Deanne Panya, an apprentice jockey, has been sanctioned with a one-month ban after returning an adverse analytical finding (AAF) for hydrochlorothiazide, raising questions as to whether some sanctioning authorities are issuing bans before adequately considering how the diuretic and masking agent may have ended up in the athlete’s sample. Many athletes who have been sanctioned for hydrochlorothiazide deny ever taking the substance, and have gone to great lengths in attempting to establish the source of their AAF.

While the circumstances of the cases vary considerably, sanctions issued to athletes who have been unable to establish the source of the hydrochlorothiazide present in their sample range from one month to two years. It also appears that athletes from ‘western’ nations are being given lesser sanctions – perhaps due to a better understanding and analysis of how the substance can present itself in an athlete’s sample.

Hydrochlorothiazide is a diuretic and masking agent prohibited under Section S5 of the World Anti-Doping Agency’s (WADA) Prohibited List. Diuretics are often abused by athletes to excrete water for rapid weight loss and to mask the presence of other banned substances. Diuretics can mask other prohibited substances by increasing urine volume, thereby diluting the presence of any other substances present in a urine sample.

Inadvertent contamination?

While both of the reasons outlined above constitute a valid reason for abuse of hydrochlorothiazide, Panya argues that she had never heard of the substance before being informed of her AAF. ‘Ms Panya pleaded guilty to a charge under AR81A(1)(a) in that a sample taken from her was found to contain the diuretic hydrochlorothiazide, a substance banned under AR81B,’ read a statement from Racing New South Wales. ‘Stewards were not able to determine the cause of the findings’.

“I have no idea, it’s not like I took anything,” Panya told G1X.com.au. “I had never heard of the word, I didn’t even know what a diuretic was when they asked me. I asked, ‘Am I am diabetic?’, when they first said it to me. It just didn’t click at the time because I’m not familiar with the word.”

The arguments presented by Panya appear to be similar to those presented by Xinyi Chen, who tested positive for hydrochlorothiazide at the Rio 2016 Olympics. However, unlike Panya, Chen lost her fourth-place finish in the 100m butterfly and received a two-year ban. She also argued that she had never taken the substance and in a ruling at the Court of Arbitration for Sport (CAS), argued that ‘deliberate spiking or accidental contamination’ could have been the cause of her AAF.

However, despite asking the WADA-accredited laboratory in Rio to test the other substances she had been taking, she was not able to establish the cause of her AAF. These were:

• Ubiquinol BioActive;
• Liposomal Methyl B12;
• Chelated Mineral;
• Mega Antioxidant;
• Active Calcium;
• Leci PA-II;
• A Chinese vitamin containing phosphatidyl cholines;
• Levonorgestrei;
• Azithromycin Dispersible Table;
• Chinese Donkey Skin Gelatin;
• Brown Sugar Cube;
• Johnson’s Baby Oil.

In the CAS ruling, Professor Moutain Wu, the head of the WADA-accredited laboratory in Beijing argued that there was a lack of harmonisation regarding the limits of determination (LOD) for hydrochlorothiazide in different laboratories, which ‘may have raised a question of fairness when LOD was so low for a specified substance’, i.e. hydrochlorothiazide.

‘Due to the lack of detailed information for the contamination with HCTZ [hydrochlorothiazide], which is emerging, anti-doping agencies need to be aware of this problem and deal with AAF cases to protect the athletes from inadvertent doping’, warned Professor Wu. Evidence was also presented by Paul Scott of Scott Analytics, who submitted a report arguing that given the non-diluted urine samples of Chen, the levels of hydrochlorothiazide present could not have been used for performance-enhancing purposes or as a masking agent.

The CAS ruled that the athlete could not rebut the established presence of hydrochlorothiazide in her body. ‘This panel has not been given such consistent alternative explanation for the ingestion of a prohibited substance’, reads the ruling. ‘A mere assumption or speculation without any corroborating evidence, e.g. that the Athlete daily drank water from the pipe in Rio and that this water is contaminated with HCTZ, does not meet such requirement. Contamination in drinking water or meat or other nutrition would presumably lead to more than just one athlete being found with HCTZ in her body’.

As such, the CAS said that the question of the possible source of the substance ‘should be considered by FINA when dealing with the responsibility of result management in terms of sanctions beyond Rio 2016’. However, the Fédération Internationale de Natation (FINA) appears to have issued Chen with a two-year ban without considering this. The full FINA Doping Panel decision is one page long and does not appear to consider the merits of the case.

Alexander Varakin, a Kazakh swimmer, appears to have borne the brunt of a similar approach, and was also issued with a two-year ban. Likewise, Brazilian footballer Fred was issued with a backdated one-year ban, despite the player, Brazilian national team and his club arguing that he had never taken the substance.

The Brazilian football confederation (CBF) sent a list of medications that the Brazilian team would be taking to the organisers of the 2015 Copa America before Brazilian footballer Fred reported an AAF for hydrochlorothiazide. The diuretic was not on the list, and Fred’s club – Shakhtar Donetsk – also denied responsibility for the AAF. As Fred was unable to explain the source of hydrochlorothiazide, he was also given a backdated one-year ban, which expired on 27 June last year.

In contrast, Dawn Harper-Nelson, who won gold in the 100m hurdles at the 2008 Beijing Olympics, was issued with a three-month ban this week after being able to establish that her AAF was due to blood pressure medication used to treat hypertension. Similarly, US gymnast Kristen Shaldybin escaped a ban after establishing that she ingested hydrochlorothiazide through tap water obtained from the municipal water supply.

Conclusion

Sanctions relating to hydrochlorothiazide appear to be erratic, with some anti-doping organisations (ADOs) considering and accepting athlete explanations that their AAF could be the result of contamination, whilst others are issuing a standard ban. It appears that some ADOs are not adequately considering how the substance may have ended up in an athlete’s sample. However, it is difficult to know this for certain when ADOs issue a standard ban without delving into the specific circumstances of each particular case.

However, the Panya, Chen, Fred and Shaldybin cases appear to illustrate that contamination is a growing problem when it comes to hydrochlorothiazide AAFs. As Professor Wu warns in the Chen case, anti-doping agencies need to be aware of this issue and deal with AAF cases to protect athletes from reporting inadvertent AAFs due to hydrochlorothiazide.