Aeromedical Newsletter - Vol. 25, Issue 3

President's Corner

FAA Policy and Personnel Updates

FAA Staffing Updates

AMAS bids a fond farewell to Dr. Courtney Scott who retired from the FAA in July. Dr. Scott was a prior Manager of the Aeromedical Certification Division and has helped countless airmen return to flying over the years. Additionally, we welcome Dr. David Snell who replaced the retiring Dr. Steve Veronneau as the Northwest Mountain Regional Flight Surgeon.

FAA Medical Certification Backlog

The Federal Air Surgeon, Dr. Northrup, recently provided further updates on the FAA’s efforts to decrease medical certification backlog. As of August, Dr. Northrup estimates an approximately 44% decrease in cases pending since January of this year. She also emphasized the importance of having all of the necessary aeromedical issues addressed up front noting that if the FAA has to ask for additional information it typically results in an additional 3-month delay for certification reviews.

FAA Medication Updates

In August, the FAA approved another antidepressant medication, Viibryd (vilazodone), which is a serotonin modulator increasing levels in the brain to regulate mood. This medication is often mentioned as having fewer sexual side effects and possibly less weight gain than others. With this new addition, there are now nine medications for which the FAA is willing to consider Special Issuance to return to flying while taking the antidepressant. There is a requirement for at least six months of observation on the medication with monitoring by an FAA trained AME or “Independent Medical Sponsor”.  

The FAA recently added several medications to their Acceptable Combinations of Diabetes Medications list.  All medications for diabetes would require a Special Issuance as outlined here. Newer medications include Tanzeum (albiglutide), Adlyxin (lixisenatide), Orinase (tolbutamide), Tolinase (tolazamide), and Brenzavvy (bexagliflozin). Please contact an AMAS physician if you need assistance with this FAA reporting and clearance.

The FAA recently made significant updates to allow pharmaceuticals for many of their Conditions that AME Can Issue (CACIs), such as those for migraines, psoriasis, arthritis, and colitis. Your AMAS clinical team would be happy to review your particular situation if you feel you may have been affected by these changes.

New policies were released regarding intraocular lens (IOL) placement, typically completed for cataracts. If surgery is to be within 3 months of an upcoming FAA exam, you will be required to provide your AME with a completed Eyes – LENS Implant Status Summary found here. There is now a mandated 2-week recovery for standard IOLs, including Toric lenses, before returning to flying. There is a 6-week recovery required for light-adjustable lenses, with at least 2 weeks since the final adjustment is made.  Finally, there is a 12-week recovery required for those using lenses that correct for near vision, multifocal lenses, or extended depth of focus lenses.

The FAA also issued new guidelines for refractive surgery. If surgery is completed within 3 months of the upcoming exam, the FAA’s Eyes – Refractive Surgery Status Summary is required as noted here. There is a mandated 2-week recovery period after a LASIK or SMILE procedure and a 12-week recovery period after PRK. See related vision articles on the AMAS website for further information.

For those who take a PCSK9 inhibitor such as Repatha (evolocuab) or Praluent (alirocumab) for difficult to control cholesterol, the FAA dropped the previously required 4 hour waiting time after each dose.

In September, the FAA made some minor changes to their CACI requirements for well-controlled asthma and low testosterone with supplementation. Your AMAS physician can review these conditions with you if applicable to ensure you are prepared for your next FAA exam.

Airman & Controller's "Ask the Doc"

from the AMAS Clinical Team

Question: The FAA is making me do a CT scan for my waiver and I am concerned because as a pilot I think I already get too much radiation. What are my options?

Answer:  As a former submarine officer, I am familiar with the health effects of radiation.  One aspect to understand is that there is not a direct dose/response relationship for radiation. The effects of radiation are instead what we call stochastic, which I like to explain using a lottery ticket analogy. Every bit of radiation received is like getting a lottery ticket, with the “prize” being cancer or some other adverse health effect. You can buy many tickets and never “win,” or if unlucky, you can hit the “prize” after just a few.  The correlation is statistical and depends on the chances that a damaging bit of radiation causes just the right type of cell damage to start the process towards malignancy. Just like the lottery, the odds are vanishingly small, but with enough chances, an event will eventually occur.  

Another difficulty with radiation is that it is still very unclear just what that statistical risk actually is. Cancer can result from a wide variety of causes – genetic, nutritional, environmental, hormonal and metabolic. It can be extremely difficult to tease out the role of any individual factor. The best information we have is on studies that followed the health of survivors after the atomic bombs were dropped on Hiroshima and Nagasaki.  But those doses were extremely high, and it is not certain whether the risks seen in that population can be extrapolated linearly down the low doses typically received from exposures such as living at altitude, flying, medical imaging and treatments, etc. A lot of research has been done, and a VERY rough estimate is that the dose associated with a typical CT scan correlates with about a one in 10,000 chance of some adverse event.  

An individual cannot avoid all radiation. It is always present in our environment to some degree. Therefore, the guiding principle is ALARA – as low as reasonably achievable – simply meaning don’t buy unnecessary lottery tickets. Relatively speaking the risk of a single CT is very low, and that is why doctors order them without much concern.  Multiple tests combined with other exposures like flying at higher altitudes and over polar routes (where the earth’s magnetic field offers less protection from cosmic radiation), living at altitude, radon and other natural sources can raise the overall dose and therefore risk, but it still remains relatively low.  The federal dose limit for people who work with radiation is 5 REM (a unit that measures the overall health effect of radiation exposure) per year. A typical airline pilot will not approach this limit even after several medical imaging tests.

The FAA acknowledged the ALARA principle when they eliminated the "every other year" nuclear stress test requirement for most 1^st class coronary artery disease Special Issuance renewals. However, the FAA’s primary concern is airspace safety, so given the relatively low risk of medical imaging they generally will not accept a fear of radiation as a reason not to perform what is deemed a necessary study. Of course, your primary care doctor knows your health status the best, and can discuss the risks and benefits of any test or procedure in the context of your overall health history. If there is a pressing argument as to why a particular test is unwarranted, we at AMAS are happy to assist in making that case to the FAA. 

Question: I am scheduled for my regular screening colonoscopy. When can I return to work afterward?

Answer: This depends on the type of sedation used. Most commonly, it will be a medication called Propofol alone. If that is the case, the required wait time is 48 hours. Another possibility is what is called “conscious sedation” with a combination of Fentanyl and Versed. This only requires a 24-hour wait. However, in rare cases, other drugs may be used that could have considerably longer “down times.” If you find your procedure will involve medications not listed above, call our office for specific guidance. Also, if your doctor tells you a longer recovery time is appropriate for whatever reason, then certainly abide by that. If the results are benign, then you can simply wait the appropriate amount of time, clear yourself back to flying, and then report the routine procedure on your next medical application. But should there be a significant finding, such as a malignancy or other diagnosis, you should again call our office for advice. In general, you do not need to ground yourself awaiting the pathology results of any biopsies/polyps taken unless there is a high degree of suspicion. The presence of diverticuli (outpouchings in the colon) is not disqualifying. However, these can sometimes become inflamed and cause abdominal pain, fever, and other symptoms. Of course, it would be appropriate to ground oneself until any such acute episode of diverticulitis has been treated – usually with antibiotics - and resolved.  

AMAS in the News Advocating for Health and Safety

Aviation Medicine Advisory Service