More on Martin Maes' Doping Ban and the TUE Rule
Martin Maes and Dr. Clark Lewis Respond to UCI Ban
On June 26, EWS fans and racers the world over were shocked to hear Martin Maes had tested positive for a prohibited substance. The substance in question was Probenecid and while not considered a performance enhancing substance, it’s listed on the World Anti-Doping Agency’s “Diuretics and Masking Agents” prohibited list. The drug was prescribed to Maes by a volunteer doctor during the NZ Enduro. Maes had sustained a deep laceration to his shin that had become infected despite antibiotics. Soon after consulting the event doctors, the infected cut had become “potentially life-threatening,” probing doctors to administer Probenecid in conjunction with a higher dose of the antibiotic, Flucloxacillin.
In an effort to learn more about the situation and drug in question, I reached out to Martin Maes, the UCI and Whistler Emergency doctor, Clark Lewis. Martin, understandably upset, had little more to say on the situation and the UCI refused to comment any further. Dr. Lewis was very helpful.
Clark Lewis – Emergency Doctor with 14 Years Experience
Clark’s been riding throughout the Sea To Sky since 2003. He’s raced downhill, cross-country, and some enduro but now prefers to rip everyone’s legs off during full day excursions. He was also instrumental in the development of Chromag’s new Doctahawk frame. He’s been an emergency doctor in the area since 2005 and started working in Whistler on a part-time basis in 2007, and full-time since 2013. He also accompanied Red Bull's North of Nightfall crew to the arctic as their on site medic.
It’s no secret there are a lot of riders flocking to Whistler each year and with that, Clark has seen a disproportionate amount of mountain bike trauma while working there. That experience has seen him work regularly with Probenecid, which he uses on a daily basis with patients. He had some great insights on the Maes situation.
NSMB - What is Probenecid typically used for?
Dr Clark Lewis - We've used Probenecid literally every day to prolong the metabolism of antibiotics, just as in Martin's case—it's very, very common. In Whistler there are several people every day that come in once daily for intravenous antibiotics to treat their infected shin and elbow lacerations from bike crashes. Probenecid allows the antibiotics to be given once daily instead of three times, which is much better for "outpatient" treatment.
No matter how well these lacerations are scrubbed, the infection rate is high due in part to poor tissue vascularity—likely an evolutionary remnant from caveman days, so you wouldn't bleed to death defending yourself from people and animals trying to murder you.
Could Martin have accessed more than he was prescribed by the doctor?
Probenecid is prescription only, at least in the developed parts of the world. In some places it's used to treat gout by enhancing uric acid elimination, but we treat gout differently here.
In his situation, what options would you consider Martin Maes had aside from Probenecid?
We would have given Martin the same treatment, it’s very standard.
I’ve read that it needs to be taken in high doses of between 2–5g to prevent banned substance detection (Maes was prescribed 1.5g/day). Does that sound accurate to you?
I'm not familiar with using it to mask illegal agents. We give one gram orally, once daily with the intravenous antibiotic Cefazolin.
How long does Probenecid remain in the system?
Its half-life in plasma varies with dose, but it's generally thought to be 4–8 hours for the dosing we use, making it ideal for once daily dosing (5 half-lives generally takes the plasma levels down to very low levels). However, the half-life is long enough that you'd expect to detect trace amounts many days after stopping use. A pharmacist could shed more light on details around plasma concentrations.
Is there an alternative that could have been used, or would Maes have needed to pull out and head to the hospital?
There are alternative intravenous options, like once daily Ceftriaxone, but this is broader spectrum and generally overkill. There aren’t better oral options in this scenario.
Overall, this is a real bummer for Martin. Professional athletes must be extremely careful about what they ingest, almost to the point of paranoia. It would seem prudent these days to avoid any type of supplement (they're mostly bullshit anyway), and just eat good food, drink water and coffee and beer.
Martin is understandably upset by the UCI decision and probably wants it all to go away already. His responses here are short but there’s one area that keeps coming up and that’s the TUE (Therapeutic Use Exemption) filing.
The team statement notes that you and Mark Maurissen asked the medics whether Probenecid was banned but no one was able to confirm due to location. Did you consider checking once in a location with wifi access?
I followed the doctor’s advice without questioning what was prescribed because it was medically necessary to treat my wound, and nothing prescribed would aid or benefit my performance. In fact, it might have inhibited my performance. Yes, we should have researched these prescriptions more closely but in the moment, I was confident with the information I was given.
When did you take your final dose of Probenecid?
I followed the prescription per the doctor’s advice, taking the Probenecid as it was prescribed.
When was the TUE filed? Why was the TUE filed when it was?
We received the denial for the TUE on June 1st.
Would you have pulled out of the race if you knew you couldn’t take Probenecid?
Being healthy was my first priority. If I knew that I couldn’t have taken the Probenecid, I would have found alternative courses of treatment.
What are your thoughts on medics who work events having to know what is and isn’t banned?
All the medics and volunteer medics at these events are great. My doctor made the best decision for my health.
Do you think riders should be just as aware of banned substances?
If riders are taking a substance that they think might be questionable, it's up to them to do the appropriate research.
Is the suspension across disciplines?
What are your plans for the remainder of the year?
This situation was obviously not planned. I’ll be evaluating the timing and shift of my goals for the rest of the 2019 season.
Unfortunately it appears Maes will be the example that other athletes learn from. I reckon his peers have been hitting WADA’s Prohibited Substance list hard over the last week and possibly downloading whatever they can for later reference. While many have argued that it’s up to athletes and their teams to know what’s safe and what isn’t, I still believe medics at UCI sanctioned events should only be prescribing legal options. In Martin’s case, it was up to him and his team and it’s at similar events that aren’t under the UCI ‘brolly where competitors will need to take note in future.
An error was made by Martin and his team and they’re now paying the price with a 90-day suspension from racing. Whether we believe it's fair or not, it does appear, as other fans have speculated, that the TUE was filed later than the UCI would have preferred. I believe that it’s for this reason the UCI followed through with the penalty Maes has received, despite acknowledging the use was for valid health reasons. And while they acknowledge the use of Probenecid, they still claim other treatments were available. As Clark mentioned above, other treatments would have involved a trip to the hospital for intravenous treatment.