Abebe Aregawi, the 2013 women’s 1500m world champion, has been provisionally suspended after Meldonium was found in her A sample. Days later, Endeshaw Negesse, the 2015 Tokyo marathon with a personal best of 2:04.52, was also banned after reportedly testing positive for the same substance. This news came in the same week that Solomon Meaza, the general secretary of Ethiopia’s anti-doping agency, told the Associated Press that nine of the country’s runners, five of them “top athletes”, are under investigation for doping. Aregawi represents Sweden, but was born and resides in Ethiopia, and Negesse is also Ethiopian.

2013 world 1500m champion, Abebe Aregawi, tested positive (A sample) for meldonium

Meldonium is an anti-ischemic drug used clinically to treat angina, myocardial infarction and chronic heart failure. It is manufactured in Latvia under the commercial name of Mildronate and is one of the countries largest exports, with turnover reaching EUR 65 million in 2013. It is not yet approved by the FDA for use in the USA.

Meldonium was added to the WADA list of banned substances on January 1st, 2016 because of “evidence of its use by athletes with the intention of enhancing performance.” Therefore, none of the athletes banned for this substance will have performances prior to that date removed from the records and Aregawi will keep her 2013 world title.

The process by which WADA adds a substance to the banned list involves the substance first being placed on the WADA monitoring program. The addition of a substance to the monitoring program usually comes about as a result of athlete statements and any other evidence that WADA collects. The “other evidence” in this case was that WADA repeatedly detected Meldonium in urine samples during the validation of their new high resolution/high accuracy mass spectrometry multi-target screening assay. A peak at 147.1128 appeared in the MS spectra of many but not all urine samples during the validation process, indicating that the peak represented an exogenous substance. WADA determined that this peak indicated the presence of Meldonium. This evidence, coupled with athlete statements on sample use control forms reporting the use of Meldonium, led to the addition of Meldonium to the WADA monitoring program a year prior to its ban, on January 1st, 2015.

All substances on the monitoring program are evaluated to determine whether they have performance enhancing effects and, if deemed necessary, anti-doping tests for these substances are developed.

The WADA monitoring of Meldonium involved:

A literature review of the research conducted on the mechanism of action of Melodonium and its effects on sports physiology.

Development of an easily repeatable, accurate and reliable test for Meldonium

Analysis of 8320 random doping control urine samples for the presence of Meldonium.

The literature review showed that Meldonium is an effective anti-ischemic drug with further applications in immunomodulation and in the treatment of neurodegenerative disorders and bronchopulmonary diseases.

Meldonium is a structural analogue of the carnitine precursor, gamma-butyrobetaine. Carnitine is a key regulator of fat metabolism, since it is required to transport fatty acids into the mitochondria for fatty acid breakdown via beta-oxidation. Meldonium affects carnitine metabolism by inhibiting its biosynthesis and transport and this protects mitochondria from an overload of Fatty Acid metabolites. Meldonium also increases gene expression related to glucose metabolism and thereby stimulates the aerobic oxidation of glucose (2).

Meldonium decreases the beta-oxidation of fatty acids and shifts cellular metabolism towards the oxidation of carbohydrates, which requires far less oxygen per ATP molecule than beta-oxidation of fatty acids. This sparing of oxygen could be of huge benefit under hypoxic conditions. The most obvious benefits have been seen in the treatment of ischemic heart disease, but there is evidence to suggest that Meldonium could be equally beneficial under the low oxygen conditions induced by intense endurance exercise (3).

One review (4) of the effects of Meldonium on exercise performance listed the following benefits:

Decreased levels of lactate and urea in blood

Improved economy of glycogen: level of glycogen increased in the cells during the long-lasting exercise

Increased endurance properties and aerobic capabilities of athletes

Improved functional parameters of heart activity

Increased physical work capabilities

Increased rate of recovery after maximal and sub-maximal loads

Activates CNS functions and protects against stress

A published human research study (5) on the effects of Meldonium on sports performance used Russian judokas and gave them a dose of 0.5-1.0 g twice a day before training, as a 14-21 day course during the training period 10-14 days before competition. Some of the above effects published in the review article were reported from this study. Unfortunately, quite a lot of the research into this topic is only published in Russian (6). Another Russian study, translated into English, showed a significant improvement in the swimming of rats after Meldonium supplementation (1).

WADA decided that there was enough evidence to investigate further as they developed two separate tests for Meldonium, which has the chemical name 3-(2,2,2-trimethylhydrazine)propionate dihydrate. Both tests use a urine sample – the first is easily compatible with current tests carried out for other substances in anti-doping laboratories and could be used to screen large numbers of samples, whilst the second is more specific to Meldonium and could unequivocally determine its presence in a sample (4).

Using these two tests in combination, a total of 8320 random doping control urine samples covering different classes of sport either from in- or out-of-competition were analyzed for the presence of Meldonium. 182 positive Meldonium findings (2.2%) in a concentration range between 0.1 and 1428 μg/mL were detected and confirmed using the more sensitive assay (4). This is shown in the graph below.

Figure 1. Mildronate findings in official doping control samples (n = 8320) and distribution between in‐ and out‐of‐competition samples (IC/OOC), gender (f = female; m = male) and type of sports (team sports, endurance sports, strength sports, others) (4)

This data, along with the several bans that have arisen since Meldonium was placed on the banned list on January 1st, indicates that the use of Meldonium is fairly widespread and I expect to see several more cases in the coming weeks and months. Besides track and field, there has also been a confirmed positive case in cycling for Eduard Vorganov, the Katusha former Russian national road champion and 19th place Tour de France finisher, who was an important dometique rider for Joaquim Rodriguez in his 2nd place finish in last years Vuelta a Espana. There have also been 2 positives for fairly high-profile Ukranian biathletes. Given that the drug is manufactured and distributed mostly in Eastern Europe, I expect most positive cases to come from athletes in that region. It is being reported that a Ukrainian doctor may have been involved in the transportation of the substance into Ethiopia (7) so we may see more positives from Ethiopian athletes too.

Katusha Rider, Eduard Vorganov, banned for Melodonium

I hope this article goes someway into showing how a substance can be added to WADA list of prohibited substances. It is clear to me that WADA is underfunded and is currently fighting a losing battle. They need a better network of intelligence so that they can more quickly identify the new substances that athletes are using/misusing. There should be better channels for anonymous athlete informants. Then they need more manpower in the laboratories so that tests can be developed more quickly. Adding substances to the banned list just once a year, on January 1st, is not enough. They should be added as soon as there is even an indication of a performance enhancing effect, or else the drug cheats will always be one step ahead, in their ever-changing, ever-expanding “grey area”.

References

Baulin SI, Rogacheva SM, Afanaseva SV, Zabanova EV, Karagaycheva YV. Pharmaceutical Composition for Improving Physical Working Capacity. Bull Exp Biol Med. 2015 Nov;160(1):45-8.

Dambrova M, Makrecka-Kuka M, Vilskersts R, Makarova E, Kuka J, Liepinsh E. Pharmacological effects of meldonium: Biochemical mechanisms and biomarkers of cardiometabolic activity. Pharmacol Res. 2016 Feb 2. pii: S1043-6618(15)30171-7.

Dzintare M, Kalvins I. Mildronate increases aerobic capabilities of athletes through carnitine-lowering effect. Curr. Issues New Ideas Sport Sci. 2012, 5, 59.

Görgens C, Guddat S, Dib J, Geyer H, Schänzer W, Thevis M. Mildronate (Meldonium) in professional sports – monitoring doping control urine samples using hydrophilic interaction liquid chromatography – high resolution/high accuracy mass spectrometry. Drug Test Anal. 2015 Dec;7(11-12):973-9.

Kakhabrishvili Z, Chabashvili N, Akhalkatsi V, Skhirtladze T, Chutkerashvili T. Mildronate effect on physical working capacity among highly qualified judokas. Ann. Biomed. Res. Edu. 2002, 2, 551.

Petrova VV, Petrov AA, Rukavishnikov IV. Cytoprotectors and their application in sports medicine. Med Tr Prom Ekol. 2013;(9):22-6