Federal Aviation Administration Office of Aerospace Medicine

Acceptable and Non-Acceptable Medications/Drugs in Aviation Medicine

Melchor J. Antuñano, M.D. Director, Civil Aerospace Medical Institute SUBSTANCE

MEDICATION: Substance use in diagnosis, prevention, or treatment of illnesses or symptoms

DRUG: Narcotic of other substance with potential for abuse FAR 91.17

NO PERSON MAY OPERATE OR ATTEMPT TO OPERATE AN AIRCRAFT:

• Within 8 hrs of having consumed alcohol • While under the influence of alcohol • With a blood alcohol content of 0.04% or greater • While using any drug that adversely affects safety ACCIDENTS: 1989 - 2002

SCHEDULE 1 - 2: Marijuana 103 Cocaine 36 Codeine/morphine 46 Amphetamines 24 Barbiturates 30 Synthetic opiates 30 Methaqualone 1 ACCIDENTS: 1989 - 2002

SCHEDULE 3 - 5: Benzodiacepine 73 Phentermine 13 Phendimetrazine 1 OTHERS: Fluoxetine 38 Sertaline 19 Imipramine 7 Amitryptiline 10 Verapamil 35 ACCIDENTS: 1989 - 2002

OTHERS (CONT): Phentoin 14 Diphenhidramine 140 Clorpheniramine 91 Pseudoephedrine 195 Phenylpropanolamine 168 Doxilamine 34 Quinine 66 PERCENT OF PILOT FATALITIES WITH MEDICATIONS, ALCOHOL, OR OTHER DRUGS U. S. 1989–2002 (4,786 fatalities)

SCH 1-2 SCH 3-5 30 RX OTC 25 ALCOHOL

20

15

10

5

0 89 90 91 92 93 94 95 96 97 98 99 0 1 2 USE OF MEDICATIONS

FAIRLY COMMON AND VARIED PROBLEM IN AVIATION:  Prescribed medications  Over-the-counter medications  Prescribed narcotics  Alcohol, nicotine, caffeine  Natural remedies (herbs)

WIDE DIFFERENCE OF OPINION AS TO WHICH OF THESE LEGAL SUBSTANCES REPRESENT A SAFETY PROBLEM VARIATION IN EFFECT INDIVIDUAL’S KNOWLEDGE OF THE MEDICATION’S EFFECT  Pilot’s past experience with medication may not be predictive

INDIVIDUAL FACTORS  Illnesses, fatigue, tolerance

ENVIRONMENTAL FACTORS  VFR/IFR, day/night, type of aircraft, type of flight WHAT MUST BE CONSIDERED

INDICATIONS FOR USE: medication may be OK, but underlying medical condition may compromise safety

SECONDARY EFFECTS:  Predictable: antihistamines and drowsiness  Unpredictable: antihypertensives and potential decrease in G-tolerance  Idiosyncratic: heat intolerance  Synergistic: alcohol and antidepressants GENERAL FAA ADVICE

Avoid medications that list drowsiness, impaired vision, or impaired judgment as side-effects

If you must use medications wait at least twice the recommended dosing interval before considering returning to flight duties

Don’t fly for 24 hours after taking a medication for the first time FAA CRITERIA FOR NEW DRUGS/MEDICATIONS

Rule of thumb: In general the FAA does not grant medical certification for ANY medication in a NEW DRUG CATEGORY until one year has passed from FDA approval Usually Disqualifying Medications

. Any routinely used psychotropic . Muscle relaxants (skeletal or smooth) . Experimental medications . Anti-Motion sickness medications . “Sedating” antihistamines . Reserpine, guanethidine, methyldopa Specific Unacceptable Medications

. Tricyclic Antidepressants for ANY medical condition

. Selective Serotonin Reuptake Inhibitors (SSRIs) for ANY medical condition Usually OK Acute Medications (If underlying medical condition OK)

.Aspirin, acetaminophen, ibuprofen, topicals .Decongestants like pseudoephedrine .“Newer” antihistamines

.GI meds (H2-blockers, antacids, Pepto) .Low-dose steroids .Antibiotics OK If Not Intended for Use During Flight

Viagra Usually OK Chronic Medications

. Antihypertensives . Non-steroidal anti-inflammatories

. H2-blockers . Allergy shots . Prostate medications Usually OK Chronic Medications

. Xanthines, -agonists, cromolyn . Cholesterol-lowering agents . Hormones . Hypoglycemic agents . Glaucoma drops Specific Acceptable Medications

ANTIHISTAMINES:

Non-Sedating are acceptable: Allegra (Fexofenadine), Claritin (Loratidine), and Clarinex (desloratadine)

Sedating not acceptable: Cetirazine (Zyrtec); Dipenhydramine (Benadryl); Astelin (Azelastine) Nasal Inhaler Specific Acceptable Medications

ANTIHYPERTENSIVES:

ALL are allowed except: Reserpine, Methyldopa, Guanadrel, Guanabenz, & Guanethidine (because of potential sedation) Specific Acceptable Medications

ASTHMA MEDICATIONS:

ALL acceptable EXCEPT doses of steroids > 20 mg Prednisone

Xolair new (Omalizumab) for moderate to severe asthma is acceptable Specific Acceptable Medications

LIPID LOWERING AGENTS:

ALL acceptable – Pilot is required to notify FAA at time of exam Specific Acceptable Medications

Gastrointestinal Medications:

. Limited use of Loperamide (Imodium)

. Unacceptable: Diphenoxylate (Lomotil), Anticholinergics (Bentyl), Opiates (Paregoric) Special Cases

The AME must defer a pilot who is taking continuous treatment with:

. Anticoagulants . Antivirals . Anxiolytics . Barbiturates Special Cases

FAA does not grant medical certification to a pilot who is receiving:

. Radiation therapy or chemotherapy for cancer treatment

. Investigational therapy or unapproved use of FDA approved medication Special Cases

A pilot who has donated 200 cc or more blood for plasmapheresis or whole blood should not fly for at least 24 hours CASE SCENARIO

41 y/o airline transport pilot with Colitis who has exacerbation and is placed on high-dose steroids

What would you do? CASE SCENARIO

50 y/o private pilot takes his son’s Methylphenidate, (Ritalin) because he feels he has ADHD and the medication makes him more alert

Psychology testing including the Trail Making Test (TMT), Wisconsin Card Sorting Test (WCST), Pace Auditory Serial Addition Test (PASAT) CASE SCENARIO

50 y/o airline transport pilot develops Type II Diabetes Mellitus and is treated with Glyburide (sulfonylurea). He also happens to be on Atenolol for HTN

The AME issues – Was he right?

No, because beta bloquers mask hypoglicemic signs CASE SCENARIO

45 y/o airman is given Bupropion HCL (Zyban) for a trial of Smoking Cessation.

The AME issues – Was he right?

No, because bupropion can cause sedation CASE SCENARIO

71 y/o pilot elects to receive External Beam Radiation and insertion of radioactive seeds (Brachytherapy) for Prostate cancer Can he get a commercial pilot medical certificate? During he active radiation therapy NO. But after implanting radioactive seeds YES Herbal (or Alternative) Medications

. In general, the FAA accepts the use of these medications . Do not accept those containing Ephedrine due to cardiac toxicity . Remember: It is the medical condition, not the medication that is the concern! Diet Pills

. The ONLY medication approved is Xenical – Xenical (Orlistat) can cause diarrhea and thus a 30 day period of non-flying is required. Websites with Aeromedical Information . AOPA.org . EAA.org . leftseat.com . www.aviationmedicine.com . www.cami.jccbi.gov Part 61.53

. Prohibition on operations during a medical deficiency . (a) . . . A person who holds a current medical certificate issued under part 67 of this chapter shall not act as pilot in command, or in any other capacity as a required pilot flight crewmember, while that person: Part 61.53

– (1) Knows or has reason to know of any medical condition that would make the person unable to meet the requirements for the medical certificate necessary for the pilot operation; or Part 61.53

– (2) is taking medication or receiving other treatment for a medical condition that results in the person being unable to meet the requirements necessary for the pilot operation.