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the vascular tree, for the reasons previously discussed. If the diet controlled diabetic is to be returned to
flying and his fitness status maintained, screening for coronary disease is important. The gold standard for
diagnosing coronary artery disease is coronary angiography; this method, however, is not without risk and
cannot be repeated on a regular basis. The resting ECG alone lacks the sensitivity and specificity required
in this group of high risk patients and it is thus logical to use a non-invasive technique which will predict
coronary artery disease with somewhat greater sensitivity than the resting ECG tracing. The exercise ECG
is a useful diagnostic tool in selected patients. It is not of value as a routine method for general screening,
as the prevalence of coronary artery disease in the pilot population overall is low.
If the exercise ECG is normal, a diet-only controlled diabetic pilot with good quality control and no overt
complications may return to flying subject to an annual assessment with an exercise ECG and a
satisfactory report from the treating diabetologist/ physician.
Agents which decrease the absorption of glucose from the intestine e.g. the α-glucosidase inhibitors such
as Glucobay, are acceptable as an adjuvant to diet.
Biguanide control
A similar certification policy applies in this group. However, those pilots treated with metformin tend to
be overweight and do carry a small albeit acceptable risk of lactic acidosis; their overall risk is slightly
greater than the diet only patient. Their assessment requires exemplary diabetic control and annual
review, to include an exercise ECG and, if this is satisfactory, they may be returned to flying with
limitation to multi-crew operations.
Diet and sulphonylurea control
The incidence of hypoglycaemia when taking sulphonylureas in the diabetic does not fully meet the one
per cent per annum level previously described, and thus these pilots are not normally acceptable for
recertification for public transport operations.
Diet and glitazone control
These drugs, more properly known as thiazolidenediones, enhance the sensitivity of the insulin receptor,
and when used as monotherapy do not cause hypoglycaemia. They are, therefore, acceptable for
certification. In combination with metformin and/or sulphonylureas hypoglycaemia is common and this
regime is not normally acceptable for certification.
Incretin therapy
ICAO Preliminary Unedited Version — March 2010 III-4-22
Drugs which act on the incretin pathway in combination with biguanides may be acceptable for restricted
professional certification. If used in combination with sulphonylureas they may potentiate
hypoglycaemia and are not usually acceptable.
CRITERIA FOR SATISFACTORY CONTROL FOR AVIATION DUTIES
It is essential that aircrew have satisfactory control before being returned to the operational environment.
They should be free from diabetic symptoms and maintain good nutrition.
Their metabolic control should be good and should not focus solely on blood glucose. In order to decrease
cardiovascular risk, a holistic approach should be taken. The targets for the relevant parameters are shown
in Table 2.
Table 2
Good control
Glucose:
Fasting
Post-prandial peak
< 6.7 mmol/L
< 9.0 mmol/L
HbA1c
< 7.0%
Blood pressure 130/80 mmHg
Total cholesterol < 4.8 mmol/L
LDL-C < 2.5 mmol/L
Triglycerides < 2.3 mmol/L
HDL-C > 1.0 mmol/L
The key to returning diabetic aircrew to aviation duties safely is to use evidence-based medicine to avoid
incapacitation in the aviation environment.
The aviation physician must liaise closely with the endocrinologist treating the aircrew, in order that the
benefits of both disciplines can be consolidated to produce a fair and objective assessment. All policies
for certification should be audited regularly in the light of developments in the world literature, and
modified accordingly.
ICAO Preliminary Unedited Version — March 2010 III-4A-1
APPENDIX 1
ASSESSMENT OF TYPE 2 INSULIN-TREATED DIABETIC APPLICANTS UNDER THE
PROVISIONS OF STANDARD 1.2.4.8 (“FLEXIBILITY STANDARD”)
This guidance should be used in conjunction with the preceding part of this chapter.
1. Introduction
The methods used to treat diabetic patients have improved over recent decades and individuals that
require insulin to mantain satisfactory blood glucose levels may apply, or re-apply, for a licence to fly or
to undertake air traffic control work. Although Annex 1, 6.3.2.16 (and 6.4.2.16, 6.5.2.16 for Class 2 and
3 respectively) normally precludes certification of insulin-treated diabetic applicants for any class of
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Manual of Civil Aviation Medicine 1(134)
