I have diabetes treated with pills, what next

Diabetes Treated with Oral Medications

Pilots diagnosed with diabetes mellitus that is adequately controlled by diet are considered to meet the FAA medical standards and are eligible for medical certification under the revised Part 67 medical standards. Federal Aviation Regulations disqualify the use of oral diabetes medication (or insulin) for medical certification. However, after initial clearance by the FAA, a special issuance authorization may be granted for all classes of medical certification. This authorization must be granted by the FAA  Aeromedical Certification Division (AMCD) in Oklahoma City. The AME is not authorized certify the airman without approval by AMCD when diabetes is controlled with medications. However, in cases of diet controlled diabetes without the use of diabetic medications, the aviation medical examiner may issue a certificate at the time of examination for diet-controlled diabetes if you have the supporting documentation.

For diabetes treated with medication you will need a current status report from your treating doctor that mentions the absence of significant medical or surgical complications including cardiac, vascular, renal, neurologic, or ophthalmologic disease, the letter must specifically indicate that you have had no hypoglycemic (low blood sugar) reactions on the current medications and all medications and their dosages should be reported in the letter. Completion of FAA form 8500-7 by your optometrist will be agequate to address information related to any visual changes secondary to diabetes.

·      A current report of hemoglobin A1C showing a plasma glucose level of less than 9% within the last 30 days. Additional blood tests consisitng of a a lipid profile and a metabolic profile within the past 60 days. The metabolic profile should be performed after an overnight fast and will include a fasting blood sugar and renal (kidney) function studies.

The number of different types of oral diabetes medications is increasing and this is an area of confusion for many airman as certain types of diabetic medications are permissible while others or certain combinations of medications are not.

Sulfonylureas stimulate beta cells within the pancreas to increase the production of insulin in order to lower glucose levels. Sulfonylureas include Glucotrol, Glucotrol XL, Micronase, Glynase, Diabeta and Amaryl.

Another class of medications that also affect the pancreas by increasing insulin production is the meglitinides. Prandin and Starlix are included in this group. The popular diabetes medication Metformin (Glucophage) is a part of the biguanides category of drugs. These drugs slow the release of glucose from the liver while increasing muscle tissue absorption of insulin, a combination that lowers glucose levels. Drugs categorized as thiazolidinediones also decrease glucose production in the liver and may be prescribed as Avandia or Actos. Liver function has to be carefully monitored when taking thiazolidinediones.

Alpha-glycosidase inhibitors, such as Precose and Glyset, help decrease glucose levels by interrupting the breakdown of starchy foods and certain sugars in the intestine, rather than having a direct effect on the liver.

Another drug,  Januvia helps your body increase the insulin made in the pancreas and decrease the sugar made in your liver to lower blood glucose. Januvia can be used as a stand-alone drug, or in combination with other diabetes medicines including metformin (Glucophage), rosiglitazone (Avandia), and pioglitazone (Actos).

To be clear, once you have been diagnosed with diabetes you are no longer eligible to exercise the privileges of you r pilot certificate until successfully completing the special issuance process. Following the initiation of a diabetic lowering medication a 60-day observation period to determine the occurrence of any side effects must be instituted. However, if the thiazolidenodione drug or Metformin has been used for at least 60 days when Januvia is added, there is a 14-day observation period after starting the Januvia.

Byetta and Victoza (liraglutide) injectable drug that helps the pancreas produce insulin more efficiently. The FAA allows Byetta alone and in combination with certain other diabetes medications as noted below: To avoid the risk of hypoglycemia (low blood sugar), pilots should not fly for two hours after each Byetta injection.

Byetta alone is allowed but requires 30 days after starting the medication before submitting an initial evaluation for special issuance consideration.

Byetta and metformin (Glucophage) in combination are permitted.

Byetta, metformin, and a beta blocker (blood pressure medication) in combination are permitted.

Byetta and a beta blocker in combination are permitted, but require a 14-day observation period after starting Byetta to watch for hypoglycemic side effects.

Byetta and a sulfonylurea-class drug in combination are permitted, but require 30 days of observation after starting Byetta to watch for hypoglycemic side effects).

Byetta and insulin in combination are not allowed.

Byetta, a sulfonylurea, and a beta blocker are not allowed.

In addition, some medications are not allowed in combination with beta blockers (ie Tenormin, Lopressor and others) a common class 0f medications used in the treatment of high blood pressure.

·      Disqualifying Medication Combinations.

·      The FAA accepts all oral hypoglycemic agents, but there are policy exceptions. The more recent medication Januvia (sitagliptin) can only be used with metformin and/or the thiazolidinediones. We also accept Januvia and both of the above medications. The FAA does not accept the use of Januvia and a sulfonylurea (Glucotrol, Glucotrol XL, Micronase, Glynase, Diabeta and Amaryl). If Januvia is being used as the initial treatment for diabetes, then the airman must wait for 60 days to be considered, but if it is being added to the medication regimen, then the airman need only wait 14 days.

·      Certification of airmen using meglitinides or sulfonylureas, along with beta-blockers is not permitted. Commonly used meglitinides include repaglinide (Prandin) and nateglinide (Starlix). Commonly used sulfonylureas include: acetohexamide (Dymelor); chloropropamide (Diabinese); tolazamide (Tolinase); tolbutamide (Orinase); glimepiride (Amaryl); glipizide (Glucotrol, Glucotrol XL); glyburide (DiaBeta, Micronase, Glynase); glyburide plus metformin (Glucovance); glipizide plus metformin (Metaglip).

·      Allowable Medication Combinations: Certification of airmen using the combination of a beta blocker with the following diabetes medications is permitted: alpha-glucosidase inhibitors [acarbose (Precose), miglitol (Glyset)]; biguanides [metformin (Glucophage)]; thiazolidinediones [pioglitazone (Actos)]; DDP-4 inhibitors [sitagliptin (Januvia)]; and incretin mimetics [exenatide (Byetta)].

Once a special issuance is obtained yearly reports will be required to sent to AMCD on an annual basis as a requirement of the special issuance.

Because diabetes is often associated with concurrent medical problems and certain multiple drug therapy may be prohibited I would recommend an in office consultation to discuss your case and review the required documentation prior to the performance of the actual medical examination to avoid unexpected certification issues.