Current medical advice and warnings

The substance tramadol is prohibited within competitions from 1 January 2024 according to the World Anti-Doping Agency (WADA) doping regulations. This means that from 1 January 2024, tramadol may not be used within a competition or detected in a doping test within a competition. Testpool athletes who have to use tramadol permanently for medical reasons should apply for a Therapeutic Use Exemption (TUE) as early as December 2023.

You can find further information under: nada.de/SERVICE/Downloads/Infoblaetter/2023_Infoblatt_Tramadol.pdf (only in german)

The use of cannabis and cannabinoids is prohibited in-competition according to the WADA's Prohibited List. This regulation also applies to athletes in Germany, regardless of the law on the legalization of cannabis and non-synthetic tetrahydrocannabinol (THC), coming into force on April 1, 2024.

The detection of cannabinoids in an in-competition-sample can still constitute an anti-doping rule violation and be sanctioned in sports. Due to the long detection time of THC, athletes should generally avoid using cannabis, even out-of-competition. The only exception to the ban is the substance cannabidiol (CBD) which is not prohibited.

With the legalisation of cannabis in Germany, it can be assumed that the unintentional, passive consumption of cannabis will also increase. In order to avoid positive doping samples due to passive use of cannabis, WADA set a threshold for carboxy-THC (the main metabolite of THC) in 2013. Thus, in-competition doping samples with a carboxy-THC concentration of more than 150 ng/mL urine are considered positive, samples with less than 150 ng/mL urine are considered negative.

This threshold was set by WADA to reduce positive doping samples, which are potentially due to the use of THC out-of-competition or unintentional passive ingestion. Nevertheless, NADA Germany recommends reducing the passive use of cannabis as much as possible, especially shortly before competitions.

As with other prohibited substances, athletes can apply for a Therapeutic Use Exemption (TUE) for medicinal cannabis and THC-containing pharmaceuticals in case of disease. General information about TUEs can be found here.

A TUE can only be granted if certain criteria are met. For example, the medication is needed to treat a diagnosed medical condition. The medication must also be indicated for the treatment of the disease and there are no reasonable, permitted alternative treatments available. In the case of a TUE application, extensive and detailed specialist documentation must be submitted.

Even if cannabis or THC-containing pharmaceuticals have been prescribed by a doctor, this does not mean that the above criteria are necessarily met!

In WADA's guidelines, cannabinoids are only mentioned as an option for the treatment of chronic, especially neuropathic pain. The corresponding TUE Physician Guideline Pain Management and an accompanying checklist can be found under the following links: wada-ama.org/en/resources/therapeutic-use-exemption/tue-physician-guidelines-pain-management and wada-ama.org/en/resources/therapeutic-use-exemption/checklist-therapeutic-use-exemption-tue-application-pain

Athletes who are planning a therapy with cannabis or THC-containing pharmaceuticals should contact NADA Germany in advance about the requirements for a TUE (medizin(at)nada.de).

There are some asthma sprays that are allowed in certain amounts and can be inhaled without a Therapeutic Use Exemption.

Asthma sprays containing cortisone (e.g. beclometasone, budesonide or fluticasone) or cromoglicic acid are allowed and can be used directly.

Asthma sprays containing salbutamol, salmeterol, formoterol and vilanterol are allowed and can be used. However, a certain permitted dosage must not be exceeded:

• Salbutamol up to 600 µg over 8 hours and a maximum of 1600 µg over 24 hours.
• Salmeterol up to 200 µg over 24 hours
• Formoterol up to 54 µg over 24 hours
• Vilanterol up to 25 μg over 24 hours

Thus, for example, an asthma inhaler containing salbutamol at the usual dose of 100 µg/puff may be inhaled 6 times in 8 hours. After 8 hours, another 6 puffs may be inhaled, and after another 8 hours, another 4 puffs (equivalent to 1600µg of salbutamol over 24 hours).

No Therapeutic Use Exemption is required for the use of salbutamol, salmeterol, formoterol or vilanterol if the permitted dosage is observed.

The use of these four active substances in any other form (e.g. as tablets or by injection) is prohibited.  

The use of other asthma sprays containing e.g. fenoterol, reproterol, indacaterol, olodaterol or terbutaline is also prohibited.

With the WADA Prohibited List 2022 coming into effect as of 01/01/2022, the anti-doping rules for the use of glucocorticoids, sometimes also called cortisone, have changed.

Since 01/01/2022, all glucocorticoids are prohibited in-competition, when administered by any injectable, oral [including oromucosal (e.g. buccal, gingival, sublingual)] or rectal route. The use of glucocorticoids out-of-competition is permitted. Other routes of administration are permitted at all times, when used within the manufacturer´s licensed doses and therapeutic indications. These include the dermal (on the skin), inhaled, intranasal (in the nose), or ophthalmic (on the eye) application.

Comprehensive information about glucocorticoids can be found here: nada.de/en/medicine/current-medical-advice/cortisone-in-sport

The use of testosterone is prohibited in- and out-of-competition. Athletes who are member of a testing pool have to apply for a therapeutic use exemption in advance. All athletes who are not member of a testing pool, must apply for a retroactive Therapeutic Use Exemption after a doping control and upon request by NADA Germany. Athletes who want to participate in international competitions are strongly advised to contact their international sports federation beforehand for the applicable rules.

Attention: TUEs for the use of testosterone can only be approved in special exceptional cases. In particular, an organic etiology of hypogonadism has to be demonstrated. Organic causes for hypogonadism may be for example genetic abnormalities, bilateral testicular trauma or torsion or bilateral orchiectomy, radiation treatment, chemotherapy and genetic abnormalities and pituitary or hypothalamic tumors. TUEs cannot be approved for low circulating testosterone due to a functional state (i.e. due to stress, obesity, malnutrition, overtraining or aging). This rule applies to all athletes, regardless of their testing pool status.

Some athletes donate blood or blood plasma from time to time or even on a regular basis. Since methods such as administration or reintroduction of blood or blood components and intravenous infusions are on WADA's Prohibited List, athletes should follow a few rules to avoid violating anti-doping rules. Here are the most important rules for donors and recipients and the need for a TUE or a certificate:

• Giving a whole blood donation: no TUE and no certificate required, if applicable, provide information in the athlete biological passport
• Giving a plasma donation: permitted if performed by apheresis in a registered donation centre
• Dialysis: TUE for testing pool athletes; medical certificate and, if applicable, retroactive TUE for non-testing pool athletes.
• Receiving a blood transfusion: TUE for testing pool athletes; medical certificate and, if applicable, retroactive TUE for non-testing pool athletes.
• Receiving a plasma donation: no TUE for testing pool athletes, no medical certificate for non-testing pool athletes if administered as an intravenous infusion in course of a hospital treatment. TUE for testing pool athletes, medical certificate for non-testing pool athletes if administration as intravenous infusion is performed outside of a hospital.
• Receiving an intravenous infusion of more than a total of 100 ml within 12 hours with permitted substances if the administration is legitimately received in the course of hospital treatments, surgical procedures or clinical diagnostic investigations: no TUE for testing pool athletes, no medical certificate for non-testing pool athletes.
• Receiving an intravenous infusion of more than a total of 100 ml within 12 hours with permitted substances outside of hospital treatment, surgical procedures or a clinical diagnostic investigations: TUE for testing pool athletes, medical certificate for non-testing pool athletes.
• Receiving a prohibited substance as an intravenous infusion: TUE for testing pool athletes; medical certificate and, if applicable, retroactive TUE for non-testing pool athletes.

On 1 January 2023, NADA Germany’s previously valid regulation for medical certificates for non-testing pool athletes was replaced by the regulation of the WADA's International Standard for Therapeutic Use Exemptions (ISTUE). All Athletes who are not member of a NADA Germany's testing pool or a German sport league that requires TUEs, and who use any prohibited substances or methods must apply for a retroactive Therapeutic Use Exemption after a doping test and upon request by NADA Germany. The sole submission of a medical certificate is no longer sufficient. You can find more information here: nada.de/en/medicine/in-case-of-disease-therapeutic-use-exemption-tue/regulation-for-non-testing-pool-athletes 

Important: A TUE-application by athletes who are not member of a NADA Germany's testing pool or a German sport league that requires TUEs is only necessary after a doping test. In these cases, the athletes will be contacted personally by NADA Germany and asked to apply for a TUE. No application is necessary in advance. As soon as additional steps are necessary, NADA Germany will contact the athlete immediately and provide comprehensive information.

In China, Mexico and Guatemala, there is an increased risk of unintentional doping through the consumption of meat that may be contaminated with the prohibited anabolic substance clenbuterol. This was revealed by studies conducted by the Manfred Donike Institute and the Centre for Preventive Doping Research at the German Sport University Cologne (www.dshs-koeln.de/institut-fuer-biochemie/aktuelles-termine/aktuelles/meldung/meldung/clenbuterol-warning-for-athletes, among others. For this reason, NADA Germany advises special vigilance with regard to nutrition when traveling to these countries. After all, every athlete is responsible for ensuring that he or she does not ingest any substance that could test positive in a doping control. This issue has been known for many years. Such cases can be avoided by dealing sensitively with the subject and making appropriate adjustments to the diet.

In the case of major sporting events in the countries mentioned above, the relevant international sports federation may be able to provide information on whether certified caterers who process clenbuterol-free meat are recommended for the event. As far as possible, the consumption of meat products should be avoided. Suggestions for concrete alternatives to cover protein requirements with other, safe protein sources should be requested via the nutrition advisors at the Olympic Training Centres, as also recommended by the German Olympic Sports Confederation (DOSB) (www.nada.de/fileadmin/user_upload/nada/Medizin/110224_DOSB_Clenbuterol_Warnung_China.pdf). Many federations and clubs are sensitized to this topic and take appropriate precautions when traveling to China, Mexico or Guatemala.

We would also like to point out that there is a threshold for clenbuterol in urine (www.wada-ama.org/sites/default/files/resources/files/tl23_growth_promoters_eng_2021_0.pdf) that determines how a positive doping sample is handled. Based on current studies, it is assumed that the concentration of clenbuterol in urine after consumption of contaminated meat is low. Therefore, a clenbuterol concentration of more than (>) 5 ng/ml in urine is considered an adverse analytical finding A urinary clenbuterol concentration of or below (≤) 5 ng/ml is considered an atypical finding. In this case, further investigations are necessary to determine whether the consumption of contaminated meat may explain the result. Within the framework of these further investigations, a hair analysis can be carried out, among other things. If evidence can be provided that the result was due to the consumption of contaminated meat, the case will be closed. However, if no such evidence can be provided, the result will be considered an analytical result that deviates from the norm and a result management/disciplinary procedure will be initiated.

It is important to note that if clenbuterol is detected in a doping sample, even if the athlete was previously staying in the countries mentioned above, the usual standard procedure with appropriate examinations will start and evidence must be provided that the trigger for such a positive analytical result is the accidental consumption of contaminated meat.

For more information, please see the following links:

www.dshs-koeln.de/institut-fuer-biochemie/doping-substanzen/formen-des-dopings/verbotene-wirkstoffgruppen/anabole-wirkstoffe 
www.wada-ama.org/en/resources/science-medicine/clenbuterol-in-meat-a-source-for-a-positive-doping-control-search-for 
www.wada-ama.org/en/resources/science-medicine/statistical-significance-of-hair-analysis-of-clenbuterol-to-dicriminate 
www.wada-ama.org/sites/default/files/resources/files/td2022mrpl_v1.0_final_eng.pdf 

In spring, many athletes are affected by allergies and hay fever. There are a number of medications available for treatment:

So-called antihistamines such as azelastine, cetirizine, ketotifen or loratadine are permitted at all times.

So-called glucocorticoids (cortisone) are permitted if used by inhalation or applied locally to the skin, eye or nose.

Some allergy sufferers also need asthma sprays. You can find more information under „Asthma medication in sports“

The substance cannabidiol (CBD), is not prohibited, according to the Prohibited List. However, NADA Germany warns against the use of products containing CBD for the following reasons.

CBD can be extracted from cannabis plants or synthetically produced and is commercially available as a dietary supplement, aroma oil or cosmetic, for example in the form of oils or creams. For athletes who are subject to a doping control system, CBD products can be a doping trap, because cannabis plants contain the  substance tetrahydrocannabinol (THC), which is prohibited in-competition, and other cannabinoids that are prohibited in-competition. CBD products can therefore contain indefinable amounts of THC. Even though the labels of CBD products often state that the THC content is very low, it often turns out much higher. This means that there is a risk of a positive doping test for THC. In addition, the risks and side effects of using CBD are not yet completely known. Health effects on the body are not yet predictable.

A scientific publication on the assessment of the risk potential of a positive doping result for athletes when using CBD products – amongst others by Dr. rer. nat. Anja Scheiff (Head of the Medical Department) – can be found here: dshs-koeln.de/institut-fuer-biochemie/doping-substanzen/doping-lexikon/c/cannabidiol

In the case of hemp products, there is also the possibility that unknown concentrations of THC and other cannabinoids may be contained. Independent control of the THC content is practically non-existent. Even though the labels of hemp products often state that the THC content is very low, this statement cannot be verified by the athletes.

Current information on this can be found on the website of the German consumer protection organisation: verbraucherzentrale.de/wissen/lebensmittel/kennzeichnung-und-inhaltsstoffe/hanfsamen-hanfoel-hanftee-wie-steht-es-mit-der-sicherheit-12881

NADA Germany therefore recommends refraining from consuming any CBD and hemp products.

Many athletes believe that they can only cover their special energy and nutrient requirements with dietary supplements. NADA Germany urgently warns against taking such products under this aspect alone. This is because, as with medicines, the following also applies to dietary supplements: "Dosis facit venenum" (The dose makes the poison). If individual nutrients are taken in excessive quantities, serious side effects can occur. Dietary supplements often contain nutrients in large amounts and in isolated form. In addition, contaminated dietary supplements are found regularly. Depending on their origin, banned substances may have been purposefully added - these dietary supplements were deliberately counterfeited - or may have entered the products as residues during the filling process. The consumption of such dietary supplements can lead to a positive doping sample. Therefore, NADA Germany advises a reflective handling of dietary supplements.

The necessity of taking a dietary supplement must be critically questioned. If deficiency symptoms are present, only medically prescribed pharmaceutical should be taken. These are subject to strict legal controls and requirements; for example, all ingredients must be listed in the package insert without exception, all possible side effects must be pointed out and they have to undergo strict quality and purity testing. The doctor will also specify exactly how the drug must be taken to avoid overdose.

Before consuming a dietary supplement, it is essential to check whether the desired product has been tested by an independent institution for the presence of prohibited substances, or at least to obtain a self-certification of product purity from the manufacturer. All these measures help to reduce the risk of doping, associated with the use of dietary supplements. However, it can never be completely ruled out.

Dietary supplements are foods intended to supplement the general diet. Since they are considered foodstuffs, dietary supplements - unlike medicines - do not require regulatory approval. Accordingly, they are also not tested for their health safety and material purity. According to the regulations in Germany, all ingredients must generally be listed on the package, but this is not always realized in practice.

Another important aspect is that dietary supplements are regarded as an entry point into the so-called doping mentality. According to the motto "for every problem there is a remedy" they promote a doping mentality.

To the video "Nutritional supplements in sports" 

Cologne List®: 
The Cologne List® lists dietary supplements that have been tested for a range of doping substances.

To the Cologne List