Pilot Protection Services Medical Mailbag- June Q&A

QUESTION:  How many mgs prednisone allowed per day dosage and still pass the commercial physical? 

ANSWER: Prednisone is an oral steroid that is used for a number of different medical conditions to suppress the body’s natural reaction to inflammation. The FAA allows up to 20mg equivalent of prednisone daily; however, the reason for the use of steroids is an important part of the equation, so you should have a brief report from your treating physician with you when you see your AME that explains the reasons for the need for prednisone. Some examples of use include rheumatoid arthritis, inflammatory bowel disease and even in the short term, poison ivy! 

QUESTION: I am a 56 yr. old instrument rated private pilot, flying a single engine turboprop and with 1,000 hours logged. My third class medical renewal is due shortly and I was just diagnosed  with acute deep vein thrombosis and have been prescribed a 7 day course of Lovenox injections and 90 days of Coumadin. I am freaked out right now don't know how this is going to affect my flying privileges and would appreciate some advice on best steps to take and what information to provide the AME  from my primary doctor ? 

ANSWER: Deep vein thrombosis (DVT) is where blood clots inside – surprise, surprise, veins deep inside the body, usually the lower leg. This can be precipitated by, among other things, being recumbent (as during long flights), smoking, cancer, obesity and the oral contraceptive pill. It can be pretty dangerous as a segment of clot can break off, travel to the lung and cause sudden death or damage to impair breathing. Untreated, long term problems include leg swelling and ulceration. Medications used to treat this condition work by anti-coagulating or “thinning the blood” and Coumadin is especially interesting in that it is also used in rat poison! 

FAA allows both medications, but you should self-ground until the FAA has cleared you with a special issuance authorization.  You will need a report from your treating doctor explaining the circumstances under which the DVT developed, a statement on the treatment plan, and reports of your INRs (a blood test used to monitor treatment) to verify that your dosage of Coumadin is correct.  The FAA expects to see at least 80% of the values of INRs to be in the 2.0 - 3.0 range.  You should have at least a couple of months of INR reports before you submit anything to the FAA.  Once you are granted the special issuance, you will need to provide an annual report to the FAA with INRs if you are still on Coumadin.  

QUESTION: Is there a specific range one must stay within as it pertains to blood pressure and a 3rd class medical? 

ANSWER: Just as every pilot knows the various speeds for the aircraft cockpit they inhabit, every one should know the BP of the body they inhabit! The maximum allowed blood pressure for FAA certification is 155/95, and that applies to all classes of medical certificates.  You can take up to 3 separate blood pressure medications and still maintain an unrestricted medical certificate.  If your blood pressure is maintained within normal limits by drugs, FAA will want a brief report from your treating doctor confirming the medications you are taking, the dosages and frequency of use, the absence of side effects, and confirmation that your BP is adequately controlled. 

QUESTION: I have a 1st Class medical, which I will renew in a few months.  I have been diagnosed with gallstones, one of which is in my common bile duct.  I have been advised that I will require surgery to remove the gallbladder and the stone in my duct. I will have the proper documentation and a release from the doctor.  Should I expect any difficulties when I renew my medical? 

ANSWER: The gallbladder holds a special place in my heart (JMS) if that does not sound too bizarre, as I did a lot of work on the laparoscopic means to deal with the organ and escaped stones; you may want to check out “A rolling stone” from the January, 2011 AOPA Pilot magazine. 

For your AME have a copy of your surgical report and a status report from your treating doctor that you are fully recovered from the surgery.  The AME can reissue you a new medical in the office if you are found otherwise qualified. 

QUESTION: Am I required to have a current 3rd class medical prior to taking a biannual flight check? 

ANSWER: Probably not.  If your most recent biennial flight review (BFR) was more than 24 months ago, you are not eligible to act as PIC anyway, so your CFI who does the BFR will be pilot in command.  You are required to hold a current and valid medical certificate in order to act as PIC, so once you are signed off for the BFR and otherwise meet the recency of experience requirements, and again hold a current medical, you will be good to go. 

QUESTION: Is Invokana currently approved as a combination pharm (along with Metformin) for the control of A1c in a Type 2 diabetic? 

ANSWER: Diabetes is rampant in our country and it is critically important to maintain tight control of blood sugar to limit the chance of long term sequelae like nerve and kidney damage, stroke, heart attack and blindness. Although measuring blood sugar directly has been a standard for a long time, the newer test, to monitor Hemoglobin A1C gives a snapshot of how the sugar has been behaving for several weeks rather than just at the time the sample is taken. 

While metformin is a long-established medication, Invokana has not yet been cleared by the FAA as an allowed diabetes medication and we do not have any indication from the FAA when, or if, they will allow it.  By policy, the FAA waits at least one year after the Food and Drug Administration approves a new medication on the market to observe the effects of that medicine in the general population.  Even then, some medications may have the potential for adverse side effects that would be considered by the FAA to be incompatible with aviation safety.  There are many newer diabetes medications that the FAA does now allow to be used with metformin. 

QUESTION: The FAA web site has data relative to atrial fibrillation and what they allow and do not allow in the way of heart beats, space between beats, medicines that are allowed, etc. They also want a 24 hr. Holter Monitor data from the Cardiologist. Do you know if they accept a Zio Patch read out instead of a Holter Monitor? If one meet all the criteria as outlined on their web site, will they pretty much provide the waiver for a GA pilot? 

ANSWER: This is a good question that we have not seen before, so good on you for challenging us!  Atrial fibrillation (AFib) is the most common heart rhythm abnormality and although often asymptomatic, it can cause problems and there are a number of ways to treat it including drugs and zapping the errant heart cells with extreme cold, electricity or other forms of energy. The time-tested and standard way of diagnosing this is to attach a device that measures heart rhythm over the course of 24 hours, the Holter Monitor. The Zio Patch is a comparatively new mobile device that although cleared by FDA is not yet approved by FAA for the purpose described above and is likely to remain that way for at least a year, but for now, expect the FAA to continue to ask for the standard 24 hour Holter monitor. If your AFib is well controlled, chances are good that you will be able to get a special issuance. 

QUESTION: I have been diagnosed with Irritable Bowel Syndrome (IBS) by my Gastroenterologist. Recently he prescribed Amitriptyline, 10mg to control the IBS. First we tried Dicyclomine but that was not totally effective. Looking through the AOPA Medication Database I see that Amitriptyline is a “Not Allowed” medication.

I am 70 years old and would like to continue to fly. What recommendations can you suggest so that I can pass a Class III medical?

ANSWER: IBS is a common affliction where the bowel does not behave properly causing abdominal distension, gas, disordered bowel motion and a general sense of feeling unwell. However, not only is Amitriptylline an unacceptable medication but so is Dicyclomine!  It is the "medical condition" that is the most important issue here and if your IBS cannot be controlled with diet, bulk agents, increased fiber in diet and limited use of over the counter Imodium, you will not be able to gain medical certification.  By the way, IBS does require a special issuance!

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