list; furthermore a licensed physician cannot prescribe Clen from a local pharmacy, since it isn’t marketed in this country.

From NOLA:

Thomas tested positive for clenbuterol, which is a Beta-2 agonist, part of a daily prescription regimen that helps facilitate his breathing and allows him to partake in the physical activity necessary to play professional football.

Found here is the NFL's reponse:

NFL spokesman Greg Aiello said Wednesday that the league's testing procedure is sophisticated enough to detect approved asthma medications, some of which are steroidal, and substances such as beta-2 agonists, such as clenbuterol, that are prohibited.

Thus, Thomas defense does not make medical sense. The issues of beta-agonist or inhaled steroid would be easily solved by a medical letter of clarification. Those substances are different enough from anabolic steroids so as not to confuse the detection tests by gas-chromatography/mass-spectrometry.  This is a link to Don Catlin's lab, which handles most anti-doping tests in this country:

Likewise legal prescribed drugs for asthma should not test positive for clenbuterol.

Therefore Thomas either tested positive for clenbuterol, an illegal beta-agonist, or for an illegal anabolic steroid.

A man of Thomas' size should be concerned about using a drug which can adversely affect his cardiac functioning, with serious consequences.