AINsight: Medications and Flying

 - December 14, 2018, 6:31 AM

One of the more confusing aspects of FAA medical certification is the role of medications. Whether a medication is prescription or over-the-counter, the FAA usually has justifiable reasons to be informed as to their use. That said, the “rules” involved can be mystifying both to pilots and their AMEs.

Before you run to the medicine cabinet to discard all of your medications or assume that you must shred any documents that even mention prescriptions, please take comfort in that many medications and the conditions for which they are being taken are potentially approvable. For the most part, a pilot is not dead in the proverbial water if he/she needs to take medications.

You’ll notice that I mentioned “the conditions for which they are being taken.” Medication usage is evaluated not just on the basis of the medication itself, but always additionally in the context of why it is being taken. For example, a medication might be entirely acceptable in one circumstance but not in another.

Consider the following: beta-blockers (such as metoprolol, carvedilol, and their cousins) are used routinely in treatment for hypertension (high blood pressure) and cardiac rhythm control. FAA certification in such instances usually requires a bit of documentation, but these medications are quite routinely approved. However, beta-blockers can also be used in the treatment of intractable migraines and panic attacks. In those situations, it’s the medical condition itself more than the medication that is of interest to the FAA

Therefore, when asking the AME if you can fly when taking a certain medication, the question must always include the reason it is being prescribed.

A word of caution: if a medical treatment or medication is needed on an urgent basis, do not delay that care waiting to chat with the AME. This happens all the time. I have had pilots in emergency departments refusing an evaluation for chest pain or possible stroke symptoms until they could get in touch with me. As I’ve said before, it’s easier to keep you flying if you are still alive. If the care is “urgent” or “emergent” just do what you need to do, and the AME can interface later.

That said, if a non-urgent medication recommendation is given by a physician, of course run that by your AME (or your airline’s consulting physicians) before embarking on that particular course of treatment. If, for example, your physician is recommending that you begin treatment for hypertension, allergies, erectile dysfunction, thyroid conditions, etc., discuss those with the AME. Usually, such treatments will be acceptable. If formal documentation will be required, usually it’s simple to obtain. The AME can help guide the pilot as to whether the medication recommended is acceptable to the FAA in the setting for which it is prescribed. Again, the medication and the medical condition are equally important.

There are times, however, that the prescribing physician will say to a pilot, “The FAA shouldn’t have any problems with this medication.” The pilot begins that treatment in good conscience, only to find out at the time of the next FAA examination that the recommended medication is not one approved by the FAA. Suddenly, there will be some hasty last-minute adjustments made to ensure that the treatment meets acceptable protocols.

Did the prescribing physician lead the pilot astray? Certainly not intentionally. It is the prescribing physician’s job to provide good care, and that’s what he/she did when giving the medication to the pilot. However, it is not the prescribing physician’s job to know all of the nuances that the FAA (and AMEs) must consider when the medication is used in the aviation community. Once again, ask the AME.

Another typical problem is when a prescribing physician reaches into the sample cabinet for the newest, greatest medication for a given condition. Please understand that the FAA typically waits a year or longer before approving any new medications. It must be determined that there are no significant post-research problems that are uncovered in mass usage before permitting them to be used in pilots. Again, ask the AME.

In addition to the AME, there are resources that can help a pilot make appropriate medication decisions. Both AOPA and ALPA publish lists of general guidance. These are “general guidance” and not doctrine. There is, in fact, no formal list published by the FAA. It’s not that the FAA takes joy in perpetuating some mystery in this process, it’s just that it would be impossible to publish a single medication document that outlines every potential nuance of why a medication might be prescribed. 

The process, therefore, remains a bit nebulous and an ongoing moving target. The AOPA and ALPA lists are useful but not the final word. There are times when a medication might be listed as unapproved for flying, but on a case-by-case basis, it might be approved. And, of course, there are times that a medication listed as approved might not be in the circumstance for which it is being prescribed. What is the best course of action? Ask the…I’m sure you get it by now.

There are also neither formal FARs nor guidance in the Code of Federal Regulations for the use of most prescription medications. Obviously, drugs of abuse are not ever going to be approvable. However, most other medications require some thought. Hence, in addition to the AOPA and ALPA resources, a pilot can search the FAA website for the Guide for Aviation Medical Examiners. This is a public document that requires no password to review. There are sections within this massive set of protocols that specifically address medications. There is also a section that clearly lists medications that a pilot should not take while flying (and the AME shouldn’t approve without FAA review). This is found in  “Pharmaceuticals, Do Not Issue – Do Not Fly.” Again, these are policies, not FARs. However, the FAA would consider adherence to published policy as, in essence, the pilot’s legal responsibility. This can bring about the kind of debate that attorneys and expert witnesses truly enjoy. My best advice is to stay away from situations that involve legal challenges by doing your homework thoroughly in regard to medications and flying.

When does a medication decision become unquestionably regulatory?  An example would be when a pilot has listed a medication on the 8500-8 MedXpress application form and the FAA has responded with a formal disposition letter. Hopefully, this letter will state that it’s acceptable to fly, but it might also mandate some restrictions to its use.  One such example is that there could be a formal waiting period before flying after taking the medication. No different from operations specifications, once the medication has been formally ruled on in a disposition letter to that pilot, the provisions become regulatory.

In my next blog, I’ll discuss more in regard to commonly used specific classes of medications and how the FAA reviews their usage. In the meantime, ask the AME if you have questions. All AMEs are busy, and questions outside of the time for the FAA exam itself can become burdensome (so please respect that the AME’s time is precious). However, I believe that all AMEs want what is best for their pilots, including proactively keeping them out of trouble. Seek the AME’s guidance when new medical conditions and/or medications are now part of your medical history.