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include previous hypoglycaemia, long duration of diabetes, and impaired hypoglycaemic awareness.
From the literature review, the risk of hypoglycaemia in Type 1 diabetes is outside that which would be
acceptable in terms of the “1 per cent rule”. States using different risk criteria should make their own
assessment of risk.
For aircrew with Type 2 diabetes, whether taking insulin or not, individuals should be at low risk of
hypoglycaemia. What follows is a cautious protocol that may assist States to determine fitness in
applicants who present with Type 2 diabetes. It provides guidance and may be adjusted by individual
States to suit their own requirements.
PROTOCOL
Initial assessment
ICAO Preliminary Unedited Version — March 2010 III-4A-8
• Stimulated C-peptide levels > 25 per cent of normal;
• No previous hypoglycaemic episodes requiring the intervention of another person;
• Stable blood glucose control: satisfactory HbA1C ~ 7 – 8 per cent;
• Adequate self-monitoring with a memory chip glucose meter;
• No evidence of hypoglycaemic unawareness;
• Good diabetes education and understanding;
• Positive attitude to monitoring and self-care.
An annual assessment may include:
• Review of adequate self-monitoring with a glucose meter;
• Review of blood glucose control with satisfactory, stable HbA1C;
• Report from the treating physician to confirm no complications of diabetes, including renal
and visual complications;
• Annual cardiovascular assessment such as a symptom limited exercise ECG and clinical
review by a cardiologist.
Follow-up should be agreed jointly between the treating physician and the medical assessor.
This approach could be extended to encompass pilots and air traffic control officers with Type 2 diabetes
taking sulphonylureas as well as those requiring insulin.
Acknowledgements
Dr. Hugh O’Neill, Transport Canada
Dr. Warren Silberman, Federal Aviation Administration.
Julie Eden-Brown UK CAA
REFERENCES
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Barnett A, Grice J. NICE Guidance into Practice. Newer agents in the management of blood glucose in
type 2 diabetes. Practical Diabetes (Supp) 1-11, October 2009.
Berger W. Incidence of severe side-effects during therapy with sulphonylureas and biguanides. Horm
Metab Res 1985; 17:Suppl 14:111-5.
ICAO Preliminary Unedited Version — March 2010 III-4A-9
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