3 June 2021

Athletes sanctioned for low levels of diuretics can apply for ban elimination

Athletes who tested positive for low levels of six diuretics can apply for the elimination of bans, the World Anti-Doping Agency (WADA) has confirmed. Under Technical Letter 24, which came into force on 1 June, positive tests for acetazolamide, bumetanide, furosemide, hydrochlorothiazide, torasemide, and triamterene should not be treated as a positive test when the concentration of the substance in urine is below 20ng/mL. 

‘Where the case involves one or many of the six diuretics in question at a concentration equal to or below 20ng/mL, if the Athlete is still serving a period of ineligibility, he/she could apply to the Anti-Doping Organization that rendered the decision in order to benefit from the new provisions’, wrote a WADA spokesperson in an email. The reason for this change is because WADA now accepts that trace quantities of these six substances have been found in oral pharmaceuticals. In addition, a urinary concentration of less than 20ng/mL would not mask the presence of other Prohibited Substances in the sample, which is the main reason that diuretics are abused in sport.

WADA’s answer suggests that if an athlete returns a positive test for more than one of the six named diuretics, it will be treated as an adverse analytical finding (AAF) if the combined concentration in urine exceeds 20ng/mL. This prevents an athlete from using small amounts of each of the six named diuretics, if the combined concentration exceeds 20ng/mL in urine.

Complications for sport

The updated guidance could cause complications for sports and anti-doping organisations (ADOs) who have sanctioned athletes for anti-doping rule violations (ADRV) involving low levels of the six diuretics. In September 2020, Dzmitry Nabokau was sanctioned with a two year ban for an ADRV involving furosemide, after the Athletics Integrity Unit (AIU) of World Athletics refused to accept his explanation that a positive test was caused by mistakenly consuming his grandmother’s medication. 

Nabokau’s ADRV involved 17ng/mL of furosemide, so under WADA’s new guidance it wouldn’t even have been considered a ‘positive test’. The Belarusian high jumper would appear to have a case for his ADRV to be cancelled. It is debatable whether Nabokau – who competed in the Rio 2016 Olympics – would have a case against the AIU for keeping him out of the postponed Tokyo 2020 Olympics.

In August 2020, Natalіia Krol was sanctioned with a 20 month ban for an ADRV involving hydrochlorothiazide. The level of the diuretic in the Ukrainian middle distance runner’s sample was not disclosed, but the AIU accepted that her ADRV was due to prescribed medication. If the level of hydrochlorothiazide in her sample is below 20ng/mL, a ban that would keep her out of the postponed Tokyo 2020 Olympics should also be cancelled.

Earlier this year, the Association of National Olympic Committees (ANOC) cancelled a Silver medal won by Nigerian wrestler Miesinnei Genesis at the Qatar 2019 World Beach Games, due to an ADRV involving furosemide. The level of furosemide in Genesis’s sample was not disclosed but if it fell below 20ng/mL in urine, should her Silver Medal be reinstated?

Strictly speaking it shouldn’t, since the updated guidance only came into effect on 1 June this year. But if Genesis’s ADRV involved furosemide at levels below 20ng/mL, could an appeal calling for ANOC to reinstate her Silver Medal be justified?

Elena Gaddoni…

Similarly, the change in guidance could have implications for Andre Onana’s case. The Ajax goalkeeper appealed a 12 month ban issued by UEFA in February due to an ADRV involving furosemide, arguing that he had mistakenly taken his wife’s medication. Again, the concentration of furosemide wasn’t announced. 

Italy’s national anti-doping tribunal (TNA) recently postponed a case against Elena Gaddoni, who was provisionally suspended on 15 February after returning an AAF for acetazolamide. This was after WADA’s Executive Committee approved the new limits for diuretics on 21 May. The level of acetazolamide in her sample wasn’t disclosed, and her case will be heard tomorrow (4 June).

Adeline Bervoux

In January, the International Tennis Federation (ITF) sanctioned wheelchair tennis player Adeline Bervoux with a two year ban after an AAF for the same substance. She was taking acetazolamide for medical reasons but lacked a therapeutic use exemption (TUE). This perhaps suggests that the concentration of acetazolamide in her sample would have been higher than the trace amounts referred to in WADA’s updated guidance.

In June last year, the AIU decided against provisionally suspending Brazilian race walker Caio Bonfim, accepting that his AAF for bumetanide was the result of a contaminated product. In March this year, Indian boxer Ms. Ruchinka was sanctioned with a two year ban for an anti-doping rule violation (ADRV) involving furosemide. Again, the concentrations of the prohibited diuretics in urine were not announced, but this could explain the difference in sanctions.

Meat contamination – a fair solution

WADA’s new guidance regarding meat contaminants…

Alongside its updated guidance regarding diuretics, WADA also published Technical Letter 23, which relates to meat contaminants. However, WADA’s guidance here is more complicated, and doesn’t set a limit below which no ‘positive test’ will be recorded. However, it does change the evidential burden of proof regarding AAFs for clenbuterol, ractopamine, zeranol, and zilpaterol. 

To interpret WADA’s updated guidance regarding meat contaminants, it is necessary to understand that under anti-doping rules, an athlete is considered guilty of a doping offence unless they can prove their innocence. Previously, it was up to an athlete to prove that meat contamination was the cause of any positive test for any of the four meat contaminants. If they couldn’t prove that they weren’t at fault for their positive test, they could be sanctioned with a four year ban.

The Code requires all ADRVs to be vigorously pursued…

The sport or anti-doping organisation (ADO) pursuing the case was under no obligation to help an athlete discover the source of their positive test. Sport and NADOs are required to ‘vigorously pursue’ all ADRVs under the World Anti-Doping Code (see right). This led many to push for maximum sanctions against athletes for known meat contaminants. 

Whilst the requirement to pursue all ADRVs still exists, the new guidance requires sport and ADOs to shoulder the financial burden of exploring whether meat contamination is a possibility. Under the updated guidance, if an athlete reports a positive test for any of the above four substances that involves levels of 5ng/mL or below, then the sport or ADO will be obliged to investigate whether meat contamination is the likely explanation. 

This could help lower level athletes who do not have the financial resources to prove contamination. In 2019, UK Anti-Doping (UKAD) sanctioned an amateur rugby union player who had volunteered to take a doping test with a four year ban due to an ADRV involving clenbuterol at levels below 5ng/mL in urine. Mark Jones, a care assistant and junior rugby coach, appealed against his ban and on Christmas Eve 2020, his appeal was dismissed.

Jones maintained that contaminated meat bought from a Cardiff market was the reason for his positive test, but had no way (or money) to prove it. UKAD didn’t believe him and sanctioned him with a four year ban. Under WADA’s revised guidance, UKAD would be required to investigate if meat contamination was a likely explanation. It would be required to spend the money that Jones couldn’t afford.

In 2017, an American Arbitration Association (AAA) Panel argued that its ‘hands are tied’ into issuing a four year ban to Masters cyclist Tony Blazejack, who failed to prove that contaminated meat or supplements was the cause of his positive test. Under the new regime, if the concentration of clenbuterol fell below 5ng/mL in urine, the US Anti-Doping Agency (USADA) would have been able to consider a more lenient sanction, as it and the AAA accepted that contamination was the likely cause, but it hadn’t been conclusively proven.

There have been many other cases where athletes have argued that contaminated meat was the cause of their positive test. Perhaps the most famous is that of Alberto Contador, who lost his 2010 Tour de France victory and was banned for two years after returning an AAF for clenbuterol. Although the level of clenbuterol in his sample was 0.05ng/mL, subsequent investigation of a sample provided the day before his positive test revealed high levels of phthalates, indicating that he may have received a blood transfusion.

The CAS ruling in Contador’s case, concluding that supplement contamination was more likely than meat contamination…

Under the new regime, Contador’s sanction would still stand, as the international cycling union (UCI) would have been required to investigate Contador’s low level clenbuterol positive to determine if meat contamination was the likely source. As such, it is likely it would have made the same discovery regarding his high level of phthalates, and discounted his claim that meat contamination was to blame.

WADA’s guidance regarding potential meat contaminants is therefore cleverly constructed. It allows sport and ADOs to pursue ADRVs against elite athletes whom they suspect are doping, as a ‘meat contamination’ defence can still be investigated for credibility. For lower level athletes who do not have the financial resources to prove contamination, the new guidance prevents them from being railroaded into a four year ban. 

Help or headache?

WADA appears to have accepted that positive tests can be caused by contamination. ADOs will not have to relentlessly pursue ADRVs against athletes when both sides know – or at least suspect – that positive tests were caused by contaminated medication or meat. If a sport or ADO suspects that more than contamination is involved, they will still be able to investigate.

As those familiar with anti-doping will have noticed, contamination isn’t confined to medication and meat. Supplements, water, and even kissing have been found responsible for athletes reporting AAFs for prohibited substances. As the equipment used by anti-doping laboratories becomes more sensitive, ever smaller amounts of prohibited substances can be detected in athlete samples. For most of the substances that feature on WADA’s Prohibited List, any amount detected constitutes an AAF.

Contaminated water has also led to bans…

In Madisyn Cox’s case, the amount of trimetazidine detected in her urine was compared to ‘a pinch of salt in an Olympic size swimming pool’. Yet at 0.1ng/mL, this was twice as much as the amount of clenbuterol detected in Contador’s sample. Trimetazidine is an anti-ischemic – it isn’t a diuretic or meat contaminant. 

As such, despite the international swimming federation (FINA) accepting her evidence that the AAF was caused by a contaminated water supply, Cox was sanctioned with a two year ban. If she had tested positive for a diuretic, her positive test wouldn’t be considered an AAF. Given WADA’s acceptance that contamination is possible in medication and meat, why isn’t contaminated water also a possibility? 

Similarly in March last year, the CAS annulled a four year ban issued to Jarrion Lawson by the AIU, finding it ‘more than likely’ that an AAF to epitrenbolone was caused by contaminated beef. The anabolic steroid isn’t listed as one of the four meat contaminants in WADA’s guidance, suggesting that other prohibited substances can turn up in food. The full Decision has yet to be published by the CAS, but is available via doping.nl.

As such, WADA’s new approach to diuretics and meat contaminants could present a headache for sport and ADOs, especially if applied across the hundreds of substances covered by the Prohibited List. But it is fairer towards athletes, and for that WADA should be commended.

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