Pilot Protection Medical Mailbag- March Q&A

QUESTION: I read the Fly Well article, “Eyes on the prize” (AOPA Pilot, June 2015) with great interest since I have a condition that is also treated with Avastin. 

I have RPP (Recurrent Respiratory Papillomatosis) and have been getting KTP laser removal of the papillomas on my vocal chords once or twice a year followed by intra-lesional injections of Avastin every 14 weeks to retard the growth. 

I was first diagnosed 3 years ago and had 2 surgeries in the fall of 2012 in the hospital. Other treatments have been in the office and I have to be careful of speaking for a day or two. 

Do you know whether or not the FAA would  issue a 3rd class medical to me with this condition? 

ANSWER: Thanks for writing, as you probably know, RRP is a rare disorder with about 1 in 100,000 having the condition and it is sometimes caused by HPV, the human papilloma virus. Currently, Avastin, a drug that was designed to cut down blood supply to cancers, has been acceptable for use as an injection into the eye for macular degeneration treatment. Although it has been used for your situation, we are not sure whether Certification will accept for this condition and would have to make an ordered submission. If you are a member of AOPA Pilot Protection Plus program (I am) they can review the data and help you through that process. 

I am a pilot for the State of South Dakota on a part time basis.  They send me to Flight Safety each year and I fly for them May through December.  The rest of the time I winter in Arizona.  I have a prostate check up each year at the Mayo Clinic in Phoenix and have just been informed that a biopsy, driven by an elevated PSA of 7, I have prostate cancer.  I am due to meet my surgeon to discuss the future and at this time I am leaning toward having the prostate removed because neither the MRI nor CT Scan show anything outside the prostate.  What advice can you give me regarding how I handle my second class medical and the FAA.  My present medical is good through September 2016.  What steps do you recommend I take between now and then?  

Sorry to hear this but glad you are on top of things. The first observation is to ensure you review all possible therapeutic options, including clinical surveillance; many men die with, not from, prostate cancer, my father included. For instance, “saturation perineal biopsy” and MRI is now considered more state-of-the-art for characterizing the disease. 

As far as your flying is concerned, you should ground yourself when you go in for treatment and for 6 weeks post.  This is now a “ CACI” - a Condition an AME Can Issue, as long as the prostate cancer has not metastasized (spread to other places).  

You need to collect: Hospital admission and discharge summaries, operative and pathology reports and if you have any other treatments (radiotherapy, hormonotherapy) you should again ground yourself. At the end of the 6 week period you can resume flying and you will need a current status report and PSA level done at least 2 months prior to having you next FAA exam. You should then hand-carry all of these records into your AME at that time. 

A link to the CACI worksheet can be found at:

QUESTION: Could you please address the new rules regarding retained urinary tract stones with an existing Special Issuance (SI)?  I have had an SI for my 1mm retained stone that has not moved or grown for the past three years.  I have not passed a stone in over 10 years.  I have normal kidney function and am stable.  My AME says that I still need to keep my SI current and the new rules don’t apply to me. 

ANSWER: Sir, we are sad to say that your AME is incorrect! This has to do with the new “CACI’s” - Conditions AME’s Can Issue as it relates to kidney stones, although the guidance should have been entitled "retained kidney stones."  If your stone is not causing any symptoms, the size has not changed, or you have new stones present, the stone has not become obstructed in the ureters (the tubes that exit the kidneys and lead to the bladder), has not moved and is not likely to pass, and you do not have a metabolic condition that can result in the production of more stones, your AME can issue you in the office without the requirement for a special issuance. 

QUESTION: I was recently declined issuance of my third class medical as a result of elevated protein in my urine. My kidney function is indeed impaired and my nephrologist has been tracking the issue for several years. He estimates that my kidney function is about 40% and has remained relatively constant for 10 years. Will the FAA medical folks accept those results as an indication of consistency and grant my third class medical? 

ANSWER: The AOPA medical certification folks will want to review your records.  You will need to obtain a letter from the kidney specialist (a Nephrologist) that states his/her opinion as to the cause of the kidney disease. You will need to provide the results of kidney function studies, to include the Glomerular Filtration Rate, a set of electrolytes and any other test results that have been done.  If you had x-rays or scans of the kidneys, you will need to provide those. If the doctor performed a kidney biopsy, you will also need to provide that as well. The FAA currently has a policy that they will not grant certification to an airman who has a Glomerular Filtration Rate of less than 40, which is what your kidney doctor may be referring to. 

QUESTION: When it comes to kidneys, I would like to know what constitutes "possible renal insufficiency "? Why is it called "Possible" ?

ANSWER: "Renal insufficiency" is the terminology that a physician uses to tell someone that they have a condition that has resulted in abnormal kidney function tests. They would use the term "possible" if they just discovered this and were in the process of performing testing and evaluation to see if the person really had a problem. This merits close attention and needs to be taken seriously.

QUESTION: I would love to understand what the FAA requires to regain a first class medical following a kidney transplant, a procedure I recently underwent. If possible, it would be great to learn what the anti-rejection drugs FAA allows. In fact, prior to my surgery, I called the regional medical office to make sure the drug I was to be prescribed would be allowable for my medical in the future, and I was told it was. Also, perhaps some type of mention of the importance of a kidney donation from a living relative?  I was very fortunate that my sister was a match for me and was willing and able to donate her organ, so I never had to be on dialysis prior to my transplant, a therapy that I understand can be quite tough. Even so, due to pre-op testing and qualification issues and etc., it was about a year from my initial transplant clinic visit until the actual my surgery. 

ANSWER: Once an airman goes onto kidney dialysis, the FAA will deny medical certification. Those individuals are very unstable metabolically and would not be considered safe to fly.  The FAA has many airmen of all classes who have had a kidney transplant.  An airman must wait 6 months after surgery before they can reapply for a special issuance.  They should provide the hospital admission and discharge summaries, operative report and pathology report from the transplant surgery.  At the end of the 6 month waiting period, they will need a letter from the Kidney Specialist as to how they have been functioning, the results of current kidney function studies, and a complete blood count. The FAA accepts all the usual anti-rejection medications. For those airmen who are taking the cortisone derivative "prednisone" they will not permit an equivalent dose higher than 20mg. Living related donation is a wonderful gift and those who donate are obviously loving and generous people. Every year thousands of Americans die from lack of suitable organs for donation, so we encourage everyone to carry a donor card.

QUESTION: I had shock wave lithotripsy recently and have a follow up visit soon to ascertain whether or not the stone has passed. A couple of weeks after that I am due to see my AME for my medical and I need to know if the doctor will be able to pass me if my urologist clears me?  

ANSWER: Stones developing in the kidney and passing down the ureter (the tube joining the kidney to the bladder) can cause severe pain, fever, vomiting and the passage of blood in the urine. When the diagnosis of stones has been made, doctors want to ensure there is not an underlying reason that might lead to more stones developing, such as a metabolic issue. 

One way of dealing with stones is to focus sound waves from outside the body (“Extracorporeal Shock Wave Lithotripsy” or “ESWL”) If this was your first stone "episode", your AME will be able to issue you. But, you will need to provide a report from the Urologist that states how they discovered the stone, the dates of the lithotripsy, the results of a current metabolic evaluation (lab tests performed to determine if you are prone to produce kidney stones), and proof that the stone is gone or, if there are stones remaining, their location and size.  

AOPA Pilot Protection is commemorating National Kidney Month in March with a series of questions and answers focused on the nation's attention on kidney health.

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