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Features Safety
Medication Pitfalls

Beware of the Risks


September 26, 2007
By Tarek M. Sardana MD

Topics

Many pilots may not consider the risks or problems associated with many
prescription or over-the-counter (OTC) medications. The following case
example will highlight some of these concerns.

JS
is a 40-year-old pilot who flies for a small executive aircraft company
that shuttles oil workers from southern Alberta to the northern Alberta
oilfields for their weekly work schedule.

He is married and has
three children aged 13, 7 and 6. He finds the pressures of juggling his
flying schedule with his family time to be extremely challenging. He
doesn’t sleep well partially due to his shift schedule and also due to
the ‘stress’ of his career. He has lost weight and seems frazzled most
of the time. His wife also finds that he has become withdrawn recently
and is moody. After a few months of feeling this way, JS finally agrees
to see his family doctor to discuss his present situation. After a few
visits with his physician, JS is diagnosed with a generalized anxiety
disorder (GAD) and started on an anti-anxiety medication known as
Effexor (venlafaxine) which belongs to a group of medications known as
SSRIs (Selective Serotonin Reuptake Inhibitors) of which Prozac
(fluoxetine) is probably the most recognized among the general public.
His mood and energy level increases over the next few weeks, and his
anxiety settles down nicely. He is happier and more productive at work,
and his family and friends have noticed a positive change. So what is
the big concern with this case?

There are actually several concerning issues which this case illustrates:

1.
JS went to see his family doctor and was treated for a condition and
with a medication that is not at present approved for flying by
Transport Canada. JS did not let his Civil Aviation Medical Examiner
(CAME) know that he was on a new medication and consequently he is now
flying with an unreported medical condition and he is using a
non-allowed medication. These medications have side effects which may
make them unsafe in the flying environment (see below).

2. The
family doctor had forgotten that JS was a pilot and he was not aware of
the concerns, from an aviation medicine point of view, with the types
of medications on which he started JS. As a physician he is obligated
to report JS to the Regional Aviation Medical Officer (RAMO) in order
for the RAMO to review the case.

3. Had the family doctor
remembered that JS was a pilot, he may have considered other forms of
non-pharmacological therapy such as Cognitive-Behaviour Therapy (CBT)
which is a specific form of psychological counseling which could
alleviate JS’s symptoms while allowing him to continue to fly.

Specific Drug Classes/Medical Conditions of Concern:

Transport
Canada published an excellent summary article entitled “Mandatory
reporting of Unfit Pilots, Air Traffic Controllers and Flight
Engineers” in the Aviation Safety Letter (ASL 4/2006). In this article,
several common medical conditions are discussed with their specific
aeromedical disposition. There are literally thousands of medications
(prescription and OTC) available in Canada and I obviously won’t be
able to cover all the issues, but I will summarize some of the more
common groups below:

1. Psychiatric Conditions
Psychiatric
conditions include all conditions that may interfere with judgment,
decision- making and/or reaction time; and these must be reported to
your CAME. This includes reporting any medication that you may be
taking to treat this type of condition. Medications in this group
include medications such as Prozac, Effexor, Celexa, and Ativan among
others. People suffering from these types of conditions often have
subtle and/or unrecognized impairment in concentration, reaction time
and thought processing. These subtle incapacitations may have
disastrous consequences in a critical phase of flight. Individuals
often need to be evaluated by a psychiatrist, preferably with an
aviation background, to facilitate treatment and return to flight
status.

2. Cardiovascular Conditions
All cardiovascular
conditions must be reported including any heart rhythm disturbances,
hypertensions, cardiac inflammation and infection, heart attacks,
angina, cardiac surgery, pacemakers etc. Some common medications in
this group include Coumadin, blood pressure medications, and
cholesterol medications such as Lipitor. Most individuals will be
returned to flight status once all investigations and assessments are
completed; assuming of course that no significant underlying pathology
is uncovered.

3. Erectile Dysfunction
Medications used to
treat ED may cause vision changes, specifically in the blue-green
vision band and this could affect night vision. If being treated with
these medications, you should discuss it with your CAME in order to
understand potential flight restrictions. While medications such as
Viagra obviously benefit the user (and his partner?), there are some
subtle issues related to using such medications in the flying
environment.

4. Allergy/Decongestant Medications
Many OTC
medications can cause significant side effects including drowsiness and
dizziness. Obviously, these are of significant concern in the aviation
environment and should be used with caution under the supervision of
your CAME. Common medications of concern include Sudafed and Actifed
which may cause dizziness, fatigue, drowsiness etc. While no medication
in this group is necessarily contraindicated in the civilian flying
environment, it is nevertheless important to discuss any
concerns/issues with either your family doctor or CAME. Mixing
medications (whether prescription or OTC) is another area of great
concern as the effects of mixing many common types of medications are
not known. Individually, a medication may not have any significant side
effects, but in mixing there could be disastrous issues. It would be
wise to discuss multiple medication use with either your family doctor,
CAME and/or your pharmacist.

While the above discussion is by no
means a comprehensive examination of all drug classes, it is a good
starting point. The bottom line is that if you have been started on any
new medications and/or have experienced a new medical condition, you
must discuss it with your CAME as soon as possible.

Conclusion
There
are many subtle and not commonly known issues with many medications
that are used in Canada today. If you are taking any over-thecounter
medications and/or any prescription medications that your CAME may not
be aware of, you should schedule an appointment as soon as possible
with him/her in order to discuss your medication profile. Our role as
CAMEs is to keep pilots flying and we may be able to do so with perhaps
some minor adjustments in medications. When in doubt, always check with
your CAME as we would rather help you sooner than when it may be too
late.