Medication Pitfalls

September 26, 2007
Written by Tarek M. Sardana, MD
Beware of the Risks
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 His wife also finds that he has become withdrawn recently and is moody.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.

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