Pilot Protection Services Medical Mailbag- May Q&A

QUESTION: My family has a history of high cholesterol. If I need to start using medication for this condition, will I need to self-ground during any period or will my next medical be cause me to be grounded for anytime? 

ANSWER: Good on you for thinking about such things – abnormal blood lipid levels (it is a bit more complicated than just “high cholesterol” – check out our prior articles on the topic) are a leading cause of cardiovascular disease, but one that can be addressed by diet, weight loss, exercise and yes, medications. As we have noted on several occasions in the past, the use of cholesterol lowering medication needs to be reported in Block 17(a) of the FAA medical history and the AME needs to comment on whether you have had any side effects.  This condition does not result in a waiver nor must you report the results of current cholesterol levels.  To be safe, if you are placed on a new medication, you should ground yourself for 72 hours.  The next time you have an FAA examination performed you can report the new medication.

QUESTION: What impact does taking Metformin (500mg/day) have on my Class III medical?

ANSWER: Metformin is a medication commonly used to treat diabetes that the FAA accepts, but the medical condition will determine whether the airman will require a special issuance.  So, it depends on the medical condition. Since it is commonly used to treat Type II diabetes mellitus and if this is your condition you need to ground yourself for 60 days and report this to the FAA.  You will also need to provide the FAA with the results of a hemoglobin A1C level at the time of your reporting.  You can locate the information your treating physician needs to provide from the AOPA medical certification website. They state that: “An applicant with a diagnosis of diabetes mellitus controlled by use of a medication may be considered by the FAA for an Authorization of a Special Issuance of a Medical Certificate (Authorization). Following initiation of medication treatment, a 60-day period must elapse prior to certification to assure stabilization, adequate control, and the absence of side effects or complications from the medication.

The initial Authorization decision is made by the AMCD and may not be made by the Examiner. An Examiner may re-issue a subsequent airman medical certificate under the provisions of the Authorization.

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.

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, however, you are being treated for a “pre-diabetes” condition with Metformin this is considered by the FAA as a CACI (Condition that AME Can Issue). That means that your AME can issue you without a special issuance providing you provide a letter from the treating Doc that notes why he placed you on this medication and comments on any side-effects of the medication.  You will still need to obtain a hemoglobin A1C level.   

QUESTION: I have had kidney stones in the past and have declared them to the FAA.  They gave me a special issuance and had requirements to have scans and a report from my Urologist to make sure that I was free of stones.  They dropped the requirement for reporting a few years ago.  I had a recent KUB done for another purpose; my doctor found retained stones in my kidney again.  I had them removed by lithotripsy and they went in and removed all of the debris.  My Urologist confirmed by a post KUB that they are all removed.  I am going to see my AME soon – can he issue a new medical or does it have to be deferred to the FAA?  Is there any possibility that they will deny my next medical since I have had multiple bouts of kidney stones? 

ANSWER: Kidney stones are a common source of grief and one that airman write to us about frequently and that we have addressed on several occasions – check out “My favorite pie” in the March 2012 edition of AOPA Pilot Magazine or online. 

Once an airman has passed kidney stones and they can demonstrate that they do not have retained stones, this will not result in a special issuance.  You must report all of this to the FAA at the time of your next examination.  You will need to provide all the information that you list in your history including how you presented and the results of the x-rays(KUB stands for “kidney, ureter, bladder” and refers to the type of X-ray view a doctor will request)  or scan studies. Lithotripsy means literally to “smash stones” either by a directly applied medical device or sound waves delivered from outside the body (“Extracorporeal Shock Wave Lithotripsy” or ESWL) and you will need to provide what kind of lithotripsy was used on you and on what date as well as the results of the follow-up radiology.  You will also need the results of all lab tests that they performed to include the results of the stone analysis.  Since this is at least your second bout of kidney stones, your AME should phone the doctors at the FAA to get a verbal clearance to issue you a medical.  You can elect to report all of this to the FAA prior to your next medical examination and obtain a clearance directly from the FAA. Then, you can hand carry the letter to your AME at the time of your exam. 

QUESTION: I am a 59 year old private pilot and weigh 210lbs. I have a special issuance for Inflammatory Bowel Disease and have been in remission for 5 years. My 3rd class medical is due in shortly and I was recently diagnosed with mild-to-moderate sleep apnea. I do not have a sleep problem during the day or feel tired, but my wife reports irregular breathing during sleep time. I promptly grounded myself pending an understanding of this and getting my "homework" done on this condition.  

Any advice on this problem? Should I ground myself? Should I let my 3rd class medical certificate laps? Are there alternatives to CPAP? (Continuous Positive Airway Pressure) 

ANSWER: Firstly, glad to hear you are doing well with your inflammatory bowel disease – sometimes the steroids used to treat Crohns Disease or Ulcerative Colitis can cause one to put on weight, although chronic conditions like this are often debilitating and cause weight loss.

Sleep apnea literally means one is not breathing for periods of time during sleep and is often, but not always, a reflection of being overweight and FAA has developed guidance on this. 

For Sleep apnea, you need to obtain a special issuance and must provide the FAA with the original sleep study, which is called a “Polysomnogram.” 

If you are overweight, slimming down can help resolve this condition and there are surgical options to effectively “put a pleat” in the upper part of the airway. Additionally, there are a host of dental appliances that claim to thrust the lower jaw forwards and hence support the airway. 

However, CPAP, or similar devices are commonly used and use positive pressure to keep the airway open. Yes, it is a bit of an inconvenience to wear a mask at night but the modern machines are quiet and unobtrusive and for many patients it is the best treatment for this condition.   

Once you have had the initial titration on the device, you should begin to  wear the device for at least two weeks. All CPAP machines these days have a smart card in the device that saves all the data each night. At the end of the two week period take the card and have it read. The FAA policy guidelines are that you must wear the device for a minimum of 75% of days and for an average daily use of 6 hours.  This readout is easy to obtain and providing that result for the month or several weeks each year to comply with the special issuance would be all you needed to do. 

The FAA does accept the use of a dental device, but you will need to obtain a letter from your Sleep Specialist each year that affirms that you are not having any daytime fatigue.  

QUESTION: I have retired from flying commercial aircraft requiring a First Class Medical and now only need a class II or class III medical. I have a Special Issuance for a previous single stent procedure after a heart attack. In previous 1st Class medicals, I accomplished a stress treadmill and every other year I also had a nuclear injection test. I was required to achieve 100% of my heart rate for my age on the treadmill and accomplish the first three phases of the Bruce protocol.

I would like to know what the specifications are for a Class II or Class III medical and how they differ from a Class I. I assume I still require a treadmill every year but at what level of heart rate and Bruce protocol? Is a nuclear stress test still required? How about Light Sport flying? Thank you in your assistance in explaining these requirements. 

ANSWER: Pleased to hear that you were obviously rapidly treated and got a good result and trust that you are taking good care of yourself. 

There are no differences in the requirements for first or second-class as far as stent procedures and heart attacks.  They also recently changed the requirements such that first and second-class airmen only require a plain stress test each year. The reason why you are still required to alternate a plain stress with a nuclear one must be answered by the FAA medical certification physicians.  Based on that you may still be required to do the alternate stress testing for third-class as well.  There are no differing requirements for the duration that one must exercise for a stress test based on medical class of certificate; they remain the same. 

You can write to the FAA and tell them that you are no longer going to obtain a first-class special issuance and ask them to spell out your requirements for special issuance for the stent and heart attack for a third-class medical.

QUESTION: I was diagnosed about a year ago with an acoustic neuroma, a benign tumor affecting my hearing nerve on one side.  Is my third class medical at risk? 

I discovered this after I had tinnitus and some hearing desensitization in one ear.  I haven't had any balance, dizziness, or vertigo symptoms that often occur with acoustic neuroma.  Multiple MRI's over time have shown the tumor to be small and stable in size.  I'm in great health otherwise and I should have no problems passing FAA medical exam otherwise. 

I've visited an otolaryngologist and the recommended course of treatment is simply to "wait and watch" with a yearly MRI.  I'm confident that I am fit for flight, but I can imagine the FAA taking issue with some of the potential symptoms of this condition that I do not have. 

What information should I provide proactively as part of my physical this fall? 

ANSWER: Acoustic neuroma is a disqualifying condition, especially if it is just being "watched". You will need to provide testing and evaluations to prove to the FAA that you are safe to fly!  Acoustic Neuroma is a classic "aeromedical condition" as the tumor can cause hearing loss and dizziness.  Just because you do not have these symptoms currently does not mean that you could not develop them.   

You will need to have records or a letter from the treating physician that tells the FAA how the tumor was discovered, including characterizing your symptoms. You should also provide the results of a current MRI of the brain – films and report as they may want to obtain a third party consultant opinion. This MRI scan should be no "older" than 90 days when you send it into the FAA. 

Also include results of a current Hearing evaluation (Audiogram) that should also include a "speech discrimination test" and an evaluation by the Attending physician who is following you for this tumor. 

Once the FAA reviews this material, they will determine if they will grant you a special issuance. You will more than likely be required to provide yearly evaluations and MRIs.  

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