Therapeutic Use Exemption Process

Every TUE is judged against the same four conditions, all of which must be met. First, the athlete has a clear diagnosis and the prohibited substance is needed to treat that condition. Second, the treatment is highly unlikely to produce any performance benefit beyond returning the athlete to normal health, so it restores rather than enhances. Third, there is no reasonable permitted alternative that could treat the condition instead. Fourth, the need for the prohibited substance is not itself a consequence of having previously used a prohibited substance without a TUE.

These criteria explain a great deal about how applications are decided. A treatment that would clearly improve performance beyond health, or a condition that a permitted medicine could manage just as well, will struggle, because it fails the second or third test. The criteria also make clear that a TUE is not a reward for having a diagnosis, but a careful judgement that this particular athlete genuinely needs this particular prohibited treatment and has no permitted way around it. Understanding these four tests is the foundation for building any application, since a strong file is one that shows, with evidence, that each of them is satisfied.

Not every athlete needs a TUE in advance, and the rules depend on the level at which they compete. International-level athletes apply to their international federation, and national-level athletes apply to their national anti-doping organisation, which in the United Kingdom is UK Anti-Doping (UKAD). The relevant organisation defines who counts as international or national level. Athletes competing below these levels generally do not need to hold a TUE in advance, but they remain subject to the rules and must apply for a retroactive TUE if they are tested and found to have used a prohibited substance.

Where a TUE is required, the principle is to apply in advance, as soon as the need is known and normally well before the substance is needed, rather than after the event. Relying on a retroactive application is not a substitute for planning, and an athlete should never assume one will be granted, so the safe path is to sort the exemption out before treatment wherever the rules require it. There are, however, defined circumstances in which a retroactive application is allowed, which the next section sets out.

Two situations change the timing. The first is a genuine emergency. If an athlete needs urgent or life-saving treatment, that treatment is given first and is never delayed for anti-doping paperwork, and if a prohibited substance or method was used, a retroactive application follows afterwards. The second covers the other defined circumstances in which a retroactive application is permitted, such as where there was insufficient time or opportunity to apply before being tested, where a lower-level athlete who was not required to hold an exemption in advance is tested, or other exceptional circumstances agreed with the anti-doping organisation.

The deadlines are specific and matter. Under the World Anti-Doping Agency International Standard for Therapeutic Use Exemptions, a retroactive application must be submitted as soon as possible after the treatment. In the United Kingdom, UK Anti-Doping sets a defined deadline for an athlete who returns an adverse finding and needs a retroactive exemption, requiring the application within five working days of being notified. Because these timeframes are set by the rules and can change, the clinician should confirm the current deadline with UK Anti-Doping or the relevant international federation, act promptly, and keep clear records of the treatment given and why it was necessary.

An application is made to the relevant anti-doping organisation and reviewed by a TUE Committee, a panel of independent doctors who assess it against the four criteria. If granted, a TUE covers a specific substance, dose and route for a defined period, and is renewed rather than assumed to continue indefinitely.

The quality of the medical evidence largely determines the outcome. A strong application includes a confirmed diagnosis with the investigations that support it, a relevant history, and clear details of the treatment, the substance, its dose, route, frequency and duration, together with an explanation of why permitted alternatives are unsuitable or have been tried and failed. The treatments that most often raise the question are worth knowing: some inhaled asthma medicines are permitted up to specified limits without a TUE while higher doses or other agents need one, stimulant medication for attention deficit hyperactivity disorder (ADHD) is prohibited in competition and needs a TUE, insulin for diabetes needs one, and injectable glucocorticoids for joint and tendon problems are prohibited in competition and require a TUE or careful timing. Building the file around the four criteria, with evidence for each, is what turns a genuine clinical need into a successful application.

The clinician's role runs right through the process. It begins with recognising that a proposed treatment is prohibited, which depends on checking the substance in the first place. The next step is to consider whether a permitted alternative would do the job, since a TUE will not be granted if one exists, and trying a suitable alternative is often both better medicine and a smoother path. Where a prohibited substance is genuinely needed, the clinician gathers the evidence, completes the application accurately, and submits it in good time, keeping clear records throughout. It is important not to start an athlete on a prohibited treatment on the assumption that an exemption will follow, because approval is never guaranteed and the athlete carries the risk.

If an application is refused, there is a route to have the decision reviewed or appealed, and the World Anti-Doping Agency can also review TUE decisions, so a refusal is not necessarily the end of the matter. Throughout, the clinician balances two duties that usually align: treating the patient properly and keeping them compliant with the rules of their sport.

• •The World Anti-Doping Code and the International Standard for Therapeutic Use Exemptions set out the four criteria and the process, and are published by the World Anti-Doping Agency (WADA).
• •UK Anti-Doping (UKAD) administers TUEs for national-level athletes in the United Kingdom and provides guidance and application forms, while international-level athletes apply to their international federation.
• •Global Drug Reference Online (Global DRO) allows a medicine's status to be checked before deciding whether a TUE is needed.
• •Faculty of Sport and Exercise Medicine (FSEM) and British Association of Sport and Exercise Medicine (BASEM) resources support clinicians in advising athletes and completing applications.

• •A Therapeutic Use Exemption must satisfy all four criteria: a diagnosed need, no enhancement beyond normal health, no permitted alternative, and a need not arising from prior prohibited use.
• •International-level athletes apply to their international federation and national-level athletes to their national anti-doping organisation, which in the United Kingdom is UK Anti-Doping.
• •The principle is to apply in advance where a TUE is required, with retroactive exemptions allowed only in defined circumstances such as emergency treatment.
• •Applications are reviewed by a TUE Committee of independent doctors and granted for a defined substance, dose and period.
• •A strong application needs a confirmed diagnosis, supporting investigations, and a clear reason why permitted alternatives are unsuitable.
• •Do not start or rely on a prohibited treatment assuming approval, and remember that stimulants for attention deficit hyperactivity disorder and insulin for diabetes need a TUE.