NJ AC disagrees with ARP call for TRT ban

Thursday, January 30, 2014

Association of Ringside Physicians recently released a consensus statement calling for the phasing out of Therapeutic Use Exemptions for Testosterone Replacement Therapy.

However, two of the most respected individuals in the sport, New Jersey State Athletic Commission Counsel Nick Lembo and NJSACB Medical Chief for Mixed Martial Arts and Muay Thai Dr. Sherry Wulkan take issue with a wholesale ban.

“We are testing the hell out of those who voluntarily come forward seeking TUE's for TRT, but akin to a 'don't ask, don't tell' policy, we athletic commissions aren't testing enough of those who are not coming forward,” explained Lembo, to BloodyElbow. “The focus by the ARP should be on improving drug testing parameters for those who are not forthcoming and open.”

Dr. Wulkan further made that case against a wholesale ban.

In my opinion, the determination as to whether athletes requiring replacement therapy should be allowed to compete is an administrative decision for the athletic Commissioners and Executive Directors.

The determination as to whether or not a patient currently requires a given therapeutic intervention is a medical decision. It is incumbent upon physicians to treat patients, (provided the appropriate work-up and documentation has been done), to help assure their best quality of life.

The ABC medical committee, which I serve as Co-Chair with Dr.Wayne Lee, in 2011, published strict requirements to determine whether, in fact, a TUE for TRT should be granted. We had already established guidelines which fully addressed the concerns now raised in the ARP's press release. 'Steroid use' and 'unmerited testosterone' have never been supported or encouraged by any combat sports physician or athletic commission of which I am aware. However, some athletic commissions have been lax in their drug testing for PEDs for all athletes.

In New Jersey, it is a very onerous procedure to be considered for the grant of a TUE for TRT.

The procedures in New Jersey, are as follows:

A letter from a Board Certified Endocrinologist stating that the athlete stopped all hormone replacement therapy for a minimum of 8 weeks prior to repeat testing. The letter should include copies of medical records that address the following issues:
•If the athlete has been on testosterone (T) therapy already, then the combatant should cease using testosterone therapy for at least two months, preferably three, before measuring baseline T;
•Measurements must be made using an accurate method such as calculated free testosterone by equilibrium dialysis;
•Results should demonstrate T levels consistently below the low normal value for the reference laboratory;
•The obtained values must be interpreted by a Board Certified Endocrinologist in this case;
•Provide LH and FSH values measured at the same time as T above. In this case, the obtained values must be interpreted by an endocrinologist.
•Provide results from stimulation of the gonadal axis by hCG as applicable;
•Provide confirmation that the athlete does not have any short term illness or other condition that would influence testosterone production at the time of evaluation, and that the athlete is NOT on any medication that may affect T levels such as narcotics or corticosteroids, or androgen replacement therapy.
•Provide a detailed treatment plan including how systemic T levels will be monitored to ensure maintenance of therapeutic levels. The dosage must be decided by an endocrinologist in this case. The intervals between assessments of therapeutic maintenance levels must be so stated and the results of at least two therapeutic levels submitted by an endocrinologist in this case.
•The athlete is subject to at least three separate drug tests prior and immediately thereafter the fight date, the timing and type of which is to be determined by this agency. Samples of blood, urine and/or hair may be taken one month, two weeks, and immediately post competition in an attempt to ensure competitive equity.

Without a Commission's adherence to the above ABC medical committee and NJSACB adopted procedures and requirements, the ARP's position may seem the easier and more rudimentary solution for all involved.

The glaring and overlooked concern regardless of the ABC medical committee TUE requirements or the ARP's recommended ban, is the fact that the large majority of athletes using performance enhancing drugs are not, in fact, subject to ANY testing because measurements of PED are minimal or non-existent in many jurisdictions.

Perhaps it might have been more prudent for the ARP to endorse the concept of regular and stringent drug testing for PED's via hair, blood and urine by all athletic commissions.

The ARP may have placed the cart before the horse by cracking down on TUE applicants who freely and voluntarily come forward seeking medical clearance at a time when commissions are still granting TUEs, while ignoring the fact that those who are not forthcoming are either not tested or are tested in a fashion that is not designed to catch PED usage, or testing that it fraught with obvious and glaring weaknesses.

While it is clear that the request/need for TUEs for TRT is multitudes higher than in the general age-matched cohort, several considerations must be taken into account. First, we must bear in mind that in certain cases, requests from athletes with, as examples, primary hypogonadnism, (albeit rare), certain pituitary disorders, transgender athletes, and testicular loss from IED explosions, need be entertained. 2. A TUE policy should be consistent and equal across a wide group of substances and medicines. TUE's are also utilized for substances other than testosterone and steroids, for conditions such as attention deficit and asthma.

Most notably, we must bear in mind that the blanket elimination of TUEs alone will not mean that PED usage and abuse will be reduced in these combat sports.

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