Therapeutic Use Exemptions in Sport: How to Get Approval
Athletes get ill, injured and diagnosed with chronic conditions like everyone else. Sometimes the right treatment contains a substance on the World Anti-Doping Agency (WADA) Prohibited List. A Therapeutic Use Exemption, or TUE, is the mechanism that allows legitimate medical treatment without an anti-doping rule violation. Our editorial team explains how the system works in the UK and how to avoid the errors that most often lead to refusals.
What a TUE is and why it exists
The World Anti-Doping Code holds athletes strictly liable for any prohibited substance found in their samples. Intent does not need to be proven. Without an exemption system, a diabetic athlete needing insulin or a teenager with ADHD treated with a stimulant would be barred from competition or forced to abandon appropriate care.
A TUE is formal permission, granted in advance or in specific cases retrospectively, to use a named prohibited substance or method, at a specified route and dose, for a defined period. The rules are set out in WADA's International Standard for Therapeutic Use Exemptions (ISTUE), which every signatory, including UK Anti-Doping (UKAD), must follow.
Not every medicine requires a TUE. Most prescription drugs are not prohibited at all, and some substances are prohibited only in competition, only by certain routes, or only above certain thresholds. Inhaled salbutamol within defined limits, for example, does not require a TUE, while other inhaled beta-2 agonists may.
Because the Prohibited List is updated each year, usually taking effect on 1 January, a medicine that was permitted last season may need a TUE now, and vice versa. Checking status is therefore an ongoing responsibility, not a one-off task.
The four criteria for approval
Under the ISTUE, a TUE committee may grant an exemption only if the athlete demonstrates, on the balance of probabilities, that all four conditions are met:
- The substance or method is needed to treat a diagnosed medical condition supported by relevant clinical evidence.
- Its therapeutic use is highly unlikely to produce any additional enhancement of performance beyond a return to the athlete's normal state of health.
- There is no reasonable permitted therapeutic alternative.
- The need for the substance is not a consequence of prior use, without a TUE, of a prohibited substance or method.
The fourth criterion is particularly relevant in strength sports. Someone who has developed low testosterone after misusing anabolic steroids cannot simply obtain a TUE for testosterone replacement. Male hypogonadism TUEs require a robustly documented organic cause, and committees scrutinise them closely.
The third criterion often causes problems. If a permitted medicine could reasonably treat the condition, the committee expects to see why it was unsuitable, for example documented failure, intolerance or contraindication.
Committees are made up of physicians with relevant expertise, and they may consult external specialists. Their decisions can be reviewed by WADA, and athletes have a right of appeal.
Who applies, to whom, and when
Where you apply depends on your competitive level. International-level athletes, as defined by their international federation (IF), generally apply to that federation. National-level athletes in the UK usually apply to UKAD. For major events, organisers may operate their own TUE procedures.
Timing also depends on level. Athletes in a registered testing pool, international-level athletes and those competing at defined national levels are typically expected to apply in advance. The ISTUE recommends submitting at least 30 days before the exemption is needed, except in emergencies.
Lower-level and recreational competitors subject to the Code may be eligible for a retroactive TUE, meaning they apply only if they are tested and return an adverse finding. That does not remove the need to keep medical records. UKAD publishes guidance on which athletes are covered by the advance and retroactive routes, and it is worth checking the current version for your sport.
| Situation | Typical route | Key point |
|---|---|---|
| International-level athlete | Apply to international federation | Apply in advance |
| National-level athlete (UK) | Apply to UKAD | Usually in advance; check sport-specific rules |
| Lower-level competitor | Often retroactive eligibility | Keep full medical records ready |
| Medical emergency | Treat first, apply retroactively | Document the emergency clearly |
| Major event (e.g. Games) | Event organiser's procedure | Check recognition of existing TUEs |
A TUE granted by a national organisation is not automatically valid internationally. Athletes moving up to international competition must check whether their federation recognises it or whether a new application is required.
Building a strong application
Most refusals stem from incomplete medical documentation rather than doubts about the athlete's honesty. A TUE committee needs to see the diagnostic journey, not just a prescription. A good application typically contains:
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- A completed application form signed by the athlete and treating doctor.
- A detailed clinical history, examination findings and the date of diagnosis.
- Results of relevant investigations, such as spirometry, laboratory tests or imaging.
- Specialist letters where appropriate, for instance from an endocrinologist or psychiatrist.
- An explanation of why permitted alternatives were not suitable.
- The exact substance, dose, route and frequency, with planned duration.
WADA publishes "TUE Physician Guidelines" for common conditions, including asthma, ADHD, diabetes, male hypogonadism and inflammatory bowel disease. These describe the evidence committees expect, and doctors unfamiliar with anti-doping will find them invaluable.
Before applying, check the status of the medicine. Global DRO, the drug reference online service supported by UKAD and partner agencies, lets athletes search UK-licensed products by brand name and see whether they are prohibited in or out of competition. Nutritional supplements are not covered and carry their own contamination risk.
Common mistakes and controversies
A frequent error is assuming a prescription is enough protection. Being prescribed a medicine by a GP does not prevent an anti-doping violation if no TUE is in place when one is required. Strict liability applies.
Another is letting a TUE expire. Exemptions are time-limited, and continuing treatment after expiry without renewal leaves the athlete exposed. Changes of dose or route may also require a new decision.
Glucocorticoids illustrate how rules evolve. Since 2022, injectable routes of glucocorticoids have been prohibited in competition, which means local injections close to competition may now require a TUE or careful timing with medical guidance. Athletes should not assume older practice still applies.
TUEs have attracted public controversy, particularly after leaks of athletes' medical data in 2016. Analyses such as Fitch's review of TUEs at Olympic Games show that legitimate needs exist across sports, but they also underline why committees must be independent and rigorous. Transparency and careful scrutiny protect both clean athletes and those with genuine conditions.
Conclusions of the editorial team
The TUE system exists so that athletes can receive proper medical care without breaching anti-doping rules. Approval depends on meeting all four ISTUE criteria, backed by thorough clinical evidence.
Knowing your competitive level determines whether you must apply in advance or may rely on a retroactive route. When in doubt, contact UKAD or your governing body early rather than after a test.
Check medicine status regularly, keep records up to date and work with doctors who understand the process. That combination prevents most problems.
Readers may also wish to explore our articles on the WADA Prohibited List and its annual updates, contamination risks in supplements, and what happens during a doping control.
References
- World Anti-Doping Agency. World Anti-Doping Code 2021. Montreal: WADA; 2021.
- World Anti-Doping Agency. International Standard for Therapeutic Use Exemptions. Montreal: WADA; 2023.
- World Anti-Doping Agency. The Prohibited List. Montreal: WADA; updated annually.
- Fitch K. Therapeutic use exemptions (TUEs) at the Olympic Games 1992–2012. Br J Sports Med. 2013;47(13):815–818.
- Gerrard D, Pipe A. Therapeutic use exemptions. Med Sport Sci. 2017;62:55–67.
