AINsight: Medications and Flying, Part Two

 - February 8, 2019, 12:19 PM

I previously presented some of the ground rules in regard to medications, reporting their usage, and how the FAA provides some guidance. However, remember that there is no formal document that can provide absolute guidance pertaining to every medication and every possible nuance of its usage.

So it’s important to ask an AME to clarify whether a new medication is acceptable and if there will be any required documentation. In addition to the name of the medication, always tell the AME why the medication is being prescribed, since there are many “off label” uses of medications.

In the FAA’s Guide for Aviation Medical Examiners, there is a discussion on medication usage that precludes issuance of a medical certificate by the AME. This basic guidance also puts some responsibility on the pilot to self-ground per FAR 61.53 for situations that come up during the six to 12 months (or longer for private pilots) between FAA medical exams. Remember, the AME’s opinion is only regulatory at the time of the FAA exam itself, but FAR 61.53 applies at all times.

In the AME guide, under a section titled “Pharmaceuticals; Do Not Issue—Do Not Fly,” there are some reminders of day-to-day importance and relevance.

Importantly, it states that controlled substances—and marijuana where legal on a state-by-state basis—are not permitted at any time. As the precedents evolve over the coming months and years, I’ll comment further on FAA rulings in regard to medical and recreational marijuana. For now, be advised that any use of marijuana is still disqualifying. Regardless of state law, marijuana is still illegal on a federal basis.

In addition, it notes that while narcotic pain medications and muscle relaxants are not illegal, and often there are very appropriate uses for them, a pilot cannot fly while taking them. As I mentioned when I discussed drug and alcohol testing several months ago, a pilot is advised to only use such medications for a documented medical reason and through a current valid prescription. Once the condition for which the medication was being taken has been resolved, a pilot can usually resume flight duties (after a period of time for the medication to get fully metabolized).

This is a situation to discuss with the AME if at all possible before returning to the flight deck. The AME can advise if any documentation is required or if the pilot should not fly until FAA reviews the case in its entirety. If a pain medication was used after routine orthopedic or dental surgery, for example, usually a pilot can resume flying when off the medication for at least several days and when adequately recovered post-operatively.

Enough with scare tactics and doom and gloom. Let’s chat about typical medical conditions that pilots might develop over time, especially as they get older, and how to keep flying even if medications are required. 

Some of the most typical conditions requiring medications that pilots need to report include:

Hypertension. Many pilots develop high blood pressure as they get older. Recent medical recommendations in regard to blood pressure advise lower readings than previously were considered acceptable. High blood pressure can contribute to heart disease, stroke, erectile dysfunction, and possibly contribute to dementia risks.

The old days of “around 140/90 is fine” are gone. Now we want to see readings more in the 110/70 to 120/80 range. The FAA actually accepts readings surprisingly higher than these, but the FAA mandate is to predict your chances of having “sudden incapacitation” during the valid period of the certificate itself. Your private physician, of course, has the goal for you to meet currently accepted medical standards.

Most of the medications for blood pressure are acceptable to the FAA with some minor documentation. Instead of listing all of these, suffice it to state that only a small group of hypertension medications (that are “centrally acting” in the nervous system) are blanketly not permitted—and, in practice, are rarely used anyway. For the majority of the hypertension medications, ask the AME. Usually, you’ll be told that they are fine, and to just bring in a short note from your physician to your next FAA exam.

Both the AME and the FAA understand that it’s easier to keep you flying if you are still alive. We’d all prefer to see you on blood pressure medications than to see you in the ICU at the hospital or in the morgue. Diet, exercise, optimum weight goals, and the responsible use of alcohol should also be part of all hypertension management programs.

• Thyroid. Medications for hypothyroidism (low thyroid), such as levothyroxine (Synthroid) are acceptable. All the AME needs is a current blood test and a short note from the physician. Don’t avoid treating your thyroid—you’ll be better off in the long run if you do.

Treating hyperthyroidism (high thyroid) is a bit more challenging and will be followed under FAA special issuance. That said, such treatments are also routinely approved.

• Asthma. As long as the asthma isn’t causing emergent hospital visits and can be controlled with routine inhalers, then certification is possible. Typically, a note from the physician and a report of pulmonary function testing (breathing tests) is required, but approval is usually done without any delays. The most common inhalers are albuterol (including ProAir and Ventolin) and steroid (including Qvar and Flovent).

• Erectile dysfunction. Many of you were hoping I’d mention this without your asking. This approval process had an interesting evolution, but the answer is “yes” for these medications, so you can breathe now.

When the FAA began accepting ED medications, waiting periods (six to 36 hours, depending on the medication) were placed, for several reasons. A very small subset of users experience a transient red/green color deficiency. It’s rare and wears off quickly, but obviously would not be compatible with flying.

These medications might also lower blood pressure, so the FAA wanted to avoid problems such as near-fainting. And, of course, in the initial considerations, it was hoped that the pilot had something other than flying to consummate after taking such medication.

The FAA publishes a list in the AME guide, but the most common current “bottle to throttle” restrictions include sildenafil (Viagra), eight hours, and tadalafil (Cialis) for higher doses (10 mg or more), 24 hours, but daily use is now permitted at the 2.5 or 5 mg dose. Low-dose Cialis is sometimes prescribed by urologists on a daily basis for prostate maintenance, and thus recent approval for this use is appreciated by many pilots.

GERD. Gastroesophageal reflux disease (in essence, heartburn) is treatable with both over-the-counter and prescription medications. Common medications acceptable to the FAA include antacid/antihistamines such as ranitidine (Zantac) and the proton-pump inhibitors such as omeprazole (Prilosec) and lansoprazole (Prevacid). 

• Sleep aids. This topic is very complex. Until such time that I can revisit it more thoroughly, accept that the FAA is acutely aware that circadian rhythm disturbances can cause significant sleep disorders and general health problems. The FAA is, quite understandably, motivated to prevent a pilot from having a sleep medication fatigue hangover or an amnesia reaction while attempting to pilot an airplane. So, this situation needed careful consideration.

While being reasonable in its protocols for the use of sleep aids, the FAA doesn’t want anyone to become dependent on them. Therefore only “occasional” use is permitted.  Daily use is never acceptable. Just as with the ED medications, there are prescribed waiting periods based on the length of action of the medication. Some of the more common medications include zolpidem (Ambien), 24 hours; zaleplon (Sonata), six hours; temazepam (Restoril), 72 hours; and eszopiclone (Lunesta), 30 hours. As you can see, these vary significantly.

Discuss the FAA protocols with your treating physician. Before initiating the use of prescription sleep aids, first develop a sleep-hygiene program that is at least somewhat helpful and effective. Carefully analyze your situation with your physician with a goal of minimizing the use of sleep medications.

A typical scenario is when a pilot who flies internationally (or the West Coast-based pilot who has the dreaded 04:00 wake-up on the East Coast, which is 01:00 for the internal body clock) returns from a long trip. This pilot has maybe a few days at home before returning to work, and wants to get back on a normal schedule to interact effectively with family during that time (and not be a grumpy ogre for the first 36 hours). A one-time use on the first evening after returning from the trip can be useful to reset the pilot’s internal clock.

The use of sedating antihistamine medications such as diphenhydramine (Benadryl) also warrants a more thorough discussion in the future. These medications are long-acting, and the FAA requires a five-dosing interval wait before flying. Until I discuss this more specifically in the future, the bottom line is that the FAA doesn’t want a pilot to take this type of over-the-counter sleep aid very often, and certainly not during a “minimum rest” overnight.

Other Medications

Other classes of approvable medications that require more in-depth discussions include those for cardiac arrythmias (irregular heartbeats such as atrial fibrillation), arthritis (including some of the newer injectable treatments), depression (since 2010 we have had a program to return pilots to flying with the use of one of four approvable medications), and type-II diabetes (on oral medications; a pilot who requires insulin can only qualify for a third-class medical certificate presently). I will discuss these conditions, and many more, in subsequent writings.

For now, rest assured that many medical conditions requiring medications are approvable without opening excessively complicated cans of worms. Check with your AME for advice before going to your first FAA exam after a medication has been prescribed.

For non-urgent “maintenance” medications such as those discussed above, research first through the AME guide and the resources published by AOPA and ALPA, then contact the AME for final guidance.

Dr. Sancetta is a former DC-10 captain with 11,000 flight hours. He has worked as a Senior AME since 1993 and is appointed as AME Consultant to the Federal Air Surgeon.