Medications and Flying

Air Line Pilot, November/December 1999, page 18
By. W. Keith Martin, M.D. Associate Aeromedical Advisor

The U.S. Federal Aviation Administration does not publish a list of approved medications, and the agency has been extremely inconsistent in approving medication for use while on flight duty. We are providing here an updated list of medications that the FAA commonly approves for use during flight, plus restrictions on medication use and a list of the medications the agency does not normally approve for airmen to use. Remember--the FAA's primary concern is whether the medical condition for which you are being treated will compromise flight safety. The issue of treating the condition with medication is of secondary concern. The FAA also will ground pilots who experience unacceptable side effects from approved medication. Please contact the ALPA Aeromedical Office if you have a question about a specific medication or need a full explanation of the current FAA policy.

New medications that the FAA does not currently approve:

* Celebrex (celecoxib) and Vioxx (rofe-coxib) are two of a new category of arthritis medications, Cox-2 inhibitors, which have much lower irritating effects on the stomach than other anti-inflammatory medications. They do not affect clotting or bleeding. We anticipate FAA approval in early 2000.

* Meridia (sibutramine) is a weight-reduction drug that suppresses appetite and is being marketed as a replacement for "Fen-Phen" without Fen-Phen's potentially lethal heart and lung side effects. We do not anticipate FAA approval in the future.

* Celexa (citalopram), a new antidepressant medication with generally minimal side effects, comes under the FAA's blanket ban on antidepressant medication and is not approved for pilots' use.

* Avandia (rosiglitazone), the newest oral antidiabetic medication and similar to Rezulin, is not yet approved. If side effects from using the drug are minimal through May 2000, the FAA likely will approve the use of Avandia by pilots.

New medications that the FAA has recently approved:

* Detrol (tolterodine) is a bladder antispasmodic that controls overactive bladders without side effects affecting vision and sensitivity to light. Pilots must undergo a 1-month ground observation period without side effects, such as altered near vision, before the FAA will review and approve use of the drug.

* Xenical (orlistat) is a "fat blocking" lipase inhibitor that helps the user lose weight by blocking fat absorption from the intestines by one third, thus reducing calories absorbed through the intestines. A pilot must complete a 2-week observation period without significant side effects, such as abdominal gas production and greasy, loose stools, before returning to flying. The unwanted side effects may be worse at altitude. The drug may also reduce vitamin absorption.

* Prandin (repaglinide) is used to control blood glucose in diabetics who do not require insulin to control the disease.

* Micardis (telmisartin), a new Angiotensin-II type medication used to control blood pressure, may be approved after the FAA or your AME reviews your cardiovascular evaluation.

Allergy and cold medications: The FAA will approve the use of the over-the-counter (OTC) decongestants pseudoephedrine (the active ingredient in plain Sudafed) and phenylpropanolamine, if they are not combined with any antihistamines. In general, pilots should use only the "non-drowsy" or "daytime" products. Additionally, the FAA has approved the prescription nonsedating antihistamines Hismanal, Claritin, and Allegra for flight deck use.

The FAA does not currently approve the prescription antihistamines Zyrtec or Astelin for use during flight duty. If you use one of these medications, you must wait 24 to 36 hours after the last dose before flying.

The FAA approves treatment with desensitization injections (allergy shots), which you should document and report to the FAA during your routine FAA airman medical examination.

The FAA also permits airmen to use nasal steroid inhalers such as Becanase, Vancenase, Nasalide, and Flonase. Inhalers such as Afrin are not permitted for use before flight, but you may carry some Afrin in a flight bag to use in emergency situations with ear or sinus blocks on descent.

All other OTC cold and allergy medications require that you wait twice the dosing interval since your last dose of the medication before you fly again. In other words, if the label states, "Take every 6 hours," you must wait at least 12 hours since your last dose before flying again.

Many liquid and inhalant medications contain alcohol, which may produce a positive reading if you take an alcohol breath test. The FAA prohibits airmen from ingesting alcohol in any form less than 8 hours before flying.

Antacids/stomach medications: For normal "acid indigestion" or reflux esophagitis, OTC antacids (Tums, Rolaids, Mylanta, etc.) are allowed. The FAA permits airmen who can document that they do not have an ulcer to take prescription medications such as Tagamet, Prilosec, Pepcid, and Zantac.

Several of these medications are now available in OTC strengths, and the FAA approves of airmen using them while on flight duty.

Antibiotics: The FAA allows airmen to use most antibiotics, as long as the airmen experience no side effects after using the medication for 48 hours or have used the medication previously without suffering any side effects. The underlying condition must be improved enough so as not to interfere with flight safety.

Antidepressants and psychoactive medications: The FAA will not approve any of the medications in this category--including serotonin uptake inhibitors (Celexa, Effexor, Prozac, Paxil, and Zoloft) as well as other psychoactive medications (Lithium, Buspar, Elavil, Sinequan, Amitripityline, etc.). Pilots who undergo treatment with these medications can be cleared to return to flight duty after they have stopped taking the medication and the treatment issues have been resolved. The FAA generally requires the pilot to wait 60–90 days after completing treatment with the medication. You must submit records of your treatment to the FAA for the agency's approval.

Antihypertensive (blood pressure-reducing) medications: These include a wide variety of medications such as diuretics, beta-adrenergic blocking agents, ACE inhibitors, calcium channel blockers, labetolol, prazosin, and minoxidil. The FAA does not automatically approve use of these medications. The agency requires that you demonstrate normalization of blood pressure and undergo a required evaluation to make sure you have no other disease. Your aviation medical examiner (AME) can grant initial approval for using these medications if you hold an airman medical certificate of any class.

Anti-inflammatory/pain medications: OTC medications such as aspirin, Tylenol, Advil, Aleve, Mediprin, and Motrin IB are allowed for flight deck use. Prescriptions for similar medications, including Motrin, Naprosyn, Voltaren, Ansaid, and Indocin, are allowed as long as you experience no side effects after 48 hours of use. This assumes that the condition for which you are using the medication will not interfere with your safe performance of flight duties.

Again, the FAA does not now allow pilots to use the new Cox-2 inhibitors, Celebrex and Vioxx, while flying.

The FAA does not approve for flight duty use any medications containing narcotics or codeine--Tylenol No. 3, Demerol, Darvon, Darvocet, Lortab, Percodan, Ultram, etc. If you use any of these, you must wait a specified amount of time--usually 72 hours--after stopping the medication before flying again.

Asthma medications: The FAA approves use of certain medications, including inhaled corticosteroids, for treatment of mild asthma. The agency must review and approve the condition and treatment on a case-by-case basis before permitting the airman to return to flight duties.

Attention deficit disorder medications: Current FAA policy does not allow persons who use the medications Ritalin or Dexedrine to hold a first- or second-class airman medical certificate. The FAA now has a protocol--a defined method--for evaluating pilots with attention deficit disorder before the agency will issue a waiver. Some pilots using the above medications have received a waiver after neurocognitive testing showed adequate performance off the medication. The waiver prohibits the pilot from flying until 24 hours after taking these drugs.

Cancer medications or other chemotherapy: While the patient is undergoing treatment, these medications are not allowed for flight duty. After treatment is completed, the FAA will review the case and consider approving the airman's return to the cockpit. In certain situations--initial hormonal therapy for prostate cancer or immunosuppressive medications for transplants and arthritis, for example--the FAA will allow continued cockpit duty during treatment. To fly on these medications, a pilot must experience no ill side effects and have a waiver.

Cholesterol-lowering medications: The FAA permits airmen to use medications such as Mevacor, Lopid, niacin, Questran, Pravachol, Lipitor, and Zocor without obtaining prior approval.

Diabetes/hypoglycemic medications: The FAA will approve most blood-sugar-lowering medications after appropriate evaluation and review. A specific protocol is available for those pilots with diabetes who need a waiver. The agency now approves use of some of the newer agents, including Amaryl, Glucophage, Rezulin metformin (Glucophage), Prandin, and Precose. The FAA has not yet approved Avandia (rosiglitazone), but a decision is pending. Insulin is now allowed for third-class medical certification under special issuance on a case-by-case basis. The need to use insulin to control diabetes, however, will still disqualify an applicant for a first- or second-class airman medical certificate.

Diet supplements/herbal preparations/appetite suppressants: Most OTC medications of this type contain antihistamines and are not allowed for flight deck use. Pilots who use them must wait before flying for a period of time similar to that required for use of OTC cold medications. Prescription appetite suppressants such as Redux, Fen/Phen, Meridia, and Pondimin are not allowed for flight deck use. For Xenical (orlistat), see "New medications," page 18.

General nutritional supplements and herbal preparations that are manufactured and sold within the United States, such as ma huang, usually are not regulated by the FDA, and the FAA does not restrict them for flight duty use. However, pilots should be careful to take these supplements only in recommended doses. Dietary supplements and herbal preparations produced in the United States have not been found to cause positive urine drug test results.

Fungal medications: The FAA generally allows airmen to use oral medications such as Gris-PEG and Sporanox to treat chronic nail fungal infections if the airmen using the drugs undergo proper medical monitoring and do not suffer side effects.

Glaucoma medications: The FAA approves use of most anti-glaucoma agents. To obtain FAA permission to use the medication, a pilot must provide to the agency an initial condition evaluation on FAA Form 8500-14 (Evaluation for Glaucoma).

Heart/cardiac medications: The FAA has approved airmen to use a wide variety of these medications in certain conditions, depending on the individual's health, provided the airman's condition is stable and the agency reviews the case.

Intestinal/antidiarrheal/antispasmodic medications: OTC preparations such as Kaopectate and Pepto-Bismol are allowed if the symptoms are not severe. If you use prescription medications such as Lomotil, Bentyl, Levsin, Donnatal, and Librax, you must wait for a period of time after the last dose, varying with the specific medicine involved, before returning to flight duty. Cantil, another antispasmodic for irritable bowel syndrome, is not approved.

Male impotence medication: The Food and Drug Administration recently approved Viagra (sildenafil citrate) as the first oral form (pill) for the treatment of erectile dysfunction. The FAA recommends that pilots use the medication strictly in the dosages that the manufacturer recommends and that pilots who use it strictly observe all contraindications (reasons not to use the medication). Pilots should not use Viagra less than 6 hours before performing their aviation duties.

Migraine headache medication: Individual cases vary greatly; however, after evaluation and FAA review, the agency will permit use of certain prophylactic migraine-headache medications. These medications to prevent migraines--beta blockers and calcium channel blockers--are primarily used for heart conditions and high blood pressure, but they may also be effective in vascular (migraine type) headaches.

The FAA generally does not allow pilots to use injectable medications (Imitrex and Zomig) and oral agents (Imitrex, Zomig, and caffergot) to abort a migraine headache while on flight duty. Pilots who succeed in eliminating a migraine with these medications may be allowed to carry them in flight for emergency use only in flight, but such pilots will not be approved for using these medications as a primary means of controlling the headaches. Use of these medications automatically grounds a pilot for a minimum of 72 hours following the last dose and resolution of the migraine.

Muscle relaxants: Medications in this broad category, such as Robaxin, Flexeril, and Valium, are not allowed. They all have definite sedating and judgment-impairing side effects.

Oral contraceptives: All birth control pills are allowed.

Parkinson's disease medications: In certain situations, the FAA allows airmen to use certain medications to control Parkinson's disease. The FAA must review and qualify each individual case before the airman can return to flight duty.

The FAA has approved Sinemet and Eldepryl. Until recently, the FAA had approved two new medications, Mirapex and Requip. Tasmar is not approved.

Pain control: Pain control medications fall into four broad categories. Two--non-steroidal anti-inflammatory medications (NSAIDs) and acetominophen (Tylenol and other "non-aspirin" pain relievers)--are approved. Two--narcotics for short-term relief of severe pain and antidepressant medications (even in very low doses) for long-term chronic pain relief--are not approved; both have the potential to impair alertness and judgment. Narcotic-type medications may also produce a positive result in DOT drug testing programs.

Prostate medications: In most cases, the FAA approves use of medications such as Cardura, Flomax, Hytrin, and Proscar for treatment of benign prostatic hypertrophy (BPH). Airmen treated with these medications should ground-test them for several days to determine whether they develop any side effects. Pilots can report this use to the FAA during their next medical examinations. The use of saw palmetto to control BPH symptoms does not need to be reported on your FAA medical application.

Use of Zoloft for treatment of BPH is not approved for flight duty.

Sleep-inducing medications: No over-the-counter sleep preparations, which include Sominex, Tylenol PM, and Excedrin PM, are allowed for flight deck use; and all require waiting 12–24 hours from last dose to flight duty. Prescription medications such as Halcion and Restoril are not approved for airmen.

Pilots who take Ambien (zolpidem), another prescription medication, must wait 24–48 hours after the last dose before flying.

Some dietary supplements, such as melatonin, reportedly help reduce sleep problems. The FAA generally allows airmen to use these supplements if those airmen do not suffer side effects from them. However, claims about these dietary supplements' benefits in treating insomnia and "jet lag" are often overstated.

Smoking cessation medications: The medication Zyban (bupropion) is not approved for use while on flight duty. Zyban is generally recommended for use over a period of 7 to 12 weeks, which is not generally practical for most pilots. Pilot who use short-term medication should discontinue it at least 5 days before flying. Nicotine gum or dermal patches are allowed for flight use, provided the pilot has used one or the other over a 2- to 3-day period without significant side effects.

Steroids: On a short-term basis, FAA allows use of oral corticosteroids at a total dose of 20 mg or less of prednisone per day provided the pilot has suffered no ill side effects. Initial treatment with steroid dose packs at a total daily dose of greater than 20 mg is not allowed for flight duty use. The FAA approves chronic use of oral steroids on a case-by-case basis. The underlying condition that the steroids are treating is the key issue with the FAA. Many medical problems are treated with steroids. Conditions such as poison ivy are not aeromedically significant, whereas conditions such as multiple sclerosis or asthma treated with steroids would restrict a pilot from flying until receiving an FAA waiver.

Anabolic steroids (muscle-building compounds) cause significant side effects and are used legally only for very specific medical conditions. The FAA may issue a waiver for use for these conditions after an observation period and reporting to the FAA. Use without a prescription is illegal--the FAA will not approve that use for pilots.

Thyroid medications: The FAA approves use of these medications once the treated condition is stable and the airman's physician provides documentation indicating that the airman's thyroid function has returned to normal (euthyroid). Thyroid cancer treated with medication requires an FAA waiver before the pilot can return to flight duties.

Topical (skin) medications: All, including antibiotic and steroid creams, psoriasis treatments, and sports creams, are generally allowed.

Skin/acne medications: Acne is treated with both topical (applied to the skin) and oral medications. All topical medications, such as benzoyl peroxide, Retin-A, and anti-biotic creams, are allowed without waiver. Oral antibiotics are also allowed after a 2-day observation period without side effects.

Accutane is approved, but because of the medication's potential to produce a harmful effect on night vision, pilots taking Accutane will have a restriction placed on their medical certificates stating "Not Valid for Night Flying."

Hair growth medications: Topical medications that promote hair growth (Rogaine, minoxidil) are approved for flight duty use. Oral medications such as Propecia (finisteride) and Procaine are allowed if the pilot has no side effects after a ground test period of at least 2 days.

Vaccinations: Shots and immunizations, including anthrax immunization, are not disqualifying for flying. Some people experience some side effects following immunizations, particularly from live, attenuated types of vaccines, and a pilot should remain grounded if feeling poorly. However, the FAA has established no minimum grounding period for pilots after receiving an immunization. Side effects may be minimized by taking aspirin or acetominophen after the shot.

The ALPA Aeromedical Office is available to answer your questions regarding medications and their use. A full text version of the above information and related links can be found on the "Members Only" section of the ALPA website www2.alpa.org in the "Aeromedical" section of "Other Services."

W. Keith Martin, M.D., M.P.H., is an associate aeromedical advisor with ALPA's Aeromedical Office, which is located in Aurora, Colo.