Item 18k: Diabetes

My Flight Surgeon

Sr. Aviation Medical Examiner
This is one of a series of posts about medical issues potentially affecting a pilot’s ability to obtain a medical certificate. In this series, we will look at common problems seen by the AME, review the requirements the FAA has to consider allowing one to fly and discuss what you need to do to expedite consideration by the FAA to allow you to fly. We plan to go through all of the medical history items in Section 18 on the front of Form 8500-8 over the next several months.



I would suggest that if you are unsure of how to answer these questions in Item 18, you discuss them with your AME before you complete the form. Some things may not be significant while others will require explanation.



Item 18.k. Diabetes



Diabetes is a disease that affects small blood vessels and subsequently the eyes, heart, kidneys, brain and eventually the legs. The FAA wants pilots with this or any other disease to control and manage their disease process thus limiting any disability that may arise.



If there is a history of diabetes, the applicant should describe the condition to include, symptoms and treatment. Comment on the presence or absence of hyperglycemic and/or hypoglycemic episodes. A medical history or clinical diagnosis of diabetes mellitus requiring insulin or other hypoglycemic drugs for control are disqualifying.



We are discussing diabetes mellitus, the common form of diabetes, in this thread. There are three large categories the FAA has defined for diabetes; 1) diet controlled diabetes, 2) type 2 diabetes controlled with oral medications, and 3) diabetes controlled with insulin. This later category applies only to Class 3 medical certificates. The FAA is not granting Special Issuance for Class 1 and 2 medical certificates to insulin dependent diabetics.



Diabetes Mellitus, Diet Controlled: As always, the airman must submit medical records and the results of appropriate studies to document the status of the disease. If there is no glycosuria and the Hgba1c is normal, the AME may issue the medical certificate. The protocol for evaluation of these pilots is: Applicants with a diagnosis of diabetes mellitus controlled by diet alone are considered eligible for all classes of medical certificates under the medical standards, provided they have no evidence of associated disqualifying cardiovascular, neurological, renal, or ophthalmological disease. Specialized examinations need not be performed unless indicated by history or clinical findings.



Diabetes Mellitus Type 2, Medication Controlled: The initial medical certificate after the diagnosis is made requires approval of the FAA. The initial Authorization determination will be made on the basis of a report from the treating physician. For favorable consideration, the report must contain a statement regarding the medication used, dosage, the absence or presence of side effects and clinically significant hypoglycemic episodes, and an indication of satisfactory control of the diabetes. The results of an A1C hemoglobin determination within the past 30 days must be included. Note must also be made of the presence of cardiovascular, neurological, renal, and/or ophthalmological disease. The presence of one or more of these associated diseases will not be, per se, disqualifying but the
disease(s) must be carefully evaluated to determine any added risk to aviation safety.




Subsequent medical certificates may be issued by the AME if the FAA has issued an Authorization to do so. An Examiner may re-issue a subsequent airman medical certificate under the provisions of the Authorization. Re-issuance of a medical certificate under the provisions of an Authorization will also be made on the basis of reports from the treating physician. The contents of the report must contain the same information required for initial issuance and specifically reference the presence or absence of satisfactory control, any change in the dosage or type of medication, and the presence or absence of complications or side effects from the medication. In the event of an adverse change in the applicant's diabetic status (poor control or complications or side effects from the medication), or the appearance of an associated systemic disease, an Examiner must defer the case with all documentation to the AMCD for consideration. If, upon further review of the deferred case, AMCD decides that re-issuance is appropriate, the Examiner may again be given the authority to re-issue the medical certificate under the provisions of the Authorization based on data provided by the treating physician, including such information as may be required to assess the status of associated medical condition(s). The guideline follows:



Examiners may re-issue an airman medical certificate under the provisions of an Authorization, if the applicant provides the following:

An Authorization granted by the FAA;


A statement attesting that the airman is maintaining his or her diabetic diet;


A statement regarding any diabetic symptomology; and


The results of a current HgA1c level performed within last 90 days.


The Examiner must defer to the AMCD or Region if:

The applicant has been placed on insulin;


The HgA1c level is greater than 9.0 mg%; or


The applicant has developed cardiovascular, neurological, renal and/or ophthalmological disease.


It is important to note that should their medication be changed or the dosage modified, the applicant should not perform airman duties until the applicant and treating physician has concluded that the condition is:

under control;


stable;


presents no risk to aviation safety; and


consults with the Examiner who issued the certificate, AMCD or the Regional Flight Surgeon.


An applicant who uses insulin for the treatment of his or her diabetes may only be considered for an Authorization for a third-class airman medical certificate.



Diabetes Mellitus, insulin controlled: The FAA is not granting Special Issuance for Class 1 and 2 medical certificates to insulin dependent diabetics. For Class 3 medical certificates, the decision regarding issuance of the medical certificate lies with the FAA. Consideration will be given only to those individuals who have been clinically stable on their current treatment regimen for a period of 6-months or more. Consideration is not being given for first or second class certification. Individuals certificated under this policy will be required to provide substantial documentation regarding their history of treatment, accidents related to their disease, and current medical status. If certificated, they will be required to adhere to stringent monitoring requirements and are prohibited from operating aircraft outside the United States.



The following is a summary of the evaluation protocol and an outline of the conditions that the FAA will apply:



Initial Certification

1. The applicant must have had no recurrent (two or more) episodes of hypoglycemia in the past 5 years and none in the preceding 1 year which resulted in loss of consciousness, seizure, impaired cognitive function or requiring intervention by another party, or occurring without warning (hypoglycemia unawareness).

2. The applicant will be required to provide copies of all medical records as well as accident and incident records pertinent to their history of diabetes.

3. A report of a complete medical examination preferably by a physician who specializes in the treatment of diabetes will be required. The report must include, as a minimum:

a. Two measurements of glycosylated hemoglobin (total A1 or A1c concentration and the laboratory reference range), separated by at least 90 days. The most recent measurement must be no more than 90 days old.

b. Specific reference to the applicant’s insulin dosages and diet.

c. Specific reference to the presence or absence of cerebrovascular, cardiovascular, or peripheral vascular disease or neuropathy.

d. Confirmation by an eye specialist of the absence of clinically significant eye disease.

e. Verification that the applicant has been educated in diabetes and its control and understands the actions that should be taken if complications, especially hypoglycemia, should arise. The examining physician must also verify that the applicant has the ability and willingness to properly monitor and manage his or her diabetes.

f. If the applicant is age 40 or older, a report, with ECG tracings, of a maximal graded exercise stress test.

g. The applicant shall submit a statement from his/her treating physician, Examiner, or other knowledgeable person attesting to the applicant's dexterity and ability to determine blood glucose levels using a recording glucometer.

Monitoring and Actions Required During Flight Operations

To ensure safe flight, the insulin using diabetic airman must carry during flight a recording glucometer; adequate supplies to obtain blood samples; and an amount of rapidly absorbable glucose, in 10 gm portions, appropriate to the planned duration of the flight. The following actions shall be taken in connection with flight operations:


1. One half hour prior to flight, the airman must measure the blood glucose concentration. If it is less than 100 mg/dl the individual must ingest an appropriate (not less than 10 gm) glucose snack and measure the glucose concentration one half hour later. If the concentration is within 100 -- 300 mg/dl, flight operations may be undertaken. If less than 100, the process must be repeated; if over 300, the flight must be canceled.

2. One hour into the flight, at each successive hour of flight, and within one half hour prior to landing, the airman must measure their blood glucose concentration. If the concentration is less than 100 mg/dl, a 20 gm glucose snack shall be ingested. If the concentration is 100 -- 300 mg/dl, no action is required. If the concentration is greater that 300 mg/dl, the airman must land at the nearest suitable airport and may not resume flight until the glucose concentration can be maintained in the 100 -- 300 mg/dl range. In respect to determining blood glucose concentrations during flight, the airman must use judgment in deciding whether measuring concentrations or operational demands of the environment (e.g., adverse weather, etc.) should take priority. In cases where it is decided that operational demands take priority, the airman must ingest a 10 gm glucose snack and measure his or her blood glucose level 1 hour later. If measurement is not practical at that time, the airman must ingest a 20 gm glucose snack and land at the nearest suitable airport so that a determination of the blood glucose concentration may be made.

Subsequent Medical Certification

1. For documentation of diabetes management, the applicant will be required to carry and use a whole blood glucose measuring device with memory and must report to the FAA immediately any hypoglycemic incidents, any involvement in accidents that result in serious injury (whether or not related to hypoglycemia); and any evidence of loss of control of diabetes, change in treatment regimen, or significant diabetic complications. With any of these occurrences, the individual must cease flying until cleared by the FAA.

2. At 3-month intervals, the airman must be evaluated by the treating physician. This evaluation must include a general physical examination, review of the interval medical history, and the results of a test for glycosylated hemoglobin concentration. The physician must review the record of the airman's daily blood glucose measurements and comment on the results. The results of these quarterly evaluations must be accumulated and submitted annually unless there has been a change. (See No. 1 above - If there has been a change the individual must report the change(s) to the FAA and wait for an eligibility letter before resuming flight duties).

3. On an annual basis, the reports from the examining physician must include confirmation by an eye specialist of the absence of significant eye disease.

4. At the first examination after age 40 and at 5 year intervals, the report, with ECG tracings, of a maximal graded exercise stress test must be included in consideration of continued medical certification.

*Italicized text from FAA documents
 
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