Insulin-Requiring Diabetes

By Hunter Heath III, M.D.

Sport Aviation, October 1997

Airmen with Type I insulin-requiring diabetes mellitus begin receiving Class 3 medical certificates!

Less than a year ago, the FAA’s Federal Air Surgeon announced a new policy that might allow people having Type I or insulin-dependent diabetes mellitus, or those having Type II diabetes needing insulin, to obtain Class 3 medical certificates. During a meeting of FAA medical people with the EAA Aeromedical Advisory Council at the EAA Annual Convention in August, we received an update on the progress of this innovative, experimental venture.

Recall that nowhere else in the world has any program been devised to allow insulin-taking diabetics to legally fly certificated aircraft. (They can fly ultralights under FAR Part 103.) Under the new program, people taking insulin for diabetes can receive Class 3 medical certificates if they are reasonably well-controlled (as shown by a measurement of glycosylated hemoglobin - what I call "sugar-coated hemoglobin"), have had no incapacitating hypoglycemic reactions for an extended period, and have no serious complications of the disease. There are very strict requirements for self-monitoring of blood sugar using the excellent portable devices now widely-available, and the airman’s status must be reported periodically to the FAA. While the requirements are strict, the FAA believes they are necessary for reasonable flight safety and public safety and confidence in the program - I agree. I wonder how easy it will be to do a finger stick and monitor one’s blood sugar in turbulence, but it probably can be done!

Dr. Steve Carpenter, manager of the medical appeals branch at the FAA’s Civil Aeromedical Institute in Oklahoma City, told us that about 137 airmen have applied for Class III medical certificates under the new diabetes program. Only about 17 have been denied - either because their diabetes was badly out of control (blood sugar too high as reflected by glycosylated hemoglobin values more than twice the upper limit of normal, a very high figure), or they were having serious "insulin reactions" (meaning episodes of blood sugar so low as to threaten incapacitation). Sixty-seven applications are still in process, but here is the really good news: about 53 diabetic airmen taking insulin have been certified and are flying legally! I cannot overemphasize what a dramatic event this is - ten years ago, I’d never have believed the FAA could come this far this fast.

Why is the FAA now comfortable with certifying diabetic, insulin-taking airmen? Their reasons include advancing technology (portable, accurate blood sugar meters), improved understanding of human physiology (how to avoid insulin reactions), and a general "get the guvmint offa my back" attitude that seems to have affected many regulatory agencies. The FAA’s caution is reflected in the fact that only Class 3 certificates are being issued for insulin-taking diabetics (non-insulin-dependent diabetic airmen are being certified up through Class 1). Note also that the FAA regards this as an experimental program; they will be monitoring the progress of the certified airmen carefully. Questions will include, how many come back for a renewal? How many drop out due to diabetic control issues? Are there any obvious safety concerns? During our meeting with the FAA, I asked Dr. Carpenter, "What will happen when the first airman certified under this program creates a smoking hole with his or her airplane?" This seemingly macabre question is of great importance - could the adverse publicity surrounding the event - which will certainly be blamed by the media on the diabetes - cause political pressure to stop the certifications? Dr. Carpenter answered that the outcome would depend strictly on how the media played the event. The message for those airmen who receive a certificate for flight while taking insulin is: be careful out there!

One airman who has insulin-dependent diabetes (Type I), Steve Fischer, and his personal doctor, AME and friend, have written to describe the experience that led to his first Class 3 medical certificate since developing diabetes in 1980. He learned of the new FAA program from his physician and fellow glider pilot, Dr. Daniel Johnson. Even before they knew the exact rules of the program, they began more careful control of his diabetes, gave him additional diabetes care education, and kept complete records of blood sugar values. His airman medical examination was performed on March 3, 1997, and his medical certificate was received on May 10, just a bit over two months later. Dr. Johnson’s comments on the FAA rules are noteworthy: ". . . the requirements, though strict and demanding, are reasonable. By this I mean that any diabetic who follows the FAA program will also be following, in essence, the recommendations for best possible management of the diabetes." He goes on to admit that avoiding low blood sugar reactions will require avoiding the kind of "tight control" that has been proved to minimize the risk of chronic diabetes complications. Of the airman, Dr. Johnson says, he "is an ideal person for such certification . . . he was interested in learning more about managing diabetes, and coachable besides; he was financially able to undertake the program; he has the compulsive character to make this work consistently. And he has a friend who is an AME . . . (and) internist . . . to help iron out the challenges. Money does not buy these things. The FAA requirements are basically in harmony with ADA recommendations, and following both will provide you with a longer healthy life as a diabetic." The joint airman/doctor letter will be available through EAA to those needing more detailed guidance on how to work through the FAA procedures.

For diabetics not taking insulin, there is also good news. The newer oral antidiabetes drug, Precoseª, is allowed for use, although the FAA doctors have some concerns over the gastrointestinal problems the drug can cause. While oral diabetes medications seldom cause insulin reactions (low blood sugar), it can happen; the FAA requires that if a certified airman taking a sulfonylurea has a low blood sugar event, he/she must switch to metformin (Glucophageª) in order to continue certification. The even newer drug, troglitazone (Rezulinª) is still under study, but as usage spreads and more safety information comes in, the FAA will reevaluate its possible use by certificated diabetic pilots late this year. A real "downer" is that the Oklahoma City office is way behind in handling Special Issuance medical applications - because of staffing cutbacks, they are out to an average of 8 weeks, often longer, to process the paperwork. The diabetic airman therefore must be persistent and patient.

As for other Special Issuance problems, it is very important that the airman work with an Aviation Medical Examiner (AME) who is able and willing to extend extra time and effort on the airman’s behalf. The EAA Pilot Advocate Program can help the airman to find a qualified, interested AME to assist.

In closing, I want to emphasize that diabetes is yet another area where the FAA has taken advantage of new medical information and technological advances to liberalize the criteria for flight medical certification. On this point if no other, a doff of the hat to our good colleagues at the FAA Flight Medical Certification Office.

(Dr. Hunter Heath III, EAA 37802, Indianapolis, IN, is a member of the EAA Aeromedical Advisory Council.)

Additional information regarding the FAA policy on Medical Certification of Insulin Treated Diabetic Applicants is available at their web site.