This will have done my Pink Bike Fantasy Enduro team no good at all! :0(

Both Martin and Mark asked if the medications I were permissible for racing. I informed them that probenicid has no performance enhancing effects, and as far as I was aware was not a prohibited substance for racing. I checked this with Dr Balance, as well as Dr Sam Grummitt (another of the race doctors), neither of whom were aware that probenicid was a prohibited substance.

So one rider, one manager and three doctors couldn’t find out if it was okay to take probenicid. Someone needs a bollocking for this mess.

Two clicks will get you to https://www.wada-ama.org/sites/default/files/wada_2019_english_prohibited_list.pdf

And keep a local copy on your phone before prescribing to athletes?

And keep a local copy on your phone before prescribing to athletes

My first thought but, as pointed out by shaley on the previous page, not a uci race so really no onus on the race doctors to know.

More to the point though, if it was your livelihood, would you not keep a copy?

And keep a local copy on your phone before prescribing to athletes?

Doctors should have no blame whatsoever. It is down to the athlete.

BruceWee

Do we want to end up in the situation where riders are refusing treatment because they are worried about not getting a TUE? If Maes had died because of this would you still have the same opinion?

No – but what he should have done (or, realistically, what his team manager should have done) is call USADA and say “Hi, Martin as been given these three drugs as an emergency treatment – is that a problem?” and if WADA say it’s a problem, then you look for a TUE. You declare the stuff you took, not fail a test and then provide an explanation.

It’s harsh, really harsh, but its up to the athlete to make sure any medication is ok to take, or ina case like this, declared so that you can get the TUE.

Looking at Maes and how balanced he is, I reckon he is probably just a bit pissed off at the situation, but glad he hasn’t risked losing his leg to infection. I also think (and can see from his post) that he agrees that he cannot race in the interim, and is pretty much ok with that.

Shit happens. People getting all high and mighty on an Internet forum, well, everyone’s got to have a hobby. Some of us even ride bikes.

Some of us even ride bikes.

:-0 Get off to Mumsnet you weirdo. Ride bikes indeed..

Weird one for me – sounds like total chaos

I’d have said that probenecid is THE (historically) definitive masking agent and pretty much any sports doc ought to know that.
OK, I’ll buy the “urgent” aspect but why not provide him with a letter for UCI/wada saying that he’s taken this for good reasons and please test his blood not piss for the next few races if it’s on the list?

I don’t work in New Zealand but I’ve seen plenty of emergency/trauma treatment of contaminated wounds. Not sure I’ve ever seen that combination. Can’t believe they couldn’t come up with be than that, oral or a once daily iv – in fact, why don’t the authorities have a treatment guideline – must be plenty of similar injuries at every event ?

tbh i seem to be the only one that thinks its the right decision.

the fact that hes failed a test and then they have applied for an exemption is not the correct way to do it. Had he submitted one before then fair enough but why wait until youve been caught?

what he should have done (or, realistically, what his team manager should have done) is call USADA and say “Hi, Martin as been given these three drugs as an emergency treatment – is that a problem?” and if WADA say it’s a problem, then you look for a TUE. You declare the stuff you took, not fail a test and then provide an explanation.

This, It is harsh on an honest athlete, but I think it has to be to stop holes in the application of the regulations that less scrupulosity athletes would abuse.

The unfortunate penalty of trying to keep the sport clean is that honest clean athletes will always be inconvenienced to some extent, and sometimes technically fail to adhere to the regulations. But that is the price that has too be paid.

I suspect that there has been quite a bit of dodgy stuff going on in the EWS for a while now, which is why they decided to get into bed with the UCI and make use of their drug testing protocols.

I’m not entirely convinced by this particular situation – it’s funny how no one ever says ‘it’s a fair cop’ – there’s always a story, often involving doctors and mistakes.

JP

This whole story is fishy AF and everyone rushing to Maes’ defence is weird.

I’m a doctor. I’ve treated infections and cellulitis in the UK but I fully accept that I’m not an expert in antibiotic prescribing. So take this as is.

1) Probenecid is not a commonly used antibiotic for skin/ soft tissue infections. In fact, I’d never heard of it being used for this indication. It is described in medical journals from the 80’s but it is not common practice in the UK. It’s not only not first second third or fourth line – it’s not even on the radar. It not even in the BNF.

Perhaps that’s different in other countries where access to hospitals is different. As I said I’m not an expert.

2) The ostensible reason fro prescribing it is to slightly increase the levels of flucloxacillin in the blood. You’d achieve this FAR more predictably with IV Abx.

3) I find the narrative that there was no way of checking in >48 hours completely implausible. They don’t have phones? It’s nonsense.

4) If I was a doctor, and a high profile athlete / the leader of the EWS came to me with a “limb threatening” (their description) leg infection, the first thing I’d be doing is sorting out hospital admission for IVs.

The whole thing stinks and I’m glad he’s got a ban. It’s becoming clear that doping is a real problem in our sport.

The explanation given is wanting to avoid an IV and hospital admission so he could continue to race IIRC. Stubborn racer meets volunteer doc at low key event leading to suboptimal management of a cut is quite plausible. Getting popped for having a masking agent in your system when you are doing some other high level cheating is amateur hour. Which of the two f&%$ ups is more plausible 😀

@superficial

You are a doctor, but you admit to not being an expert in antibiotic prescription, which you then go on to prove by saying:

1) Probenecid is not a commonly used antibiotic for skin/ soft tissue infections.

You are right because it isn’t an antibiotic at all. And you would know from the doctor in question’s letter that it was prescribed to enhance the effects of the actual antibiotic by making it stay in the blood for longer (if my knowledge is correct). Keeping an antibiotic in the blood to treat a bloody tissue infection seems quite logical to me.

It is a balls up, of that there is little doubt. He seems pretty much at peace with the sanction and the particular drug in question seems an unlikely thing to take for nefarious purposes other than to act as a masking agent for something else.

You are a doctor, but you admit to not being an expert in antibiotic prescription, which you then go on to prove by saying:

1) Probenecid is not a commonly used antibiotic for skin/ soft tissue infections.

Yes, good point. I should have used the word ‘adjunct’ in there somewhere.The point is: it’s not a commonly used drug for this indication.

In case this was a regional thing, I did a quick google search to see if there was anything specific to NZ. I only found this:

At present there is only a theoretical benefit in the combination of oral flucloxacillin with probenecid as there is no published evidence that treatment with this combination is more effective than treatment with flucloxacillin alone.

Link= https://bpac.org.nz/BPJ/2015/June/cellulitis.aspx

Keeping an antibiotic in the blood to treat a bloody tissue infection seems quite logical to me.

It may well be logical to you, but that doesn’t mean that it actually works in the body, or that it’s a normal thing for a doctor to do. For example, one can use doses of Flucloxacillin intravenously at four or even eight times the dose of the standard oral tablets AND the IV form isn’t subject to first-pass hepatic metabolism. If your first-choice antibiotics aren’t working (2 days isn’t really long enough to tell BTW) then you switch to something else. I’ve never heard of anyone using this combination in routine practice. EVEN IF the infection was indeed ‘limb threatening’ and EVEN IF he refused hospitalisation against medical advice, IV antibiotics could have been arranged, or a switch to any number of other antibiotic regimes that don’t involve drugs used by cheats. Please see the link above for various options suggested by the NZ authorities.

the particular drug in question seems an unlikely thing to take for nefarious purposes other than to act as a masking agent for something else.

Eh? That’s the whole reason it’s banned. It makes other drugs like steroids (and many others) undetectable, or less detectable/fall below threshold concentrations etc.

Even if you believe that it’s plausible this was all an accident, don’t be fooled into thinking this is a benign drug. Some Daryl Impey nonsense.

Let me offer an alternative narrative: Athlete takes drugs. <Possible extra step: Athlete discovers he has a urine test upcoming which will inevitably be positive.> Takes masking agent. When the test for said masking agent comes back positive, he cooks up some excuse involving a small cut on his leg.

I’m a doctor. I’ve treated infections and cellulitis in the UK but I fully accept that I’m not an expert in antibiotic prescribing. So take this as is.

I’m a clinical pharmacologist, I’ve worked with drugs and drug interactions and at least one well-known athlete 😉 . Probenecid reduces the renal clearance of antibiotics that are otherwise cleared relatively rapidly. It is coadministered to prolong the effects of other drugs. There are other examples of therapeutic drug interactions (e.g. hiv)

It’s an unfortunate mishap, nothing more. The athlete will have had the opportunity to explain the adverse finding. This explanation was accepted and the punishment given. If there was any nefarious suspicion it would have been two years.

I’m a clinical pharmacologist, I’ve worked with drugs and drug interactions and at least one well-known athlete

I will certainly concede that you probably know more about the action of this drug than I do and its implications.

But I can’t understand why such an atypical regime was considered in the first place. It’s so far from standard practice it’s mental. Big red flag.
They couldn’t check the WADA list? Big red flag.

If there was any nefarious suspicion it would have been two years.

It’s all about plausible deniability, though, isn’t it? Case in point: that Daryl Impey thing I linked to. It’s complete nonsense (apparently he was buying some empty capsules (why) and the Pharmacist had probenecid on his hands!) but it’s a story that allows riders to carry on and avoid yet another scandal for the UCI while sort of making it inconvenient for drug cheats so perhaps they’ll give up one day.

Superficial

Member

It’s all about plausible deniability, though, isn’t it

Getting injured then infected in a rainforest and treated by someone that isn’t your own doctor and is volunteering for the race is a hell of a long way to go to get plausible deniability…

I’m not party to the Impey case, but would imagine that much of the defence will have rested on presentation of other capsules also contaminated with probenecid from the same pharmacist. I’m sure that preparation of his defence will have investigated all avenues. Exoneration is unusual under strict liability. That’s why Maes has to serve a ban. It’s why Yates did too. Inadvertent use of a banned substance is not a defence. It’s mitigating of the punishment.

Edit. Worth a read on Impey
https://www.google.co.uk/amp/s/cyclingtips.com/2014/10/saids-uci-confirm-daryl-impey-probenecid-case-wont-be-appealed-to-cas/amp/

Probenicid is old school; that’s what nearly scuppered Delgado in the 1988 Tour Dr France. Wikipedia suggests it was used by some athletes as a masking agent for steroids.
I’m surprised at the “we had no idea…” line in the linked report. Any halfway competent athlete or sports doctor would be looking up the list to check anything they are taking.

I’ve watched enough episodes of House to know that if the antibiotics aren’t working you then put the patient on a broad spectrum antibiotic.

There are some very good and informative comments on the pinkbike interview with Martin Maes. Some suggesting that the masking agent shouldn’t have been in his system/detectable by the Tasmania round of the EWS if the timeline of the doctor is correct and as Superficial has already mentioned, some doctors casting doubt on why this would be prescribed if Martin was in the state he was in.

I really want to believe this and Graves and Rudes failed tests are part of a learning curve for EWS racers and management who aren’t used to checking everything that they are prescribed or every supplement they take, but there is a whiff of bullshit that just won’t go away.

Getting injured then infected in a rainforest and treated by someone that isn’t your own doctor and is volunteering for the race is a hell of a long way to go to get plausible deniability…

That is my thinking too. This doesn’t sound like a ridiculous story concocted after the event like a lot of drug cheats go in for.

Although on the other hand (@superficial)……

Eh? That’s the whole reason it’s banned. It makes other drugs like steroids (and many others) undetectable, or less detectable/fall below threshold concentrations etc.

You posted that in response to something I posted:

the particular drug in question seems an unlikely thing to take for nefarious purposes other than to act as a masking agent for something else.

What I posted was stupid. I thought it at the time, but yesterday was a long day and I sort of gave up. I was talking crap there.

I still think Maes is not a drug cheat, though.

There’s a lot of falsehood being peddled and accusations being thrown around so it’s hard not to jump in to heated debate in defence of the Doctors involved.

However there’s a a few things worth noting.

The nature of the backcountry races in NZ is such that you cannot e-bike between stages on forest tracks or roads. The NZ enduro stages are extremely technical (think hard Golfie tracks, slippery Grizedale roots.

The doctors involved are volunteers taking holiday and weekends away from family to be involved and support the races in NZ. They are not supported or trained by the UCI, they take their own, medical kits and ride their own bikes around the course. They’re not “race doctors”.

I don’t know where they stay after each days racing at the NZ Enduro but it’s quite likely they didn’t have reception for a prolonged period.

(been trying to reconcile this on the plane home from my hollibobs, just in case anyone cares. apologies for the bump otherwise)

I still think the assembled docs ought to have known about probenecid’s “sporting” heritage. I also think he and his management were daft not to speak to the authorities when they could, at the earliest possible point – after all, the docs said “we don’t know and we can’t check” which is not the same as “it’s fine”.
IMO It’s either fishy or he’s incredibly unlucky to have found several docs with an interest in sport but who didn’t know this shit, added to a lax personal and managerial attitude to doping control.

I can see how a doc with limited resources might end up there but see above

I can not see how UCI/WADA/whoever could ignore this or be any more lenient than they have been

However (workings below):

Seems that in NZ, probenecid has been advocated along with beta-lactams (penicillin & its cousins) for skin infections by at least one kosher-looking agency LINK , so maybe this doc would be more likely to consider it than a UK-based prescriber
(… who would virtually never do so for a skin infection – I speak from many years of experience in NHS hospitals and with a specialist interest in infection. “Nobody” here does this for cellulitis IME).

The NZ agency in the link don’t advocate probenecid with oral flucloxacillin, preferring instead to go for an injectable antibiotic because … reasons:
Oral absorption of many drugs and definitely of fluclox is incomplete (a bit variable in relation to the presence of food in the stomach/intestine but generally considered to be only around 50% (or absolute max 80%) of it being absorbed after a normal dose (250mg to 500g four times per day), probably lower percentage if you give a 1 or 2gram dose)). The extra possible “loss” due to first-pass metabolism – where the liver sees the drug before it reaches the rest of the body and can remove some, is LOW with this drug, getting on for negligible.

I don’t doubt for a moment that probenecid would increase and “prolong” the levels of fluclox in the blood (i.e. delay the rate of the drop in concentrations between doses – and this bit can be crucial in the case of effectiveness of fluclox and other beta-lactams). Fluclox is principally removed by the kidneys and probenecid blocks/slows that process, which is why it works to mask drug use by keeping other organic acids out of your urine too.

Whether that translates to better efficacy is arguable, but in a UK hospital Maes’d have likely been given (if he got injectable fluclox, and he may well have done) enough to produce levels in the blood that would be at least as high and potentially double that likely to be achieved after 2g three times a day by mouth. Just to be sure. (We’d probably have given him 2g, four times daily i.v.)

Additionally, if the “patient” is a very fit, young athlete, in strenuous competition and quite likely hydrating heavily using “sportopiss” or whatever, then actually they are at higher risk of the drug levels falling more rapidly because they likely have healthy kidneys and will be perfusing them well, at least while recovering between efforts.

… so if a doc (in the middle of a NZ forest) was presented with a rider who refused to stop riding, insisted on having an oral drug and had a potentially limb-threatening infection in a deep, contaminated wound in tissue, some of which may be at least partly dead/dying due to impact damage and interruption of blood supply, then I wouldn’t blame them for wanting high levels of “some drug” in the body and if it was a penicillin then levels have to remain high for a large proportion of the dosing interval (T>MIC around 70% for all the pk:pd fans out there).

Me, I’d have wanted “more cover” to deal with anaerobic organisms in a deep’n’mucky wound as described in the doc’s statement since fluclox isn’t that effective against anaerobes nor in poorly perfused tissue, so I wouldn’t simply have upped the dose of my original choice (even though the initial dose was a bit low)

It’s been fascinating reading all the medical knowledge on this thread. My initial reaction to the story was outrage but after reading further, not a UCI event, volunteer doctors (massive respect for these guys), and communication issues where the race was held, I have come to the conclusion that Martin and his team got this badly wrong.

The medical team acted as best they could at the time and appear to have given factual information to Martin. Martin and GT made the right call in taking the doctors orders to enable him to carry on, but, they dropped a massive bollocks in not checking the banned list once possible and then submitting a TUE when it became apparent that the substance was banned.

Waiting for a positive test to react is asking for trouble.  The UCI have got this right as far as I’m concerned.  Maes has raced DH so knows how the UCI operate and GT should be extremely well versed in how anti  dropping controls work.

A 90 day ban is a slap on the wrists and a good reminder for all the riders to get their acts together. Cycling has been massively damaged by doping and we surely don’t want to see issues like the biscuit dodgers have.

Again, great illuminating thread.

I still think the assembled docs ought to have known about probenecid’s “sporting” heritage.

If you read the Pink Bike article he says he’s basically an experienced emergency doctor, not a sports specialist, so there’s no particular reason why he’d be steeped in the history of sports doping. He should have checked yes and the rider should have checked, but they both screwed up because people are human and make mistakes even though expert posters on a cycling enthusiasts forum thing that makes them either ‘fools’ or ‘cheats’.

I’d say the UCI has been pretty reasonable. It acknowledges that there wasn’t any intention to cheat, but that the rules have been broken, so it’s reasonable that the rider is punished.

Anyone who really believes that he staged an accident so he could use a masking agent is in tin foil hat territory. Not least because if you were going to do that, you’d actually apply for a TUE otherwise you’d test positive for the masking agent, which is what happened.

I’m not sure why some posters seem so outraged by it all. He made a mistake. He got caught. He’s been punished. He doesn’t seem to have gained any performance advantage from the whole affair other than his leg not getting hideously infected. What’s the problem?

If you read the Pink Bike article he says he’s basically an experienced emergency doctor, not a sports specialist, so there’s no particular reason why he’d be steeped in the history of sports doping. He should have checked yes and the rider should have checked, but they both screwed up because people are human and make mistakes even though expert posters on a cycling enthusiasts forum thing that makes them either ‘fools’ or ‘cheats’.

Fair enough, though if you read the page I linked to (which is for NZ
GPs, not sports specialists) it says in a boxed comment, right along with the bit about not recommending it with oral antibiotics:

Probenecid is prohibited at all times by the World Anti-Doping Agency and should not be prescribed to elite athletes as it may be used as a masking agent.

Anyone who really believes that he staged an accident so he could use a masking agent is in tin foil hat territory. Not least because if you were going to do that, you’d actually apply for a TUE otherwise you’d test positive for the masking agent, which is what happened.

I don’t think anyone’s suggesting he’s staged an accident to use a masking agent.
The race organisation need to look at their staffing if (as the linked Pink Bike story suggests) they had three doctors providing medical support to a sporting competition, none of them knew it was a banned substance, and none of them had access to the proscribed list so they could check. Lack of a phone signal is not really an excuse.
Even allowing for all that, if they were prescribing a treatment whose legality they were unable to verify, why did they not fill out a TUE by default, instead of just assuming it would be OK?

I think some people need to have a reality check, about what a race “organisation” is for such an event, it is not some **** professional corporate set-up, it is a few volunteers, the doctors will probably just be parents of competitors or a community spirited GP. They are no more likely to know the list of banned substances than the old biffer your mum goes to complaining about her bunnions.

I hope this doesn’t result in highly educated volunteers such as doctors etc. not wanting to cover events.

People do understand that this happened in the NZ enduro and not the EWS, right? Would you expect the doctors at ‘ard Rocks to know about masking agents?

I tend towards cock up over conspiracy with this, but I bow to the analysis of the forum experts throwing out accusations of fool or liar

There’s been some good debate here so far. But there’s also been some posts removed where the debate was put to one side in favour of personal insults. If you notice your post has gone then consider yourself defacto warned.

Play the ball, not the player.

Interesting comment/angle on it from an ER doc working in Whistler, backs the use of probenecid in the situation and appears to be used frequently in Whistler.

https://nsmb.com/articles/martin-maes-and-dr-clark-lewis-respond-uci-decision/

I hope this doesn’t result in highly educated volunteers such as doctors etc. not wanting to cover events.

Could easily be a real issue if someone wanted to get lawyer-happy with any volunteers. I suspect though that the Docs will end up educating themselves and that the race organiser will make efforts to keep the doctors informed, so that they don’t put off the pro’s from coming.

Thanks for the info scaredypants. I can’t say if any of the NZ doc involved were GP’s (we all one Dr. Jerram is not) so can’t comment on whether they would have been likely to have come across that. All we know is that they discussed it, they concluded “not” or “probably not” and no one remembered to check afterwards.

I can absolutely understand how the UCI have reached their conclusion, I’m just aggrieved that it’s to the detriment of racing and my opinion of fairness and sportsmanship.

/edit – I didn’t explain some of my earlier comments well. On these races, you can not get by with a St Johns ambulance parked up on the forest road or a retired GP stood by their car – the doctors have to be capable of riding the entire course safely and efficiently with their kit.

Interesting comment/angle on it from an ER doc working in Whistler, backs the use of probenecid in the situation and appears to be used frequently in Whistler.

Also interesting in that article is every time he mentions it, its mentioned along side IV antibiotics not oral. (in order to alow once daily not 3x treatment [so folks can still ride I assume])

He actually says there isn’t a better oral alternative (though it’s not clear if that’s to IV or probenecid)

I’ve worked in the Nelson/Marlborough region of NZ and can confirm that Probenecid is part of the normal antibiotic guidelines there. I understand doctors from other parts of the world may not have heard of this treatment regime, it was new to me when I moved there.

MM should’ve done his homework about what he allowed into his body, but people implying cheating because they aren’t familiar with this use for Probenecid should, IMO, be ashamed.

As others have mentioned, the doctors covering these events do so out of love of the sport. They don’t get paid and donate their time, expertise and even their own equipment willingly so that these events can happen safely. There are several races in NZ which wouldn’t be viable if they had to pay the going rate for medical cover. I’ve no doubt the guys in this instance feel terrible about what has happened. It was a really unfortunate oversight, nothing more.

Think blaming the doctors and saying they should know is a bit harsh. If it’s not a UCI event and they are volunteering in their own time then why should they know.

Imagine in other sports. Say a big fell race such as 3 peaks could feasibly have some top level athletes that get tested as part of the trail or mountain running scene. Some poor at Johns ambulance guy is not to be expected to know the full banned list.

Athletes responsibility, as soon as had reception, checked to see if on list or not. If it was Tue. Not wait till tested then ask for a tue

So, MM was winning then gets a ban. Richie Rude is back from a ban. Be interesting to see just how competitive RR is and how competitive MM is when he gets back.

Sadly, now anyone winning by a big margin just seem implausible.

Are these guys tested out of season while training, or just in the race season ?

Be interesting to see just how competitive RR is

He’s already won his first race by 19s , so, pretty much right back up there.