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Introduction
Since the inception of organised sports, doping, as defined by the World Anti-Doping Agency (WADA), 1 has been prevalent. Most prominent doping is the 'presence of a prohibited substance or its metabolites or markers in an athlete's sample'. 1 The substances and methods to be considered prohibited are defined by WADA's prohibited list, which is updated annually based on specified criteria. 1
Although prohibited substances and methods are clearly defined, their detection has limitations, and athletes who use a sophisticated approach can use drugs without detection throughout their career. 2 This is problematic, especially in view of the apparent existence of new medications with performance-enhancing properties and the potential to be misused for doping purposes. 3 One such example currently in the media worldwide is meldonium (Mildronate). Meldonium is an anti-ischaemic drug, 4 originally developed by the Latvian Institute of Organic Synthesis in the 1970s as a growth-promoting agent for animals. 5 'Mildronate is the leading agent of the cardiovascular group, anti-ischemic agent of a metabolic action (that) acts as anti-ischemic cell protector in patients with angina pectoris, chronic heart failure, brain circulation disorders (and) improves physical capacity and mental function in the case of ischaemia and in healthy people'. 6 Furthermore, the manufacturer reports no serious adverse side effects. Behind Latvia, the drug is currently registered for human therapeutic use only in Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Ukraine, Uzbekistan and Russia. Even though meldonium is not a new drug per se, it was added to WADA's prohibited list only in January 2016 after having been included in WADA's Monitoring Programme in January 2015. There were anecdotal reports of increased use of meldonium during the London 2012 Olympics and Paralympics which are supported by a very recent study that provides estimates of meldonium use during the Baku 2015 European Games. 7 Results showed that meldonium use was detected across 15 of the 21 sports across 46 of the 50 countries participating. Interestingly, Meldonium use should have been declared by the athletes as part of the doping control but was under-reported. Of 662 tested athletes, only 3% (n=23), of whom 13 won medals, self-reported having used the substance, although 8.7% (n=66) were identified by laboratories. In addition, even though meldonium is only registered for...