Pilot Protection Services Medical Mailbag- May Q&A

QUESTION: I would appreciate some clarification; is there a difference between drugs to treat and depression? My doctor has started me on Alprazolam for temporary assistance with some problems I was experiencing. Is it okay for me to be taking this medication and retain my right to fly? If I get off the Alprazolam soon, do I wait 90 days and then proceed with due process with FAA? 

ANSWER: When a medicine is released by a pharmaceutical company, they will have conducted studies to demonstrate it is safe and efficacious for one or more medical indications and those studies will have characterized how long and at what dose the drug should be delivered. Once it is in the market, doctors will expand the utility and adjust dosing based on their personal experiences and studies performed not by the company, but by other doctors. For instance, a medication originally developed to treat high blood pressure was subsequently found to be great at controlling certain forms of tremor and headaches!  

Many drugs are used for multiple indications, in fact, probably half drug use out there is for problems never studied by the company. FAA is interested in both the condition and the drug and great care needs to be taken when starting a new medication. In fact Alprazolam or XANAX is an unacceptable medication under all situations because it has sedative effects.  If you are only going to be on this medication Va short period of time you should continue to take the medication under care of your doctor. The medical certification people at FAA have reduced the duration that an airman must be off the medication until they can apply for reconsideration and it is now 60 days, but you must not fly until then or while on the medication.  If you were to  be changed over to one of the 4 SSRI (selective serotonin reuptake inhibitors) that FAA finds acceptable, you would need to be taking the med for a full 12 months before you could be considered and then only after obtaining a whole slew of tests and evaluations. This is why Pilot Protection Services is such a great tool as the folks at AOPA can steer you through these perilous waters. 

QUESTION: I really enjoy the mailbag and am in the process of re-obtaining my special issuance after a hiatus of not flying for 5 years.  Back in 2009, I had my special issuance for a mild heart attack (myocardial infarction) and the placement of a stent to open up one of my coronary arteries in 2005.  I have obtained my 3rd Class Medical and my application is current deferred until the FAA receives current laboratory work and a stress treadmill (Bruce protocol) test results from me. 

My question for you is whether the Bruce protocol test standards have changed.  The FAA sent me a specification sheet describing the “protocol for evaluation of coronary heart disease”.  As I remember from before, this protocol describes the “maximal ECG treadmill stress test” achieving “100 percent of maximal predicted heart rate…”.  But, nowhere on this specification does it refer to the 9-minutes any more.  It does describe the following:  “The blood pressure/pulse recordings at various stages and actual electrocardiographic tracings must be submitted.  Tracings must include a rhythm strip, a full 12-lead ECG recorded at rest (supine and standing) and during hyperventilation while standing, one or more times during each stage of exercise, at the end of each stage, at peak exercise, and every minute during recovery for at least 5-minutes or until the tracings return to baseline level”. 

I would hate to have my test run, as described above, and completed in 8 minutes…and have the FAA tell me that I did not do the test long enough. 

Thoughts?  I just want my cardiologist to order the right scenario for me so that I only have to do this once.  I’m sure looking forward to getting back in the air!  

ANSWER: Thanks for the compliment! As you well know - but for the benefit of other readers -a heart attack occurs when one or more arteries supplying blood to heart muscle gets blocked and muscle cells die. Stents are used to prop the vessel open to improve blood supply. FAA wants to ascertain how well your ticker works when exposed to stress, in this case using physical exercise, and the "Stress Test" measures a bunch of parameters that can predict how well the heart is performing. 

To answer your question, the stress test protocol for the FAA has not changed.  They still expect a maximum exercise stress test to 100% of predicted maximum heart rate (or as close to that as you can get.)  The Bruce is three stages, each of 3 minutes for a total of nine minutes.  However, for pilots age 70 and over, the FAA allows completion of two stages of exercise, or six minutes as an absolute minimum, as long as at least 85% of predicted maximum heart rate is achieved.  Maximum HR is determined by 220 minus age = maximum predicted rate. Hope this helps and welcome back to the wonderful world of aviation! 

QUESTION: It appears that I’ll have to have a total left knee replacement in the near future.  What will I need to bring to my Aviation Medical Examiner post-surgery as part of my 3rd class medical renewal process?  

ANSWER: As we age, and especially in the very active or overweight population - or just bad luck - the cartilage lining our joints wears out and the synovial fluid that serves to lubricate movement is not sufficient to prevent bone-on-bone friction. This causes pain, swelling, reduced range of motion and can be really debilitating. Think about a reciprocating engine that is allowed to run without sufficient oil and you will get the picture.  

The good news is that one can now replace the defective joint either partially or totally and the results are splendid in the vast majority of people; the most common complaint after surgery is "I wish I had done this sooner!" In general a Total Knee replacement will not require a special issuance (waiver). However you should bring a copy of the operative report and a letter when your treating orthopedic surgeon releases you to your AME when you have your next exam.   

QUESTION: I want to be sure I have this right:  I have had a minor stroke.  Is my medical automatically on hold for 2 years or can I appeal for reinstatement sooner? 

Am I okay to fly as a Light Sport Pilot (LSA) at this time if my personal physician releases me?  

I really want to keep flying for pleasure and as my local club has LSA aircraft I am hopeful I do not have to  mess with FAA if not necessary.

ANSWER: A stroke occurs when brain tissue dies, most commonly either because an artery supplying blood to the brain is blocked or bursts due to a wall weakness called an aneurysm. "Transient Ischemic Attacks" (TIA) can presage a stroke and should be taken very seriously - if you or a loved one has a period of facial droopiness, arm (or leg) weakness, difficulty with undertanding or making conversation or any fleeting blindness (amaurosis fugax) treat this very seriously and get to an emergency room immediately. 

In general, an airman who has a stroke cannot be considered for special issuance for two-years.

At the time of reconsideration you will require a complete neurological evaluation, a cardiovascular evaluation, a Maximal Bruce Protocol stress test (see letter above), an echocardiogram (looking for signs in the heart that another stroke is a possibility) and an ultrasound of the carotid arteries in the neck (looking for signs of blockage that might also indicate another stroke is a possibility). If any of these tests were done during that two year period they will be acceptable. 

You may fly Light Sport aircraft if your treating physician feels you are able.  

Best of luck to you!

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