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gastrointestinal tract, diarrhoea, bronchial constriction, perspiration, and bradycardia. Such effects could
interfere with the safe conduct of flight duties. Some examples of pharmaca in this class are bethanechol,
methacholine, and pilocarpine.
The anticholinesterases simulate the effects of the parasympathomimetic pharmaca and in addition produce
skeletal muscle weakness. Examples of these agents are neostigmine and physostigmine.
Anticholinesterase intoxication has long been recognized as a hazard for pilots engaged in “crop dusting”
with certain organophosphates and carbamates for purposes of insect control.
Sympathetic depressants (sympatholytics) tend to be less predictable than those agents noted above but in
1 Paregoric: a preparation of powdered opium, camphor, alcohol, glycerin etc., used in liquid form as an antiperistaltic
and mild pain reliever.
ICAO Preliminary Unedited Version — November 2009 III-14-5
general may be expected to produce postural hypotension, bradycardia, sedation, weakness, and mental
confusion. In some cases one might observe tachycardia and hyperventilation, seemingly effects of
sympathetic stimulation rather than depression. Examples of this class of pharmaca are methyldopa,
guanethidine, ganglionic blockers (hexamethonium, pentolinium), the rauwolfia group, and
dihydroergotamine alkaloids.
The first four of the above will be recognized as antihypertensive medicines.
In summary, the autonomic agents, a class of pharmaca with complex effects on the autonomic nervous
system, are in general unsuitable for use in active flight crew members.
SPECIFIC CLASSES OF MEDICINES
Analgesic medicines
Medicines to treat pain can be divided into two main classes: narcotic and non-narcotic.
The narcotic analgesics are prohibited from use by an active licence holder simply because of the general
depressant effects of the narcotics. It should also be pointed out that any pain severe enough to warrant a
narcotic must in itself be disqualifying for flying. The most commonly used narcotic analgesics are opium
derivatives, morphine derivatives, the methadone group, and the meperidine group.
The non-narcotic analgesics ordinarily do not have direct effects that would preclude flying duties. The
question of flight safety while using non-narcotic medications for pain should primarily concern the issues
of the severity of the pain and the cause of the pain. If the pain is severe enough to be distracting and/or if
the condition causing the pain is in itself disqualifying, then flying should be prohibited. Non-narcotic
analgesics can be exemplified as follows: salicylates; aniline derivatives (phenacetin, Saridon®, etc.);
acetaminophen/paracetamol (Tylenol®); pyrazolon derivatives; phenylbutazone; and proporyphene.
Codeine in small doses (15 mg every six hours) is probably safe for flying. Small doses of codeine are often
combined with salicylates, phenacetin, or other non-narcotic analgesics and these combinations should be
safe for flying as long as usual therapeutic doses are not exceeded.
As is the case with all pharmacotherapy, the medical examiner must always be aware of idiosyncracy and
be certain the licence holder tolerates the medicine before resuming aviation activities during such usage.
Certain minor surgical procedures such as dentistry may require local or regional anaesthesia or even
general anaesthesia. In any such case, the licence holder should cease operating until the effects of
anaesthesia have completely cleared and the possibility of post-treatment complications is deemed remote.
Antihypertensives
With the advent of a number of safe and effective antihypertensive medicines, many pilots and air traffic
controllers, who would have been disqualified in previous years because of hypertension, can now remain
in post. Most cases of essential hypertension will respond favourably to certain general health measures and
one or a combination of the following types of antihypertensive pharmaca: sartans (angiotensin receptor
antagonists); angiotensin converting enzyme (ACE) inhibitors; slow channel calcium blocking (CCB)
agents; diuretics; and beta adrenergic inhibitors.
Not all preparations within each of the following three classes are acceptable for the active pilot but some
of the more commonly used agents of these types can be considered safe for flying: diuretics (thiazides,
ICAO Preliminary Unedited Version — November 2009 III-14-6
hydrochlorthiazide, triamterene, spironolactone); beta-blockers (propranolol, metoprolol, nadolol,
atenolol); and calcium “blockade” agents (nifedipine).
Certain classes of antihypertensives, especially the non-diuretics, while commonly used in medical practice,
must be considered incompatible with flying: rauwolfia alkaloids; hydralazine; guanethidine; and minoxidil.
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Manual of Civil Aviation Medicine 2(104)
