Hall of Fame Medical Mailbag

Your most frequently asked medical questions answered


There are certain questions our medical professionals receive more often than others. We have compiled those in a special "Hall of Fame" segment.

Non-Allowed Medications

QUESTION: Concerning FAA "Non-Allowed" medications. How long after I stop taking the medication need it not be reported on a medical application?

ANSWER: The FAA’s rule of thumb for these medications is to wait five times the dosing interval after the last dose before flying. For example, if the dosing interval is every eight hours, wait five times that eight-hour dosing interval, or 40 hours after the last dose. Some medications have a longer half life than others so the active ingredients stay in your system longer. If you have started a medication since your last AME visit, declare it on the form.  For some meds, a statement from your treating doctor explaining the reason the medication is being taken should be available to your AME. Bear in mind that some conditions, regardless of therapy, might be disqualifying, so ensure your Pilot Protection Services membership is up to date and check with the good folks at AOPA!

Atrial Fibrillation

QUESTION: I would like to know how the FAA treats pilots that are being treated for atrial fibrillation ? 

ANSWER: Atrial fibrillation (AF) is the most common cardiac rhythm disorder where the upper chamber of the heart, the atrium, “fibrillates” or wiggles like a bag of worms leading to ineffectual pumping action. You need to keep an eye on the medical sections in the AOPA e-newsletters, magazine, and Fly Well videos as this subject has been discussed many times!

The FAA treats AF as a special issuance condition. It accepts treatment with “cardioversion,” which is where the heart is shocked back into a good rhythm and radio-frequency ablation, where the errant cells causing bad contractions are destroyed, but this results in a 90-day period of grounding post treatment. Chemical conversion with medication results in a 30-day period of observation. If this is the first time you are presenting your case for review, you will need to provide a letter from your treating physician that describes how you presented, what was done to treat the AF, how you responded to the treatment, and what medications you are currently taking. You will have to have a maximal Bruce Protocol stress test, thyroid function studies, a lipid panel and fasting blood sugar, and a 24-hour Holter monitor test, performed at the end of the 30 days if you were converted with medication, and 90 days if treated with cardioversion or ablation.  

The FAA is cautious with good reason, although common and often benign, AF can lead to serious problems and merits careful review.

Sleep Apnea

QUESTION: About seven years ago my wife finally got tired of my snoring so I went for a sleep evaluation. The results showed that I was borderline apneic, so I opted for the CPAP machine since Medicare supplied me with one. Then I found out that to keep my third class medical I had to get a yearly exam from my CPAP doctor and a yearly checkup from my AME. Since then I have been flying as a sport pilot in my small experimental plane. Up to now I have not read anything about CPAP regulation in the new proposed medical requiring just a driver’s license. Can you update me on this? 

ANSWER: Obstructive Sleep Apnea is a high-profile medical condition right now because of the constellation of medical problems that can result from remaining untreated. Under the current proposed legislative language, sleep apnea is not a condition that would require a one-time special issuance, and pilots would be able to continue to self-assess and exercise privileges without any FAA oversight. However, if you are on CPAP now and well-controlled, why wait for Congress? You can qualify for a special issuance now and fly a normal category airplane under a third class special issuance. The FAA will need to see the original sleep evaluation and the results of at least 60 days of compliance data from your CPAP machine showing you are using the machine 75 percent of nights and averaging about six hours sleep per night. An AME could even issue your medical certificate in the office provided you have all the necessary documentation when you see the medical examiner.


QUESTION: Does implanting a pacemaker require any additional medical clearance to obtain a private pilot certificate or to continue with student flying lessons?

ANSWER: Implantation of a cardiac pacemaker is one of the mandatory disqualifying conditions that requires a special issuance authorization. There are about 300 or so pilots flying with a special issuance for a pacemaker. There are some hoops to jump through, however, as with any special issuance. Normally, a treadmill stress test, 24-hour ambulatory Holter monitor, an echocardiogram, and current pacemaker performance testing are the basics the FAA will need to see. You can find out more by reviewing our online information about pacemakers. 

Depression and SSRI's

QUESTION: I am a healthy student pilot but have been taking Zoloft for 19 years, which works well with no side effects. I am due to see an HIMS AME and would appreciate any advice. I am surprised to find that SSRIs are such a big issue for the FAA. Can you help me understand the concern? Do they think that anyone taking an SSRI is likely to become suicidal in midair and crash his aircraft? Or, is it a concern that the medication will impair the person’s senses and/or judgment? What kinds of evidence will most effectively convince the AME that I do not have a problem? I feel like Gary Cooper in Mr. Deeds Goes to Town, walking in to have my sanity adjudicated without really understanding the process. I appreciate any advice you can offer.

ANSWER: Thanks for writing—many pilots have similar questions. The topic of depression, and especially anti-depressant use, has its roots in U.S. military medical certification. Until the Selective Serotonin Reuptake Inhibitor class of drug (SSRI) came along, they would never allow a person who was actively being treated for depression to fly. On top of the depression symptoms, side effects from medications, amitriptyline derivatives, were a cause for concern. It was a bold act, quite frankly, to allow airmen to fly while being treated and it was the Australians who first certified pilots to fly while receiving antidepressants, and this propelled the United States to consider granting issuance after years of discussion and the FAA refining the protocol.

The FAA allows airmen with depression to be considered for certification if they are taking one of four SSRI medications, including the one you are taking, Zoloft (sertraline), as well as Prozac (fluoxetine), Celexa (citalopram), and Lexapro (escitalopram). One must be on the same dose for 12 months and the case will require review. To obtain guidance on navigating clearance to fly while taking an SSRI, review this web page.  

Hepatitis C

QUESTION: I am a private pilot working toward my instrument rating and spent 1.5 years corresponding with the FAA to get my special issuance medical so I was very happy to hear about the CACI.

My primary care physician has been monitoring my liver for evidence of damage from Hepatitis C, which has been stable for over 10 years since interferon treatment in 1995 and I have been living a healthy lifestyle. I feel great, but my doctor wanted me to talk with a specialist about the newer drug treatments. I did this and the liver specialist ordered a biopsy. The results were something like 9 out of 16 for inflammation and 5 out of 6 for scarring. He recommended that I take the treatment, but if I do, I can't fly. So I am putting it off. But I will need to have documentation for my next medical due August 2015. I don't want to have another biopsy nor do I want to risk the lengthy treatment that doesn't offer a cure, just a 60-80 percent chance of the virus becoming undetectable.

So, my question is this: Do I have to have a biopsy every two years to get my medical? Isn't my blood work sufficient? If not, then what are the criteria that dictate I am too sick to fly? I feel great, eat a healthy diet, exercise regularly, and work and play like anyone else. I am not, as far as I know, not going to "fall apart" instantaneously. If my results were 6 out of 6 scarring, does that disqualify me from flying? I haven't been able to find a good resource for this information and my pilot buddy suggested to contact AOPA.

In closing, do you know of other pilots having Hepatitis C and how they are dealing with this? Please help me. I have waited 35 years to continue my flying and now it seems as though I have to give it up again.

ANSWER: Thanks for writing on this important issue. Hepatitis is a catch-all term that means inflammation of the liver, a very important organ. Hepatitis C refers to an infection with a virus that is transmitted sexually, from contaminated blood transfusions, intravenous drug use, or some other ways. The problem with this disease—which is unfortunately very common—is that it tends to be silent until it does lasting damage, often causing damaging cirrhosis or scarring of the liver which might require a liver transplant. Sometimes the liver scarring causes veins in the gut to distend to the point that they rupture and these “esophageal varices” can be life-threatening. Additionally, chronic inflammation can lead to hepatoma, a nasty and often fatal liver cancer. So the first recommendation is to explore what specific risk you face of liver failure or cancer—it is not simply a matter of making the virus undetectable, it is about mitigating the risk of a fatal disease. Flying is important, but staying alive trumps that.

Chronic Hepatitis C infection is now under the category of CACI (Conditions AMEs Can Issue).

As soon as an airman is placed on a medication, such as the Interferon Alpha you took, they are disqualified until the treatment has been completed and any side effects have resolved.

As long as the airman is "stable," they can continue to fly and be "cleared" by their AME.

Stable means that they do not have cirrhosis of the liver (although if the cirrhosis is stable this might not preclude certification), esophageal varices, or other serious sequelae. This would likely result in a special issuance. Once more complications of the cirrhosis occur, denial is likely.

After issuance, yearly follow up status reports and liver function tests from their treating physician are required but there are no requirements for "regular" biopsies; that is left entirely to the treating physician.

Hope this answers your concerns—you also might want to read an article in AOPA Pilot magazine entitled “Stealing Fire” from October 2011 that addressed this topic.

Have a question for Dr. Jonathan Sackier or Gary Crump? You may submit your question here.

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