identified as having diabetes during the measurement year or the year prior to the members with diabetes on these medications are identified through …
Diabetes and Motor Vehicle Safety
April 19, 2006
Sponsored by Utah Department of Health Diabetes Prevention Control Program Utah Department of Public Safety Driver License Medical Advisory Board
Important Definitions
INSULIN — A hormone that allows glucose to enter body
cells and be used for energy Insulin is made by the beta cells of the pancreas and is released into the bloodstream when the glucose level rises
GLUCOSE — Glucose is the bodys basic fuel But it cant be
used for energy until insulin lets it into your bodys cells, except the cells of the nervous system brain, etc which can take in glucose without insulin And, if you dont have enough glucose or enough insulin, your body will burn fat instead of glucose to get its energy Signs that a person with diabetes has begun to burn fat, not glucose blood, are thirst or dry mouth, frequent need to urinate, and glucose blood levels are very high more than 240 mg/dL Thats not good–when fat is used for energy, it leaves behind ketones Ketones enter the urine from the blood
Important Definitions
DIABETIC KETOACIDOSIS — High ketone levels lead to
the serious condition called diabetic ketoacidosis Ketoacidosis occurs most
often in people with Type 1 diabetes–rarely in someone with Type 2 Causes include too little insulin, infection, high stress or trauma Warning signs are: excess urination, nausea, vomiting, stomach pain, heavy breathing, weak, rapid pulse, flushed face, dehydration, very dry skin and mouth, confusion, fatigue and a fruity breath odor
The Driver with Diabetes Is Responsible To Adhere To Strict Diabetes Regimen
Drivers cannot neglect diabetes medications, but taking all the insulin or pills every day can be overwhelming There are now a variety of drug and insulin options that can make dosing more convenient Drivers with either Type 1 or Type 2 diabetes must strive to keep their blood glucose sugar levels near the normal range Better glucose control reduces the risk for diabetes-related complications
HYPERGLYCEMIA — A blood glucose level that is too high
It occurs when the body does not have enough insulin or cannot use the insulin it has to enable glucose to enter cells Over time, high levels of glucose in the blood can damage blood vessels, leading to many complications Common symptoms of hyperglycemia include being very thirsty and having to urinate frequently
HYPOGLYCEMIA
– An abnormally low blood glucose level
It occurs when insulin, food, and exercise are out of balance Common symptoms include feeling weak, shaky, nervous, sweaty, confused, and hungry Very severe hypoglycemia can lead to unconsciousness, seizures, and coma
The Driver with Diabetes Is Responsible To Adhere To Strict Diabetes Regimen
Along with proper diet, exercise, and blood pressure control, taking diabetes medications exactly as prescribed–adhering to the dosing regimen–goes far toward preventing complications Studies show, however, that far too few people adhere to their regimens Treatment plans for diabetes may be quite complex– daily insulin injections or pills, or both, along with blood glucose monitoring Tracking carbohydrate intake isnt easy, either
Daily Diabetes Care Managed By Diabetic Driver
Research has revealed major barriers to diabetes control Many people fear that they will take too much insulin or too many pills, which can lead to low blood sugar hypoglycemia or weight gain To avoid these serious side effects, people sometimes take fewer doses than they are prescribed Other individuals may take excess doses of their drugs in an attempt to prevent high blood
sugar hyperglycemia Both approaches are forms of non-adherence The fact is, 99 of daily diabetes care is managed by the driver, not by the diabetes care team Its success depends largely on the drivers understanding of and commitment to the blood glucose control regimen Education, however, is critical
1
Type 1 and Type 2 Diabetes
Current treatment for Type 1 diabetes calls for multiple injections of short-acting bolus insulin and long-acting basal insulin For Type 2 diabetes, a combination of diabetes pills plus basal insulin injected once or twice a day is a common treatment regimen Other individuals with Type 2 diabetes may achieve glucose on diet alone or with oral medications Another bolus-basal approach is NPH It is usually given in 2 doses each day, but 1 can be given Insulin glargine and insulin detemir are long-acting analogs man-made insulin preparations that keep insulin levels steady over the course of 24 hours For example, studies have shown that once-daily glargine Lantus insulin can control blood glucose levels at least as well as NPH insulin administered once or twice daily
Type 1 and Type 2 Diabetes
The insulin pump, which delivers a continuous dose of insulin
under the skin, is an alternative to injections of long-acting insulin An effective type of medication now affords somewhat simpler treatment of Type 2 diabetes: Two diabetes drugs with different modes of action, for example metformin and glyburide, are packaged in a single pill, Glucovance Metformin improves the cells sensitivity to insulin, whereas glyburide stimulates the release of insulin from the pancreas Amaryl glimepiride can also provide good glucose control with once-a-day dosing, as can Glucotrol glipizide
Diabetes Must Be In Constant Check
Normal glucose range 60-100 mg/DL 33 to 56 mmol/L
Diabetes Must Be In Constant Check
Typical warning signs associated with hypoglycemia:
trembling, tremors, sweating anxiety, nausea sudden episodes of dizziness or collapse confusion exhaustion headaches, inability to concentrate generalized weakness or debility visual disturbances NOTE: Severe hypoglycemia may cause loss of consciousness, seizures convulsions, coma and even death
DIABETES Either you control it, or it controls you
Drivers with diabetes run a high risk of losing driving privileges or requiring restrictions placed on their driving privilege, if they will
not take responsibility for their diabetes to avoid complications and to drive safely at all times
Diabetes Must Be In Constant Check
INDIVIDUALS SO AFFLICTED SHOULD NOT DRIVE A MOTOR VEHICLE UNTIL THESE SYMPTOMS HAVE BEEN CONTROLLED BY APPROPRIATE THERAPY Health care professionals should report all of these types of complications and episodes
Driver Health Care Professional Must Determine Maintain Effective Daily Diabetes Management
People with diabetes have been involved in almost twice as many motor vehicle accidents as the nondiabetic driving population Careful evaluation and medical management can increase their safety and the safety of our highways Even people with diabetes whose glucoses are well controlled with insulin or oral hypoglycemic drugs may occasionally suffer a hypoglycemic episode
2
Driver Health Care Professional Must Determine Maintain Effective Daily Diabetes Management
It is important that the health care professional ascertain the cause of these occasional episodes and change the diabetes management of the patient Before deciding the drivers diabetes condition is again stable enough for them to drive a motor vehicle, the health care
professional should observe the patient under the new management program to be sure that it is effective
Hypoglycemic Unawareness
Certain insulin-requiring individuals with diabetes are much more likely than average to have altered consciousness from hypoglycemic episodes These individuals have hypoglycemic unawareness, which is a lack of symptoms to alert them of the likelihood of hypoglycemia, and the opportunity to treat the hypoglycemia with food intake to prevent the progression to severe hypoglycemia The best predictor of whether or not a diabetic patient is likely to experience severe hypoglycemia, is a history of a recent episode of severe hypoglycemia under any circumstances
Hypoglycemic Unawareness
A typical profile of such individuals includes previous episodes of hypoglycemia-induced unconsciousness, long duration diabetes and possibly autonomic neuropathy or beta blocker therapy The health care professional should take these factors into account when profiling the medical condition on the Driver License Functional Ability Evaluation Medical Report in appropriate categories
Health Care Professionals Must Educate Diabetic Drivers
It is strongly recommended that
health care professionals counsel drivers who are being treated with insulin or insulinstimulating oral medications to carry in their vehicles at ALL times, a source of rapidly absorbed carbohydrate, and their glucose meters Further, blood glucose monitoring just prior to driving is absolutely essential to maintain safety for any diabetic driver with a history of limited awareness of hypoglycemia
Health Care Professionals Must Educate Diabetic Drivers
Oral antidiabetic medications which are highly unlikely to lead to hypoglycemia unless used in combination with insulin or sulonylurea include Metformin, AlphaGlucosidase inhibitors and insulin sensitizers thiazolidenediones Examples of rapidly absorbed carbohydrates are: juice, soda with sugar not diet, hard candy, or glucose tablets
Profile Levels of Utah Drivers with Diabetes
An applicant in Utah must have their health care professional complete a Functional Ability Evaluation Medical Report in Category A and other categories as appropriate The health care professional must profile the driver according to the 8 medical profile levels which are outlined on the next slide
3
CATEGORY A: DIABETES MELLITUS AND OTHER METABOLIC
CONDITIONS PRIVATE
Profile Level
DIABETES MELLITUS
No history of diabetes mellitus or elevated blood sugar A history of elevated blood sugar, but no positive diagnosis of diabetes made Any diabetes stable on diet, adult onset diabetes stable on diet and/or oral agents which are non-insulin stimulating Diabetes stable on diet and insulin stimulating agents Stabilized Diabetes with INSULIN INJECTIONS with no episodes of ketosis or altered consciousness for one year Stabilized Diabetes with INSULIN INJECTIONS with no episodes of ketosis or altered consciousness for 6 months Stabilized Diabetes with INSULIN INJECTIONS with no episodes of ketosis or altered consciousness for 3 months Special circumstances not listed above or under evaluation DRIVING RESTRICTIONS: Speed, Area, Daylight Only, and other restrictions as recommended by health care professional Severe UNSTABLE insulin-dependent diabetes or persisting ketosis
Medical Report Required
No Yes
Interval For Review
N/A 1 Year
License Class Restrictions
Private Vehicle Private Vehicle
Category A
Profile Level 2
Non-Insulin Stimulating Medication Diet
ORAL MEDICATION ONLY GENERIC NAME
1 2 3 4 5 6 7
Glucophage Avandia Actos
Glyset Precose Avandamet Actosplus Metformin
Metformin Rosiglitazone Pioglitazone Miglitol Acarbose Rosiglitazone Metformin Pioglitazone Metformin
Yes Yes Yes Yes
1 Year 1 Year 1 Year 6 months
Private Vehicle Private Vehicle Private Vehicle Private with health care recommendations Private Veh SAD NO DRIVING
Yes
As rec
8
Yes
N/A
Category A
ORAL MEDICATION ONLY Amaryl Dibeta Micronase Glynase Glucovance Diabinese Glucotrol Metaglip Prandin Starlix Tolinase Avandaryl Byetta injection not insulin Symlin injection not insulin
Profile Level 3
GENERIC NAME Glimepiride Glybruide Glybruide Metformin Chlorpropamide Glipizide Glipizide Metformin Repaglinide Nateglinide Tolazamide Glimepiride Rosiglitazone Exenatide Pramlintide
Category A
Lantus Levemir Humulin U Humulin L Humulin N Novolin N Humalog Novalog Apidra Humalog Mix 75/25 and 50/50 Humulin 70/30 Novolin 70/30 Novolog Mix 70/30 Humulin R Exubera
Profile Level 4
Glargine Determir Ultra-lente Lente NPH NPH Lispro Aspart Glulysine NPH Insulin lispro NPH / Regular NPH / Regular NPH Insulin Aspart Regular Inhaled Insulin
Insulin Stimulating Medication Diet
INSULIN INJECTIONS
Diabetic Retinopathy
Several factors
influence whether diabetics will develop retinopathy These include the patients blood sugar control, blood pressure levels, how long they have had diabetes, and family history The longer your patient has had diabetes, the more likely they are to have retinopathy But the retinopathy that destroys vision, proliferative retinopathy is far less common Good blood glucose control is essential The sooner retinopathy is diagnosed, the more likely treatments will be successful The best results occur when sight is still normal
Diabetic Retinopathy
VISION GUIDELINES UTAHS CERTIFICATE OF VISUAL EXAMINATION PROFILE LEVELS Vision Profile Levels Regular Operator Only summary
1 20/40 or better in each eye Monocular 120 in each eye Bin VF 70 to R/L 2 20/40 or better in better eye Monocular 120 in each eye Bin VF 60 to R/L 3 20/40 or better in better eye Bin VF at least 120 total 60 to R/L 4 20/40 or better in better eye Bin VF at least 90 total 45 to R/L 5 20/50 tp 20/70 in better eye Bin VF at least 90 total 45 to R/L Speed Restriction Required for Level 5 speeds less than 40 mph or less 6 20/80 to 20/100 in better eye Bin VF at least 60 total 30 to R/L MAB Required Must successfully
pass driving skills test; add speed, area radius, daylight only restrictions to license and other restrictions as determined by DL Examiner 7 Special circumstances not covered by any of the above Bin VF 60 30 R/L -MAB 8 20/40 or better in better Bin VF at least 60 total 30 to right MAB Required 9 20/40 or better in better eye Bin VF at least 60 total 30 to left MAB Required 10 20/200 or worse Binocular VF less than 60 NO DRIVING
4
Driver License Functional Ability Evaluation Medical Report and/or Certificate of Visual Examination Report
A driver must be medically qualified to drive a motor vehicle according to Utahs Medical Guidelines When an applicant wants to obtain or renew a Utah driving privilege, they must complete a Driver License Application, ie, first-time license, or renewal, or duplicate The applicant must answer Yes or No to all thirteen 13 questions on the Medical Questionnaire These medical questions include the following medical categories: A Diabetes; B Cardiovascular; C Pulmonary; D Neurologic; E Epilepsy or Seizures; F Learning Memory; G Psychiatric; H Alcohol/Drugs; I Visual Acuity; J Musculoskeletal and Chronic Debilities; K Alertness Sleep
Disorders; L Hearing Balance; Other health problems or use of medications which might interfere with driving ability or safety
Driver License Functional Ability Evaluation Medical Report and/or Certificate of Visual Examination Report
If the applicant answers YES to one or more of the above categories, and there are NO previous medical reports on the driving history in the specified category, the applicant will be required to sign date and have their health care professional sign, date complete profile levels on the Driver License Functional Ability Evaluation Medical Report and/or Driver License Certificate of Visual Examination Report which must be filed with the Driver License Division to avoid the DENIAL of driving privileges IMPORTANT NOTICE: Once a medical profile level in one or more categories has been reported to the Driver License Division Medical Section, the medical categories will be continued to be tracked on the drivers history by the Driver License Division This requires the driver to file a Medical Report ie, yearly for Diabetes according to the specified interval for review associated with the medical category, and also depending upon the profile level, to
maintain a VALID driving privilege in Utah
Diabetes Driver Licensing Questions
Are applicants for a drivers license asked questions about diabetes?
Yes The Utah Driver License Application first time and renewals and duplicates presents a list of medical conditions one of which is diabetes and asks the applicant whether he or she has any of these medical conditions Applicants who answer Yes to these questions must have a medical evaluation form and/or visual examination completed by their health care professional
Diabetes Driver Licensing Questions
What other ways does Utah have to find out about people who may not be able to drive safely because of medical or visual conditions?
The state accepts reports of potentially unsafe drivers from: all law enforcement agencies; police officers, the courts, physicians, family members, friends, other citizens, health care professionals and hospitals Utah does not accept anonymous reports, and does not investigate reports before the driver is required to go through the medical/visual evaluation process Drivers may also be required to have a medical/visual evaluation if they have impairments which are observed by licensing agency personnel
during the licensing process, when they contribute to an accident that results in a fatality, or after accumulating a given number of crashes within a certain time period
Medical Visual Evaluations of Utah Drivers
What is the process for medical evaluations of drivers?
When the Utah Driver License Division learns that a driver has diabetes, it will require the individual to have a medical and/or visual evaluation When this happens, an evaluation forms is sent to the individual, which must be completed by the drivers health care professional On the Functional Ability Evaluation Medical Report form and/or Certificate of Visual Examination, the health care professional indicates a profile level of the patients functional ability to drive medical vision as it is impacted by diabetes and other medical conditions Functional Ability Evaluation Medical Reports and/or Certificate of Visual Examinations are completed by driver health care professionals after being signed, dated Then, the medical and visual reports are returned to the Driver License Division Medical Section for review and a licensing decision
Medical Visual Evaluations of Utah Drivers
Who makes decisions about whether
drivers are medically qualified?
Medical Reports and Visual Reports are evaluated by nonmedical licensing agency personnel who make decisions based primarily on information provided by the health care professional and the profiled category level of the drivers functional ability Depending on the health care professionals recommendation, some cases may be referred to the Utah Driver License Medical Advisory Board for a recommendation
5
Utahs Diabetes Licensing Policies
Has Utah adopted specific policies about whether people with diabetes are allowed to drive?
Yes Utah requires that diabetes be controlled with insulin, oral medication, diet or exercise to permit driving All applicants with diabetes must submit a medical evaluation and regular follow-up evaluations The frequency of follow-up evaluations is based on the stability and severity of the condition Individuals who control their diabetes without insulin, or who use insulin but have had no episodes of ketosis or altered consciousness for one year, must have follow-up medical evaluations every year Individuals who use insulin and have had episodes of loss of consciousness more than three months ago but less than one year
ago must have a follow-up evaluation in six months, and may only drive with their physicians recommendation
Utahs Diabetes Licensing Policies
What are Utahs Medical Guidelines about episodes of altered consciousness or loss of consciousness that may be due to diabetes?
No specific episode-free time period is required by Utah; however, instructions given to health care professionals filling out medical evaluation forms suggest that individuals who have had an episode of altered consciousness due to diabetes, within the last three months, should not be licensed unless special circumstances are present
Driver License Appeal Process
What is the process for appealing a decision of the state regarding a drivers license?
The individual may, within ten days of receiving notice of the action, request in writing a review of the divisions action by a panel of the Driver License Medical Advisory Board The panel will review medical reports and medical records released by the driver and health care professional, review the driving record, and provide written finding and conclusions to the licensing agency
Driver License Appeal Process
May an individual whose license is DENIED because of
diabetes receive a probationary or restricted license? Their driving privilege would be determined by the profile level on the completed Functional Ability Evaluation Medical Report and/or Certificate of Visual Examination A profile level 8 medical in Category A would deny privileges A profile level 7 medical report could possibly maintain driving privileges with restrictions such as speed, area radius, and daylight only, accompanied by licensed driver The driver may be required to successfully complete a driving skills test, either requested by the health care professional or required to pass by the Driver License Division A profile level 10 visual report denies driving privileges A health care provider, when completing the Medical Report and/or Visual Report, may recommend the driver pass a driving skills test any time they determine it should be necessary, regardless of the profile levels on the vision exam or in any category on the medical report Is a Utah Identification Card available for non-drivers? Yes, with proper identification and payment of a fee If a driver loses their Utah driving privilege due to a medical condition, they may receive a free ID Card by surrendering
their driver license
Educating Patients on How Diabetes Can Affect Driving Safety
In the short term, diabetes can make your blood glucose sugar levels too high or too low As a result, diabetes can make you: feel sleepy or dizzy, feel confused, have blurred vision, lose consciousness or have a seizure In the long run, diabetes can lead to problems that affect driving Diabetes may cause nerve damage in your hands, legs and feet, or cause diabetic eye diseases In some cases, diabetes can cause blindness or lead to amputation
Counsel Drivers To Ensure They Can Drive Safely with Diabetes
1 Insulin and some oral medications can cause blood glucose levels to become dangerously low hypoglycemia Do not drive if your blood glucose level is too low If you do, you might not be able to make good choices, focus on your driving or control your car Make sure you always carry your blood glucose meter and plenty of snacks including a quick-acting source of glucose with you Pull over as soon as you feel any of the signs of a low blood glucose level to check your blood glucose as soon as it is safe to do so
2
6
Counsel Drivers To Ensure They Can Drive Safely with Diabetes
3 If your glucose level
is low, eat a snack that contains a fast-acting sugar such as juice, soda with sugar not diet, hard candy, or glucose tablets Wait 15 minutes, and then check your blood glucose again Treat again as needed Do not continue driving until your blood glucose level has improved Most people with diabetes experience warning signs of a low blood glucose level However, if you experience hypoglycemia without advance warning, you should not drive Talk to your health care team about how glycemic awareness training might help you sense the beginning stages of hypoglycemia
Counsel Drivers To Ensure They Can Drive Safely with Diabetes
5 In extreme situations, high blood glucose levels hyperglycemia also may affect driving Talk to your health care team if you have a history of very high glucose levels to determine at what point such levels might affect your ability to be a safe driver The key to preventing diabetes-related eye problems is good control of blood glucose levels, good blood pressure control and good eye care A yearly exam with an eye care professional is essential
4
6
Counsel Drivers To Ensure They Can Drive Safely with Diabetes
7 If you are experiencing long-term complications of
diabetes such as vision or sensation problems, or if you have had an amputation, your diabetes health care team can refer you to a driving specialist Improving your driving skills could help keep you and others around you safe To find a specialist near you, call the Association of Driver Rehabilitation Specialists at 1-800-290-2344 or go to their website at wwwadednet You also can call hospitals and rehabilitation facilities to find an occupational therapist who can help with the driving skills assessment
Commercial Drivers Intrastate vs Interstate
Category A — Diabetes Mellitus DOT Medical Card Denied INSULIN INJECTIONS UTAH K RESTRICTION REQUIRED INTRASTATE ONLY A-04 Stabilized diabetes with insulin no episodes of ketosis or altered consciousness for one year yearly rev A-05 Stabilized diabetes with insulin no episodes of ketosis or altered consciousness for six months yearly rev Profiled lower: COMMERCIAL PRIVILEGE DENIED
8
GREAT NEWS FOR DIABETICS TAKING INSULIN FROM FMCSA
Required For Commercial Diabetic Drivers Intrastate Only K Restriction
Patient underwent a complete medical evaluation by a health care professional who assessed the results of the following
procedures prior to determining whether the person is qualified to operate a commercial motor vehicle
Required For Commercial Diabetic Drivers Intrastate Only K Restriction
Examination and tests to detect peripheral neuropathy and/or circulatory deficiencies of the extremities A detailed evaluation of insulin dosages and types, diet utilized for control and any significant lifestyle factors, such as smoking, alcohol use and other medications or drugs taken The health care professional certifies that the driver has been educated in diabetes and its control and thoroughly informed of and has demonstrated the understanding of the procedures which must be followed to monitor and manage their diabetes and what actions should be followed if complications arise The health care professional ascertains that the driver has the ability, willingness, and equipment to properly monitor and manage their diabetes A blood glucose monitor with electronic memory is required
At least two results of glycolysated hemoglobins Hb A1C during the last 6 months: A lipid profile, urinalysis and CBC Blood pressure readings at rest, sitting and standing Elevated blood pressure, medication for hypertension or
other evidence of any cardiovascular abnormality will require a maximal exercise stress EKG Ophthalmologic confirmation of absence of visually significant retinal disease
7
FMCSA - INTERSTATE
Federal Motor Carrier Safety Administration
Effective 11-8-2005, applications for Federal Diabetes Waivers will no longer be denied because the drivers do not have three 3 years of experience operating commercial motor vehicle while using insulin To apply for a Federal Diabetes Waiver please call the following telephone number to order your Federal Diabetes Waiver Packet:
RESOURCES
American Diabetes Association wwwdiabetesorg Federal Motor Carrier Safety Administration wwwfmcsadotgovrulesregs/medreports Utah Department of Public Safety Driver License Division wwwdriverlicenseutahgov
FMCSA FEDERAL DIABETES PROGRAM 400 SEVENTH STREET, SW, RM 8301 WASHINGTON DC 20590 TEL: 703-448-3094 FAX: 703-448-3077
NOTE: ALLOW AT LEAST THREE TO FIVE MONTHS TO COMPLETE
8
Source:annfammed.org
