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All About Salbutamol

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What will the verdict in Froome's salbutamol case?

He will be cleared
16
23%
3 month ban
3
4%
6 month ban
10
14%
9 month ban
17
24%
1 year ban
8
11%
2 year ban
16
23%
4 year ban
1
1%
 
Total votes : 71

Re: All About Salbutamol

06 Feb 2018 23:46

In the original poll thread, before it was locked and transferred to this thread, someone said Froome could not get four years. That is one of the choices in the poll, and just to be clear, that is a possibility. Article 10.2.1.2 of the WADA code says that an athlete can be banned four years for a specified substance if it can be established that use of that substance was intentional, for performance enhancement. So if Froome were ruled to have orally dosed salbutamol for non-therapeutic purposes, he could get a four year ban.

That’s unlikely, because the enantiomers test can’t actually distinguish oral from supra-maximal inhaled doses, and even if it could, Froome could argue as a last resort that he orally dosed because he needed massive relief (though expert witnesses could argue that orally dosing would not be as helpful as amounts he could inhale, and of course Froome’s argument would be at odds with his claim that he didn’t make a mistake). But it’s worth keeping in mind this possibility as we evaluate Froome’s all-or-nothing strategy. The downside risk is considerable. Two years might or might not mean the end of his career. Four years almost certainly would, at least as a GC contender, unless he proved to be the second coming of that other Chris.

As far as the outcome of this case, I’d prefer not to predict at least until there’s certainty that there will be a CADF hearing. Based on the information that’s emerged so far, I’d guess two years, but almost all of that information has been denied at some point, so it’s really hard to judge what Froome’s specific strategy is, not to mention that we don’t have access to some of the most important data.
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07 Feb 2018 07:53

I went low probability of success, but more likely to win the race (poll) by voting 4 years. Kind of like attacking solo on a false flat 80 km out.

Why? Sky is leaky these days and Froome doesn't seem well liked by all. It is possible that more information will come out that will show intent (which in itself seems highly probable) and then Froome's defense would be busted. Has he paid off enough people, or pissed off enough?
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Re: All About Salbutamol

07 Feb 2018 10:06

70kmph wrote:22.

Nebulizers are not prohibited as a device; however the amount of beta-2-agonist administered by nebulisation may surpass the allowed maximum doses of salbutamol, salmeterol or formoterol by inhalation; therefore the dose may be prohibited.

https://www.wada-ama.org/en/questions-answers/prohibited-list-qa#item-1411

Wiggins Fluimucil was of a type for use with a nebulizer


Umm, Wiggins didn't take fluimucil with a nebulizer in the back of that bus

Kenacort injection - bingo!
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07 Feb 2018 14:34

Wiggins is an example where Sky admit to using a nebuliser for general use...

Of course Froome hasn't said he used this method and if he does it wont help because he took a larger than therapeutic dose but nebulizer is a more efficient delivery system than the portable spray
It wouldn't expose him to the oral intentional doping, if they run entainomers testing
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Re: Re:

07 Feb 2018 17:49

Merckx index wrote:Article 8.5 of the WADA code. He can take it directly to CAS. WADA or UCI have to agree, but in a case this high profile, I think they would. The only reason they wouldn't is because he would be in limbo for a very long time, riding the Giro and probably Tour before a decision was announced.
8.5 Single Hearing Before CAS
"Anti-doping rule violations asserted against International-Level Athletes or National-Level Athletes may, with the consent of the Athlete, the Anti-Doping Organization with results management responsibility, WADA, and any other Anti-Doping Organization that would have had a right to appeal a first instance hearing decision to CAS, be heard directly at CAS, with no requirement for a prior hearing.

Looking at the rules and at the present situation, it actually was never realistic for Froome to go directly to CAS, because all of the other parties would have to agree to that. So I think the question about strategy is answered - they would never let Froome do that because their interest is to get him out of competition sooner, not for his case to spend less total time in court.

The Anti-Doping Tribunal seems like a cost-effective "pre-screening" stage for these doping cases, because the large majority of the cyclists gave up at that point. If something like 8 out of 10 cases are already finished by the Tribunal, then that's 80% fewer cases the UCI has to represent at CAS
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07 Feb 2018 20:52

MI. 2 Years would mean the end of his career if we consider that Sky would move on to a different rider.
Last edited by Escarabajo on 08 Feb 2018 02:21, edited 1 time in total.
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08 Feb 2018 00:28

70kmph wrote:
Of course Froome hasn't said he used this method and if he does it wont help because he took a larger than therapeutic dose but nebulizer is a more efficient delivery system than the portable spray

It wouldn't expose him to the oral intentional doping, if they run entainomers testing


In the Sundby case, they argued—on the basis of published studies as well as Sundby’s own lab tests—that the nebulizer was a less efficient means of salbutamol delivery. Also, of course, Froome has repeatedly said he takes salbutamol only for “great efforts”, i.e., in a race, where of course a nebulizer couldn’t be used.

And to repeat, the enantiomers test doesn’t distinguish between oral and inhaled use. Petacchi “failed” that test, and CAS still ruled that he had just inhaled too much.

ClassicomanoLuigi wrote:
Looking at the rules and at the present situation, it actually was never realistic for Froome to go directly to CAS, because all of the other parties would have to agree to that. So I think the question about strategy is answered - they would never let Froome do that because their interest is to get him out of competition sooner, not for his case to spend less total time in court.


Yes, that’s quite possible. I just wonder that if a party like UCI refuses to agree to go directly to CAS, whether they have to provide a reason, and if so, whether “the process takes too long” would be considered acceptable. Because going directly to CAS is generally considered a right of any defendant. After the USADA decision came out against LA, before he basically gave up, it was speculated that he might go directly to CAS, rather than defend the case in the U.S. system.

Froome could point out that regardless of the CADF decision, his case would end up at CAS, anyway. He will obviously appeal any ruling against him, and the prosecution will almost certainly appeal any decision favorable to Froome. So the final decision would come sooner if the case went directly to CAS. The argument about getting him out of competition hinges on a) reaching a CADF decision before the Giro begins; and b) the assumption that the decision will go against Froome. So if UCI prevailed on this basis, I think there must have been a considerable legal fight.

Escarabajo wrote:MI. 2 Years would mean the end of his career if we consider that Sky would move on to a different rider just.


Could Froome sign with another team before his suspension was finished? Even if he couldn't, under the two years I envision, he would be reinstated by the end of the 2019 season, and could sign with another team before 2020 began. Of course, he might be done as a GC contender even then, considering his age (about like Contador now) and the long layoff, but the odds against him wouldn't be as formidable as after four years.
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08 Feb 2018 02:42

In the Sundby case, they argued—on the basis of published studies as well as Sundby’s own lab tests—that the nebulizer was a less efficient means of salbutamol delivery.


From WADA website:
Nebulizers are not prohibited as a device; however the amount of beta-2-agonist administered by nebulisation may surpass the allowed maximum doses of salbutamol, salmeterol or formoterol by inhalation; therefore the dose may be prohibited.


Also, of course, Froome has repeatedly said he takes salbutamol only for “great efforts”, i.e., in a race, where of course a nebulizer couldn’t be used.


Walsh said that since being seen using an inhaler during a stage of the 2014 Criterium du Dauphine and been criticised for it, Froome did not use it during racing anymore.

It meant the number of puffs of his inhaler that he could legally take were no longer always spread evenly across a day.


And to repeat, the enantiomers test doesn’t distinguish between oral and inhaled use. Petacchi “failed” that test, and CAS still ruled that he had just inhaled too much.


Can we tell the difference between a general intake, which is strictly prohibited, and an inhaled intake?

We have no element of certainty. By combining certain indicators with other information on the outcome and the environment described by the athlete, however, this can lead to a relatively high level of certainty.- Oliver Rabin
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Re:

08 Feb 2018 03:50

70kmph wrote:
From WADA website:
Nebulizers are not prohibited as a device; however the amount of beta-2-agonist administered by nebulisation may surpass the allowed maximum doses of salbutamol, salmeterol or formoterol by inhalation; therefore the dose may be prohibited.


I think that refers to the fact that much higher doses are obtainable by nebulizer, not that a larger amount of a given dose gets into the lungs. From the Sundby CAS case:

WADA has never addressed the issue of nebulised Salbutamol but it is acknowledged to be an acceptable method of administration as it is ‘by inhalation’. The manufacturer’s recommended dose of Salbutamol for nebulisation by adults is 2.5-5mg three times a day –i.e. a maximum of 15mg per day which is nine times greater than 1,600mcg.


The delivery of a drug such as Salbutamol via nebulisation does not provide much superior delivery to that achieved by an MDI, used correctly with a spacer.


The dosage of Salbutamol (5mg x3) is equivalent to 1500 mcg. inhaled dosage, hence the inhaled dosage (1500 mcg.) did not exceed the limit of 1600 mcg.


The prescription of nebulized salbutamol 5 mg three times daily combined with saline should be considered to be in line with common practice, with no other intention than to reduce air trapping and to clear the lungs from excess mucus secretions. 15 mg is bioequivalent to 1500 μg salbutamol delivered by MDI with spacer and under the by WADA recommended maximum daily dose of 1600 μg.


In order to support his statement that “15 mg” inhaled by nebulization “is bioequivalent to 1500 μg salbutamol delivered by MDI with spacer” Professor Bjermer made reference to a study of S.H. Mazhar, N.E. Ismail, D.A.G. Newton and H. Chrystyn, Relative lung deposition of salbutamol following inhalation from a spacer and Sidestream jet nebulizer following an acute exacerbation, Br J Clin Pharmacol 65:3, 334-337 (the “Mazhar Study”).


These points were contested by the prosecution, and rightly so IMO, but they do indicate that the amount of salbutamol getting into the body via nebulizer is a smaller fraction of the nominal dose than is the case with a standard inhaler.

Walsh said that since being seen using an inhaler during a stage of the 2014 Criterium du Dauphine and been criticised for it, Froome did not use it during racing anymore.

It meant the number of puffs of his inhaler that he could legally take were no longer always spread evenly across a day.


That’s very interesting, I hadn’t heard that. It has a lot of implications. First, since great efforts are generally when asthma is worst, if he didn’t use an inhaler during racing, why would he need it at all? Maybe an asthmatic could comment on this.

Second, if he doesn’t use an inhaler during racing, how was he able to take several puffs at the end of stage 18? Did someone immediately hand him an inhaler after he crossed the finish line?

Third, this makes Froome’s positive even more difficult to explain. If he doesn’t take salbutamol during a race, but only at some time before, this means that, assuming he urinated at some point during the race, his levels should be quite low. Even if hypothetically he loaded up before the start of the stage, taking 800 ug all at once, if he stopped to pee at any point in the race, much of the drug would be out of his system. I had assumed he was going to claim that he took most of the drug in the final hour or two of the race, so that maximum urine levels would occur when he provided a sample at controls at the end of the stage.

Can we tell the difference between a general intake, which is strictly prohibited, and an inhaled intake?

We have no element of certainty. By combining certain indicators with other information on the outcome and the environment described by the athlete, however, this can lead to a relatively high level of certainty.- Oliver Rabin


The proof, or absence of proof, is in the pudding. Has any rider ever been sanctioned for intentionally dosing with salbutamol based on the enantiomers test? Not that I’m aware of. As I discussed upthread, the test is designed to distinguish between a sub-maximal inhaled dose and an oral dose. In theory, one could design a test to distinguish between a supra-maximal inhaled dose—IOW, inhaling too much by accident—and an oral dose, but this hasn’t been done. In fact, if one has the other information Rabin refers to, that alone will probably add more to the conclusion than the enantiomers test.
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Re: Re:

08 Feb 2018 11:12

Merckx index wrote:
That’s very interesting, I hadn’t heard that. It has a lot of implications. First, since great efforts are generally when asthma is worst, if he didn’t use an inhaler during racing, why would he need it at all? Maybe an asthmatic could comment on this.

Second, if he doesn’t use an inhaler during racing, how was he able to take several puffs at the end of stage 18? Did someone immediately hand him an inhaler after he crossed the finish line?

Third, this makes Froome’s positive even more difficult to explain. If he doesn’t take salbutamol during a race, but only at some time before, this means that, assuming he urinated at some point during the race, his levels should be quite low. Even if hypothetically he loaded up before the start of the stage, taking 800 ug all at once, if he stopped to pee at any point in the race, much of the drug would be out of his system. I had assumed he was going to claim that he took most of the drug in the final hour or two of the race, so that maximum urine levels would occur when he provided a sample at controls at the end of the stage.


I did a bit of analysis way up thread that I can share. To the first point, my personal experience with asthma is yjay it van feel totally random. Feel great all day on the bike, and wham! Hacking and coughing. Ten minutes into a gentle ride and Blam! I need to stop and sit down for a while. Sitting on the couch and Wheeze! There doesn'y seem to be a huge consistency, rather general trends of when I can expect an attack. I carry my inhaler everywhere I go just for that reason.

As for Stage 18, I used TV coverage to show that there was a maximum of 50 minutes between Froome crossing the line and him attending post race interviews. The doping control would have had to have happened somewhere in that time frame, so there's no way a post-stage puff or three would have resulted in peak plasma concentrations.

Unless he can be shown to have taken some puffs on the bike, he was nebulizing or popping pills before the stage.

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Re: Re:

08 Feb 2018 12:00

ScienceIsCool wrote:
Merckx index wrote:
That’s very interesting, I hadn’t heard that. It has a lot of implications. First, since great efforts are generally when asthma is worst, if he didn’t use an inhaler during racing, why would he need it at all? Maybe an asthmatic could comment on this.

Second, if he doesn’t use an inhaler during racing, how was he able to take several puffs at the end of stage 18? Did someone immediately hand him an inhaler after he crossed the finish line?

Third, this makes Froome’s positive even more difficult to explain. If he doesn’t take salbutamol during a race, but only at some time before, this means that, assuming he urinated at some point during the race, his levels should be quite low. Even if hypothetically he loaded up before the start of the stage, taking 800 ug all at once, if he stopped to pee at any point in the race, much of the drug would be out of his system. I had assumed he was going to claim that he took most of the drug in the final hour or two of the race, so that maximum urine levels would occur when he provided a sample at controls at the end of the stage.


I did a bit of analysis way up thread that I can share. To the first point, my personal experience with asthma is yjay it van feel totally random. Feel great all day on the bike, and wham! Hacking and coughing. Ten minutes into a gentle ride and Blam! I need to stop and sit down for a while. Sitting on the couch and Wheeze! There doesn'y seem to be a huge consistency, rather general trends of when I can expect an attack. I carry my inhaler everywhere I go just for that reason.

As for Stage 18, I used TV coverage to show that there was a maximum of 50 minutes between Froome crossing the line and him attending post race interviews. The doping control would have had to have happened somewhere in that time frame, so there's no way a post-stage puff or three would have resulted in peak plasma concentrations.

Unless he can be shown to have taken some puffs on the bike, he was nebulizing or popping pills before the stage.

John Swanson



agree 100%
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Re: Re:

08 Feb 2018 12:11

ScienceIsCool wrote:
As for Stage 18, I used TV coverage to show that there was a maximum of 50 minutes between Froome crossing the line and him attending post race interviews. The doping control would have had to have happened somewhere in that time frame, so there's no way a post-stage puff or three would have resulted in peak plasma concentrations.

That's not always the case, especially for someone who has been up on the podium. The TV interviews often get done first. TV has a schedule to keep, anti-doping can wait all day if need be.
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Re: Re:

08 Feb 2018 13:35

Parker wrote:
ScienceIsCool wrote:
As for Stage 18, I used TV coverage to show that there was a maximum of 50 minutes between Froome crossing the line and him attending post race interviews. The doping control would have had to have happened somewhere in that time frame, so there's no way a post-stage puff or three would have resulted in peak plasma concentrations.

That's not always the case, especially for someone who has been up on the podium. The TV interviews often get done first. TV has a schedule to keep, anti-doping can wait all day if need be.


“That evening at the finish (of stage 18), wanting to show he was healthy, he took two or three puffs from his inhaler hoping he would cough less or not at all through the post-race interview,” Walsh claims.

He then adds that 50 minutes after crossing the finish line he had his interview and dope test done.

http://www.stickybottle.com/latest-news/david-walsh-froome-inhaler/
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Re: Re:

08 Feb 2018 14:18

Parker wrote:
ScienceIsCool wrote:
As for Stage 18, I used TV coverage to show that there was a maximum of 50 minutes between Froome crossing the line and him attending post race interviews. The doping control would have had to have happened somewhere in that time frame, so there's no way a post-stage puff or three would have resulted in peak plasma concentrations.

That's not always the case, especially for someone who has been up on the podium. The TV interviews often get done first. TV has a schedule to keep, anti-doping can wait all day if need be.

I don't think that's possible. As soon as you cross the line, you're met by a chaperone. You'll often see crews looking for quick post-race reactions and photographs and stuff but the chaperone will be right there observing. From there, you are lead to doping control. Along the way you might be given some towels, water, etc by a soigneur, but the chaperone will be watching closely.

Now some guys are selected for random controls and they probably aren't met by a chaperone, but they're informed right away to get to doping control. There's no getting on the team bus or any of that stuff. But Froome wasn't a ransom control, was he? He was definitely met by a chaperone.

Only after the doping control do you get to have a wipe-down and a change of clothes for interviews at the press tent. If you care to look, you can see that is indeed wiped down and has a fresh change of kit. https://www.youtube.com/watch?v=SkBT13_ELCM

The time from when he crossed the line, to when the interview aired is 50 minutes. So we have a hard and fast timeline. Now you'll note that the interview in all likelihood happened after the podium presentation, and the presentation is often delayed because of the doping controls. Sponsors normally want the riders in spiffy clean clothes to look good for the cameras. So the greatest likelihood is that the absolute maximum window between post-race puffs and giving a sample is 45 minutes.

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Re: Re:

08 Feb 2018 15:09

ScienceIsCool wrote:I don't think that's possible. As soon as you cross the line, you're met by a chaperone. You'll often see crews looking for quick post-race reactions and photographs and stuff but the chaperone will be right there observing. From there, you are lead to doping control. Along the way you might be given some towels, water, etc by a soigneur, but the chaperone will be watching closely.

And the chaperone will stick with them during those media commitments. It's addressed at the top of page 2 of this: http://uci.ch/mm/Document/News/CleanSport/16/56/45/TD20Notificationofridersforanin-competitiontest.EN_English.PDF

Sometimes athletes, particularly dehydrated ones, take a long time to pee. It's a rare talent to be able to do it on demand.
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Re: Re:

08 Feb 2018 16:53

Parker wrote:
ScienceIsCool wrote:I don't think that's possible. As soon as you cross the line, you're met by a chaperone. You'll often see crews looking for quick post-race reactions and photographs and stuff but the chaperone will be right there observing. From there, you are lead to doping control. Along the way you might be given some towels, water, etc by a soigneur, but the chaperone will be watching closely.

And the chaperone will stick with them during those media commitments. It's addressed at the top of page 2 of this: http://uci.ch/mm/Document/News/CleanSport/16/56/45/TD20Notificationofridersforanin-competitiontest.EN_English.PDF

Sometimes athletes, particularly dehydrated ones, take a long time to pee. It's a rare talent to be able to do it on demand.


I'd never seen that technical document before. Thanks!! But I'd still maintain that a quick trip to the bus to freshen up for the press/podium wouldn't really be feasible until after the doping control.

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Re: Re:

08 Feb 2018 16:58

ScienceIsCool wrote:
Parker wrote:
ScienceIsCool wrote:I don't think that's possible. As soon as you cross the line, you're met by a chaperone. You'll often see crews looking for quick post-race reactions and photographs and stuff but the chaperone will be right there observing. From there, you are lead to doping control. Along the way you might be given some towels, water, etc by a soigneur, but the chaperone will be watching closely.

And the chaperone will stick with them during those media commitments. It's addressed at the top of page 2 of this: http://uci.ch/mm/Document/News/CleanSport/16/56/45/TD20Notificationofridersforanin-competitiontest.EN_English.PDF

Sometimes athletes, particularly dehydrated ones, take a long time to pee. It's a rare talent to be able to do it on demand.


I'd never seen that technical document before. Thanks!! But I'd still maintain that a quick trip to the bus to freshen up for the press/podium wouldn't really be feasible until after the doping control.

John Swanson

No, not the bus. I fully agree with you there. There's usually an area set aside for them to do that and soigneurs carry big rucksacks around.
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Re: Re:

08 Feb 2018 17:23

Parker wrote:
ScienceIsCool wrote:I don't think that's possible. As soon as you cross the line, you're met by a chaperone. You'll often see crews looking for quick post-race reactions and photographs and stuff but the chaperone will be right there observing. From there, you are lead to doping control. Along the way you might be given some towels, water, etc by a soigneur, but the chaperone will be watching closely.

And the chaperone will stick with them during those media commitments. It's addressed at the top of page 2 of this: http://uci.ch/mm/Document/News/CleanSport/16/56/45/TD20Notificationofridersforanin-competitiontest.EN_English.PDF

Sometimes athletes, particularly dehydrated ones, take a long time to pee. It's a rare talent to be able to do it on demand.


The last para of the pdf includes
NOTE: Should the Rider choose to consume fluids prior to arrival at the doping control station it is at his/her own discretion. The Rider will be responsible for the security and integrity of any drinks or food that the Rider chooses to consume.

Would that include top-up puffs?
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Re: All About Salbutamol

08 Feb 2018 23:29

Interesting discussion about how long after the finish the rider can report to the doping control, but if Walsh was correct when he claimed Froome no longer inhales during a race, it's pretty irrelevant. Two or three puffs even at a time before providing the sample that optimizes urine concentration is not going to matter much.

The really important factor here is, did Froome stop to pee at some point during the race, and if so, when? Given that information, which surely must be available, plus the volume of urine provided at the doping control, one can calculate with fairly high probability a maximum level of urinary salbutamol. Again, this assumes he didn't inhale during the race. Possibly that can be confirmed, too.

By the way, I find this Walsh claim extremely interesting for another reason than the ones I suggested before. Consider this possible sequence of events:

1) Froome never took salbutamol prior to joining Sky. I've already discussed the evidence for this, viz., a) no mention of a salbutamol TUE in the Fancy Bears hack of Froome's ADAMS account; and b) Froome himself, upon being confronted by the FB hack showing his prednisolone TUEs, said those were the only TUEs he ever had.

2) The year Froome joined Sky, a TUE was no longer needed to use salbutamol, up to the established limits. This of course was an invitation for any rider to orally dose, if he took a reasonable amount of caution. But even salbutamol levels well within the allowed amounts might look suspicious for a rider with no history of asthma. As long as Froome was a relatively unknown and unimportant rider, this was unlikely to be a problem, because this information is not public, and the difficulty of a reporter's obtaining it wouldn't be worth it for such a rider. But after the 2011 Vuelta, of course, this started to change, and after the 2013 Tour, Froome was gaining recognition as one of the best GC riders of his generation. So he not only began to use an inhaler, but made a public show of it, so everyone would know that he took salbutamol.

3) Initially, he told Kimmage he used salbutamol only for "great efforts". If Walsh's claim is correct, though Froome later changed this story. He no longer took salbutamol during a race. Why would he say this? Well, if the whole purpose of claiming to inhale was just a cover for oral dosing, actually using an inhaler during a race would not only be unnecessary, but I would think would hinder him. When you're on the edge of the red zone on a final climb, the last thing you want to do is pull our your inhaler and start puffing. So just dispense with that show. The point had already been made.

I'm not pushing this story as what likely has been going on. But I've seen nothing to refute it, and Froome, who could easily refute at least 1), by furnishing proof of his salbutamol TUE, so far hasn't done so. Also, it isn't an either-or situation. E.g., Froome could have mild, EIA, such that he does use an inhaler sometimes, but is not dependent on it regularly. As long as he uses it occasionally, he has an adequate cover for regularly testing for salbutamol in the urine.
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09 Feb 2018 00:31

Sports Integrity Briefs – 8 February

The Norwegian Olympic team has taken over 6,000 doses of asthma medication to the PyeongChang 2018 Winter Olympics, reports NRK. The broadcaster reported that the 109 athletes and 100 person support team have access to 52 different drugs and ten nebuliser devices. Last month, an article in Norwegian newspaper Verde Gang, featured the Norwegian cross-country ski team doctor, Petter Olberg, who claimed that between 50% and 70% of the team suffer with asthma. The Norwegian Olympic Committee (NIF) has yet to comment on the reports.
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