THE PROHIBITED LIST

Since 2004, and as mandated by World Anti-Doping Code, WADA has published an annual List of Prohibited Substances and Methods. The List identifies the substances and methods prohibited in- and out-of-competition, and in particular sports.

The List of Prohibited Substances and Methods comes into effect on January 1st of each year and is published by WADA three months prior to coming into force; however, in exceptional circumstances, a substance or method may be added to the Prohibited List at any time.

The Prohibited List is reviewed annually in consultation with scientific, medical and anti-doping experts to ensure it reflects current medical and scientific evidence and doping practices.

Under the IFBB Anti-Doping Rules, it is each athlete or other persons responsibility for knowing what constitutes an anti-doping rule violation and the substances and methods which have been included on the Prohibited List.

Therefore, it is essential that all athletes or other persons review carefully the 2021 Prohibited List, particularly in cases where they intend to use supplements or medication.

HOW DOES A SUBSTANCE OR METHOD MAKE IT TO THE PROHIBITED LIST?

The WADA Prohibited List may include any substance and methods that satisfy any two of the following three criteria:

  1. It has the potential to enhance or enhances sport performance;
  2. It represents an actual or potential health risk to the Athlete;
  3. It violates the spirit of sport (this definition is outlined in the Code).

Substances or methods which mask the effect or detection of prohibited substances are also prohibited.  In addition, a substance which has not been approved for human use is likely to be prohibited as well.

HOW ARE SUBSTANCES NAMED AND CATEGORISED ON THE PROHIBITED LIST?

WADA names substances according to the following convention:

  • For substances that have been given an International Non-proprietary Name (INN), as published by the World Health Organization, this name is used first.

Only when the commonly-used name of a substance is better known than the INN, this commonly-used name appear in parenthesis.

  • When the INN is not known, the International Union of Pure and Applied Chemistry (IUPAC) nomenclature is used, accompanied in some cases by the commonly-used name. As INNs are generated, the Prohibited List evolves with the addition of the INN and if deemed beneficial, the previous IUPAC name may be still included for a period of time.

Common examples of substances and methods are provided in all sections but these examples are not exhaustive.

PROHIBITED IN-COMPETITION

Subject to a different period having been approved by WADA for a given sport, the In-Competition period shall in principle be the period commencing just before midnight (at 11:59 p.m.) on the day before a Competition in which the Athlete is scheduled to participate until the end of the Competition and the Sample collection process.

PROHIBITED AT ALL TIMES

This means that the substance or method is prohibited In- and Out-of-Competition as defined in the Code. All prohibited substances in this class are Specified Substances.

Any pharmacological substance which is not addressed by any of the subsequent sections of the List and with no current approval by any governmental regulatory health authority for human therapeutic use (drugs under pre-clinical or clinical development or discontinued, designer drugs, substances approved only for veterinary use) is prohibited at all times.

SUBSTANCES OF ABUSE

Substances of Abuse are substances that are identified as such because they are frequently abused in society outside of the context of sport. The following are designated Substances of Abuse: cocaine, diamorphine (heroin), methylenedioxymethamphetamine (MDMA/ecstasy), tetrahydrocannabinol (THC).

An extensive section of Questions and Answers about the Prohibited List can be found at:

PROHIBITED LIST Q&A

The substances and methods on the 2021 WADA Prohibited List are classified by different categories:

S0

NON-APPROVED SUBSTANCES

S1

ANABOLIC AGENTS

S2

PEPTIDE HORMONES, GROWTH FACTORS, RELATED SUBSTANCES AND MIMETICS

S3

BETA-2 AGONISTS

S4

HORMONE AND METABOLIC MODULATORS

S5

DIURETICS AND MASKING AGENTS

S6

STIMULANTS

S7

NARCOTICS

S8

CANNABINOIDS

S9

GLUCOCORTICOIDS

M1-M2-M3

PROHIBITED METHODS

Anabolic steroids

Misuse of supraphysiological doses of anabolic steroids is claimed to have serious side effects. The causes of premature death among the powerlifters are suicide, acute myocardial infarction, hepatic coma and non-Hodgkin’s lymphoma. These findings add to the growing amount of evidence of an association between anabolic steroid abuse and premature death, and support the view that measures to decrease AAS misuse among both competitive and amateur athletes are justified.

Among anabolic steroids, the drugs most frequently taken (often orally, sometimes intramuscular) are: stanozolol, oxandrolone, testosterone, oxymetholone, oxymesterone, and nandrolone, which is probably the most widely used. Various cardiac adverse events have been reported with the use of these drugs: cerebral thromboembolism due to intraventricular thrombi, myocardial infarction without coronary thrombus, sudden death due to hypertrophic cardiomyopathy and myocarditis during sports activity; a particular, reversible form of hypertrophic cardiomyopathy has also been observed.

 Peptide hormones, stimulants, narcotics, anabolic agents, mimetics, diuretics, masking agents

Cardiac arrhythmias are among the most important causes of non-eligibility to sports activities, and may be due to different causes (cardiomyopathies, myocarditis, coronary abnormalities, valvular diseases, primary electrical disorders, abuse of illicit drugs).

The list of illicit drugs banned by the International Olympic Committee and yearly updated by the World Anti-Doping Agency includes the following classes: stimulants, narcotics, anabolic agents (androgenic steroids and others such as beta-2 stimulants), peptide hormones, mimetics and analogues, diuretics, agents with an antiestrogenic activity, masking agents.

Almost all illicit drugs may cause, through a direct or indirect arrhythmogenic effect, in the short, medium or long term, a wide range of cardiac arrhythmias (focal or reentry type, supraventricular and/or ventricular), lethal or not, even in healthy subjects with no previous history of cardiac diseases. Therefore, given the widespread abuse of illicit drugs among athletes, in the management of arrhythmic athletes the cardiologist should always take into consideration the possibility that the arrhythmias be due to the assumption of illicit drugs (sometimes more than one type), especially if no signs of cardiac diseases are present. On the other hand, in the presence of latent underlying arrhythmogenic heart disease including some inherited cardiomyopathies at risk of sudden cardiac death, illicit drugs could induce severe cardiac arrhythmic effects.

 Beta-2-agonists

The commonly used beta-2-receptor agonists are: salbutamol, salmeterol, formoterol, terbutaline and clenbuterol. The IOC considers them as “anabolic agents” and “stimulants”, used to increase the muscle mass and physical strength. Beta-2-agonists may induce ventricular and supraventricular ectopic beats, as well as focal and reentry arrhythmias, supraventricular and ventricular, especially in subjects with underlying cardiomyopathies and in case of concomitant administration with other drugs.

 Growth hormone and insulin-like growth factor

They are widely used in the exogenous recombinant forms (rhGH and rhIGF-I) by athletes as anabolic agents, to increase the muscle mass, cardiac performance and stamina on the job, even though the real effect on muscle strength is still subject of debate. Up to now no side effects related to GH abuse are clearly known, but a significant increase in mortality was reported among patients submitted to treatment for catabolic diseases. With regard to athletes taking these drugs for a long time and at high dosages the following side effects are possible: systemic disorders such as myalgia, asthenia, headache, arthralgia, diabetes mellitus, thyroid disorders, acromegaly, metabolic ionic alterations, hypertension and various types of cardiomyopathies (hypertrophic or dilated), similar to those observed in acromegaly. All these conditions may contribute, to a variable extent, to the development of different types (focal or reentry) of supraventricular and ventricular arrhythmias, which are often found in athletes.

 Diuretics

Diuretics are classes of heterogeneous substances prohibited by the IOC. Diuretics are often taken to mask the assumption of other drugs excreted in the urine: the purpose is to attempt to dilute those drugs the cut-off urinary concentration of which is evaluated in tests for doping control (e.g., stimulants, narcotics and anabolic steroids such as nandrolone, methandienone metabolites, methyltestosterone, stanozolol). The administration of diuretics may cause arrhythmias due to hypokalemia and dehydration. Moreover, these arrhythmias may be particularly severe in case of underlying primary or “toxic” cardiac diseases.

Stimulants

Besides cocaine, this group encompasses many other drugs, in particular amphetamines (ephedrine, methylephedrine, pseudoephedrine, caffeine and related substances), widely used among competitive athletes for their well-known effects: performance enhancement, increased level of aggressiveness, better standing of strain perception. Stimulants may cause focal and reentry arrhythmias, ventricular and supraventricular ectopic beats, atrioventricular nodal reentry tachycardia, focal atrial tachycardia, atrial fibrillation, ventricular tachycardia and fibrillation.

Their assumption may prove particularly hazardous in athletes with the Wolff-Parkinson-White syndrome (even in the subgroups of Wolff-Parkinson-White patients previously considered at low risk) because of the increase in atrial and ventricular excitability and the shortening of the accessory pathway refractoriness, with possible consequent fast atrial fibrillation and ventricular fibrillation.

Erythropoietin

EPO enhances oxygen transfer and tissue availability, increasing its arterial blood concentration, by raising the hemoglobin and red cell levels. In the bone marrow it stimulates erythroid precursors (but also regulates apoptosis), according to the physiologic inputs of oxygen requirements from the interstitial renal tubular cells. The long-term use of rhEPO and darbepoetin is characterized by many side effects. The increase in the total number of red cells leads to a rise in blood viscosity, which in athletes could be further exacerbated by natural perspiration during intense athletic performances. Besides, due to their actions on the endothelium and platelets, the thromboembolic risk could be increased in predisposed subjects, with cases of hypertension, myocardial infarction and stroke. This could be associated with the potential development of serious hematologic disorders such as acute leukemia, polycythemia and marrow aplasia.

Cannabinoids

Cannabis has a potential impact on the health of athletes as well as on performance in both training and in competition. Some synthetic cannabinoids have some substances that induce the reddening of the conjunctivae, increased pulse rate and xerostomia. Other reported effects of synthetic cannabinoid use include tachycardia, paranoia, agitation, hallucinations, vomiting, alterations in mood and perception, and a sense of being impaired.

Glucocorticoids

It provides a sensation of strength and stamina on the job, improving exercise duration. The side effects in case of long-lasting treatments are corticosteroid-like and include obesity, hyperglycemia, osteoporosis, immunodeficiency, hypertension, and metabolic disorders. Arrhythmias may result mainly from cardiac hypertrophy, metabolic and ionic disorders.