Therapeutic Use Exemptions (TUEs)

Athletes may have an illness or medical condition that require them to take a medication or undergo procedures. If this medication or method is prohibited as per the World Anti-Doping Agency’s (WADA) Prohibited List, a TUE may give that athlete an exemption to take the medication or use the method, while competing in sport without invoking an anti-doping rule violation (ADRV) and applicable sanction.

The List of Prohibited Substances and Methods (List) indicates what substances and methods are prohibited in sport and when.

The Prohibited List (PL) is published by WADA and comes into effect on 01 January every year. Many common medications that one may not associate with doping are on the PL such as insulin for diabetes treatment and some high blood pressure medications as well as prohibited methods such as intravenous (IV) use. If an athlete takes any medications, it is important to always check the List on the WADA website and/or search a trusted National Anti-Doping database.  If an athlete needs the treatment for legitimate medical reasons, then they must apply for a TUE.

Once an athlete is prescribed a prohibited substance/method or becomes subject to anti-doping rules, they should apply for a TUE as soon as possible. Some ADOs have different rules regarding TUEs so the athlete should always contact their ADO first.

See ISTUE Guidelines - Chapter 3: When to apply for a TUE

TUEs are granted by Anti-Doping Organizations (ADOs):

• International Federations (IFs) – for example, FIFA and UCI
• National Anti-Doping Organizations (NADOs) - This is an athlete’s countries’ anti-doping body, for example, in Ireland, Sport Ireland, US, USADA etc. and,
• Major Event Organizers (MEOs) - for example, the International Olympic Committee.

These organizations should be the athlete’s first port of call if they have any queries about the process. If they are unsure of what level they fit into we recommend they contact their NADO who should be able to provide guidance.

See ISTUE Guidelines – Chapter 4: Where to Apply?

The athlete should download the TUE application from their anti-doping organizations website or fill it online if they have that option (if an athlete has an ADAMS account, they can also submit their application via this route).

It is the athlete’s responsibility to provide a completed TUE application containing adequate medical information to confirm the diagnosis to their ADO. However, the application should be completed with the help of the athlete’s doctor.

The athlete should bring the TUE application form and the relevant TUE Checklists with them when they visit their doctor, or have an electronic version readily accessible. The TUE Checklists are documents specifically designed for athletes and their treating physicians to help them gather required medical evidence to submit a complete TUE application.

Once the athlete’s physician has completed the TUE application and provided the relevant medical information, the application can be submitted to the ADO.

See ISTUE Guidelines - Chapter 5: What are the responsibilities of an athlete in submitting a TUE application?

WHAT HAPPENS AFTER A TUE IS GRANTED?

All approved TUEs are only valid for a specific duration. The athlete’s exemption will have an expiry date. This means that after this date the TUE certificate is no longer valid, and if the athlete wishes to continue using the prohibited substance, they will need to reapply for a new TUE.

See ISTUE Guidelines - Chapter 7: What happens after a TUE is granted?

Four criteria need to be met:

- The prohibited substance or prohibited method in question is needed to treat a diagnosed medical condition supported by relevant clinical evidence;

- The therapeutic use of the prohibited substance or prohibited method will not, on the balance of probabilities, produce any additional enhancement of performance beyond what might be anticipated by a return to the athlete’s normal state of health following the treatment of the medical condition;

- The prohibited substance or prohibited method is an indicated treatment for the medical condition, and there is no reasonable permitted therapeutic alternative;

- The necessity for the use of the prohibited substance or prohibited method is not a consequence, wholly or in part, of the prior use (without a TUE) of a substance or method which was prohibited at the time of such use.

A retroactive TUE provides an athlete the opportunity to apply for a TUE for a prohibited substance or prohibited method after using or possessing the substance or method in question.

At least one of the five retroactive conditions set out in ISTUE Article 4.1 must be satisfied to apply for a retroactive TUE.

Note: The fulfillment of one of the retroactive exceptions does not mean that a TUE will necessarily be granted; it means that the athlete’s application may be evaluated under ISTUE Article 4.2 to determine if the specified TUE conditions have been satisfied.

ISTUE retroactive conditions:

• The athlete required emergency or urgent treatment of a medical condition.
• There was insufficient time, opportunity or other exceptional circumstances that prevented the athlete from submitting the TUE application, or having it evaluated, before getting tested.
• As per NADO anti-doping rules the athlete was not permitted or required to apply in advance for a TUE.
• The athlete was a lower-level athlete who was not under the jurisdiction of an International Federation or National Anti-Doping Organization when they were tested.
• The athlete tested positive after using a substance out-of-competition that was only prohibited in-competition (for example glucocorticoids).

In exceptional circumstances (Article 4.3) athletes may apply for and be granted a retroactive TUE if, considering the purpose of the Code, it would be manifestly unfair not to do so.

WADA’s role in the TUE process is two-fold:

1. WADA acts as facilitator for the WADA TUEC, which is an independent body of 3 physicians, convened to review TUEs granted by an ADO when necessary.
2. The athlete who submits a TUE Application to an IF and is denied a TUE, can ask WADA to review the decision. WADA is not obliged to review all cases and athletes may appeal their denial to national review boards or to CAS. There are certain cases, such as a discrepancy between an IF and NADO, where WADA must review TUE decisions.

Note that WADA does not accept direct TUE applications from athletes unless there is a request for a review. All applications must be made to the appropriate ADO.

When an athlete already has a TUE granted by a NADO/IF but then becomes a subject to the requirements of an IF or Major Event Organizer (MEO) (example: Athlete becomes an international level athlete), their TUE must be recognized at the higher level. This is to facilitate the process for athletes so they do not have to submit a new application to the IF or MEO.

If an athlete moves up a level, they need not immediately apply for a new TUE to the IF or MEO but should first consult their websites to check whose TUE decisions they will automatically recognize. If the athlete’s TUE falls into a category of TUEs that are automatically recognized, athletes need not take further action.

In the absence of such recognition, they should submit a request for recognition of the TUE to the IF or MEO either via ADAMS or as otherwise specified by that IF or MEO.

See ISTUE Guidelines - Section 6: TUE recognition process

The athlete or their NADO has 21 days from the notification of the decision of non-recognition by the IF to refer the matter to WADA for review. During WADA’s review, the NADO TUE is valid for national level competition and out-of-competition testing only.

If the athlete and/or NADO decide not to refer the matter to WADA, the NADO must determine whether the original TUE that it granted should remain valid for national level competition and out-of-competition testing. Pending the NADO’s decision, the TUE remains valid only for national level competition and all out-of-competition testing (Code Article 4.4.3.1).

A decision by a Major Event Organization not to recognize or not to grant a TUE may be appealed by the athlete exclusively to an independent body established or appointed by the Major Event Organization for that purpose.

See ISTUE Guidelines - Section 6: TUE recognition process

Yes, but these TUEs are valid only for the duration of their event. A TUE granted by a NADO or an IF is not valid for the event unless it is recognized by the MEO.  MEOs may automatically recognize TUEs from other organizations but the athlete should verify this on the MEO’s website. Note that if the TUE is not recognized by the MEO, it remains valid outside of that event.

See ISTUE Guidelines - Chapter 15: ADOs involved in the TUE process – 3.0 MEOs

• National level athletes appeal the TUE decision to national appeal bodies.
• International Level Athletes appeal the TUE decision to WADA or CAS
• TUE decisions denied by MEOs should be appealed to the MEO appeal panel
• International Federation non-recognitions appeal to WADA

See ISTUE Guidelines - Chapter 9: Where to appeal a TUE decision and Chapter 23: Requesting a WADA TUE review

A decision by WADA to reverse or uphold a TUE decision may be appealed by the athlete, the NADO and/or the IF affected, exclusively to CAS.

See ISTUE Guidelines - Chapter 23: Requesting a WADA TUE review

When a national-level athlete has a TUE granted by their NADO, it is valid only for National Events. However, that TUE is valid at the national-level on a global basis and does not need to be formally recognized by other NADOs.  If the athlete is considered an international level athlete by an IF, they would need an IF TUE or recognition of their NADO TUE.

See ISTUE Guidelines - Chapter 15: ADOs involved in the TUE process – 1.0 NADOs

Yes, athletes are advised to declare any medications or supplements taken over the past 7 days and, (if a blood sample is collected), any blood transfusions received over the last 3 months.

All the information contained in a TUE application, including the supporting medical information, and any other information related to the evaluation of a TUE request must be handled in accordance with the strict principles of medical confidentiality.

ADOs are subject to strict confidentiality requirements with respect to an athlete’s TUE information. Physicians who are members of a TUEC and any other experts consulted must be subject to confidentiality agreements. Physicians are also typically subject to a number of professional obligations to protect their patients’ confidentiality.

Under the International Standard for the Protection of Privacy and Personal Information (ISPPPI), ADO staff must also sign confidentiality agreements, and the ADO must implement strong privacy and security measures to protect athlete’s personal information.

See ISTUE Guidelines - Chapter 10: How the athletes’ personal information is dealt with throughout the TUE process?

Athletes should contact their NADO or IF to get more information on TUEs.

WADA has developed a wide range of resources related to TUEs that athletes and anti-doping organizations can consult. These resources can be accessed via WADA website or WADA Anti-Doping Education and Learning platform (ADEL) and include:

• International Standard for Therapeutic Use Exemptions (ISTUE)
• ISTUE Guidelines
• TUE Physician Guidelines
• TUE Checklists
• Code Implementation Support Program (CISP) on ADEL – ISTUE section
• Various e-learning courses and resources for athletes and Medical Professionals on ADEL