Aeromedical Policy Updates

1
Aeromedical Policy Updates

• LTC Monica B. Gorbandt, MD, MPH, FACP
• Director, US Army Aeromedical Activity
• OAP
• December 2002

2
AAMA Goals

• Medically qualified aviation personnel
• Safe mission execution
• Prevention not disease detection- Be proactive!

3
Overview

• Cyclic Process- review and update of all policies
• Approval Authority currently is CDR, USAAMC
• Multiple inputs to revision

4
Current Policy Approval Process
Policy Approval Process
Consultant Review
AAMA Review Policy Redraft Letter
Modify
CDR, USAAMC AM OTSG Consultant Review
ACAP Electronic Review
Application Feedback
ACAP Formal Review Comment
CDR, USAAMC Approval
Distribution
5
Topics Updated Oct- Dec 01

• Hypertension
• Hyperlipidemia
• Abnormal Pap Smears
• Cardiovascular Screening Program
• Coronary Artery Disease
• Abnormal Cardiac Function Testing
• ATB 6 Aeromedical GXT

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Topics Updated Oct- Dec 01

• ATB 9 Cardiac Fluoroscopy
• HIV
• Hepatitis
• Refractive Surgery and Surveillance Program

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Hypertension

• Aggressive Primary Prevention
• Use of ARBs approved
• CXR and slit-lamp exam for initial evaluation
  deleted
• No mandatory 30 day grounding for medications-
  observe for SE and FFD when stable and BP trends
  appropriately
• Goal treat borderline cases and aggressively
  use medications to prevent sequelae

8
Hyperlipidemia (HLD)

• Definition of HLD, Total Chol gt255 not 270
• Expansion of statin class
• Change to requirements for lab f/u
• Do not wait until age 40 to start treating HLD!
• Aggressive primary prevention to prevent CAD
• Initiating medications- ground for sufficient
  period to observe for side effects before local
  flight clearance.

9
Abnormal Pap Smears

• NO longer required for initial flight PE- all
  classes
• Revised to reflect Bethesda Classification
• ASCUS LGSIL- treat locally- IO
• HGSIL and CIS- treat submit for waiver

10
Coronary Artery Disease

• 3 year f/u with cardiology and either Thallium
  GXT, Stress Echo or EBCT
• No required follow-up cardiac catheterization
  unless clinically indicated
• Follow-up catheter requirements determined by
  changes in condition or on f/u testing.

11
Cardiovascular Screening Program

• Four distinct levels
• Level 1- Risk Factor Assessment
• LDL gt190 preferred over use of Total Cholesterol
  gt255.
• Ratio and FRI criteria unchanged
• Level 2- AGXT or EBCT
• Cardiac Fluoroscopy Deleted
• Abnormal EBCT- Calcium Score gt400

12
Cardiovascular Screening Program

• Level 3- Noninvasive
• Thallium GXT(Preferred) or Stress Echocardiogram
• 24 hour Holter and Echocardiogram Deleted
• Level 4- Invasive
• Cardiac Catheterization
• Proceed to level 4 only after review with AAMA

13
Abnormal Cardiac Function Testing

• Delete Cardiac Fluoroscopy
• Add EBCT
• Only submit copies of final reports to AAMA
• Do not send complete tracings or films/CD
• AAMA will request full reports if required

14
ATB 6 AGXT

• Elimination of Borderline Readings
• AGXT is either normal or abnormal
• No requirement for Potassium level prior to test

15
ATB 9 Cardiac Fluoroscopy

• Deleted

16
HIV

• No change to waiver policy
• Updated to reflect current clinical guidelines

17
Hepatitis

• Hepatitis A B unchanged
• Hepatitis C
• Guidelines for evaluation and follow-up included
• Evaluation can be done by any GI specialist
• Mandatory grounding for treatment

18
Refractive Surgery

• Class 1A, 1W, and 2- must be enrolled in studies
  to obtain ETP or Waiver.
• Class 2F, 3, and 4- can apply for waiver for
  LASIK/PRK.
• Reviewed on case-by-case basis
• Multiple criteria and information required for
  ETP/Waiver-details in APLs.
• Study Acceptance does not guarantee a qualified
  FDME or acceptance into flight training.

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Topics Updated Jan 02- Nov 02

• Allergic/Nonallergic Rhinitis
• Medications
• Renal Stones
• Endocrine
• Headache/Migraine
• Overweight

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Topics Updated Jan02-Nov 02

• Contact Lens Wear
• Dermatology
• Gastroenterology
• Alcohol Misuse
• Vision ATBs
• Herbals/Supplements

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Allergic and Nonallergic Rhinitis

• IO-mild cases with sxslt 30 days/yr on specified
  treatments.
• Rated aircrew-waiver if sxs gt30 days/yr or need
  immunotherapy or chronic nonsedating
  antihistamine.
• AMS- No longer require sinus xray, nasal smears,
  blood eosinophil counts.

22
Medications

• Additions of ARBs for HTN, COX2s for analgesia.
• Metformin now can be used for Class 2F, 3, and 4
  aircrew with waiver.
• Intranasal steroids,anticholinergics or cromolym
  sodium now class 2B.

23
Renal Stones

• APL lists indications and use of CT scans to
  guide f/u for retained stones.
• Renal stone worksheet only requires one set of
  blood chemistries vs three.
• Other lab requirements for initial waiver
  submission-unchanged.

24
Hypo/hyperthyroidism

• Both conditions can be submitted for waiver/ETP
  once euthyroid and no eye issues.
• F/U labs required with each comprehensive FDME,
  but recommend FS/APA assess annually.

25
Diabetes Mellitus and Prediabetes

• Medications for rated aviators- case-by-case
  basis.
• rare waiver.
• Metformin for Class 2F, 3, and 4 aircrew.
• Oral Hypoglycemics extended to include class 2F,
  and 4.

26
Headache/Migraine

• History is key in determining classification.
• Waiver is dependent on triggers, chances of
  recurrence, and affects on performance.

27
Smoking Cessation

• Use of Zyban as Information Only.
• Many caveats to safe use, listing in APL.
• Grounding mandatory for first two weeks of use,
  then at discretion of FS/APA.
• Usual treatment course 8-12 weeks.
• Best if used in conjunction with a formal program.

28
Overweight Aircrew

• 250 lb rule is gone.
• Search for underlying disorders.
• Safety focus- wear of equipment, access/egress,
  flight control manipulation.
• FS/APA assists Command with provisions of AR
  600-9- an administrative not aeromedical program.

29
Contact Lens Wear

• Wear allowed for all classes as Information Only
• Must meet visual standards and have initial and
  annual f/u evaluations.
• Evaluations
• Current contact lens parameters
• Visual acuity near and far with lens wear
• SLE
• Complications of wear

30
Atopic Dermatitis

• Mild to moderate cases-Information only.
• Expand treatments to include tacrolimus ointment.
• Use of intermediate or high potency topical
  steroids or oral meds is DQ.

31
Dermatophytosis of the Nail

• No longer recommend use of Griseofulvin.
• Itraconazole and terbinafine are OK for short
  term use, pulse therapy is recommended and
  aircrew must be grounded during the treatment.
• Follow-up monthly LFTs itraconazole, LFTS and
  CBC terbinafine.
• Ciclopirox topical 8 (PENLAC) OK for chronic use.

32
Psoriasis

• Additions to authorized treatments
• Vitamin D analogs Calcipotriene
• Topical retinoid Tazaratene

33
GERD

• ETP or Waiver required only if condition
  associated with the five warning symptoms
• Dysphagia or odynophagia
• Sxs persistent or progressive on chronic therapy
• Bleeding or iron deficiency
• Unexplained weight loss
• Other extraesophageal symptoms
• Other cases Information Only

34
PUD

• Impact of H. Pylori treatment for cure
• Follow-up- only if symptom recurrence
• ETP for single episode may be considered

35
Ulcerative Colitis

• Addition of Mesalamine to authorized medications

36
Crohns Disease

• Addition of Mesalamine to authorized medications.
• Information required includes radiologic reports
  and CBC/ESR.

37
Alcohol Related Disorder, NOS (Alcohol Misuse)

• Single episode- Information Only
• Requires evaluation by ASAP to ensure no
  underlying problem
• Multiple Episodes require additional evaluation
  per APL
• Considered on case-by-case basis

38
Vision ATBs

• Collection on website serves as how-to guide
  for eye examinations
• Depth Perception- Verhoeff no longer accepted for
  FDMEs dated 1 Jan 2003 or later
• Color Vision- FALANT/OPTEC 18 light pair retest
  is still authorized

39
Vision ATBs

• Current vision standards Class 1A/W DVA 20/50
• Cycloplegic Refraction
• Hyperopia- no more than 3.00 in each eye
• Myopia- no more than 1.50 in each eye
• Astigmatism- no more than /-1.00

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Herbals/Supplements

• New Policy
• Aligned with Class 1,2 and 3 medication classes
• Any substance not listed is prohibited-
  individuals can request waiver for other
  preparations via FS/APA
• Remember to assess for the underlying medical
  problem individual is treating
• Evolving area- use references and give feedback
  to AAMA

41
Herbals/Supplements- Class 1

• No FS approval but report with annual FDME
• MVI/Mineral tablets qd
• Vitamins C,E,B6, B12 (oral)
• Calcium, Folate
• Protein Supplements- shakes, capsules, and
  nutritional bars

42
Herbals/Supplements-Class 2

• Require prior approval from FS/APA
• All use must be reported in any form
• Vitamins A,K, D, Niacin, Riboflavin, Thiamine
• Magnesium, Zinc, Chromium,Selenium, Copper
• Glucosamine with or without Chrondroitin
• Echinacea for less that two weeks use
• Saw Palmetto, Creatine
• Ginseng- prohibited 24 hrs before flight

43
Herbals/Supplements-Class 3

• All other preparations not specifically listed
  are disqualifying for flight duties.
• Waivers can be requested- unlikely.

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Future Updates

• OSA
• ATB 2- administrative guide-coming soon
• Hematology
• Infectious Disease

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Obstructive Sleep Apnea

• Sleep Apnea is disqualifying for aviation duty
• Exceptions to policy rare
• Waivers possible on a case-by- case basis
• Must demonstrate resolution on posttreatment PSG
• Possible treatments for waiver weight loss,
  dental device, surgery, CPAP

46
Administrative Guide

• Comprehensive FDMES Every 5 yrs, ages 20-50 and
  then annually
• Interim FDMES No routine labs or EKG requirements

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Changes on Initial FDMEs

• Currently in effect
• Deletion of 4700 Medical history continuation
  sheets
• Delete RPR and body fat
• CXR required only if clinically indicated
• EKG required, no need to send tracing, initial
  and then only as clinically indicated until age
  40-then annually
• Pap smear not required

48
Changes for all FDMES

• Currently in effect
• DRE- by inspection to age 40 unless clinically
  indicated
• Both Hb/Hct acceptable

49
Consultants

• List updated on website in November
• Specialties in need endocrine, rheumatology,
  neurosurgery, addiction medicine, ENT.
• If you know of a particular specialist who is a
  FS or are a subspecialist and wish to assist- let
  us know!

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Backlog

• Personnel Reduction
• Total FDME Increase
• Information Technology-transition
• Resolution Efforts

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POC

• LTC Monica Gorbandt
• Director, AAMA
• Monica.gorbandt_at_se.amedd.army.mil
• (334) 255- 7346/7575
• FAX [phone]
• DSN 558

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APLs on the Web

• Website http//usasam.amedd.army.mil/_AAMA/policy
  letter.htm
• Via USAAMC or USASAM websites
• Updates published on a monthly basis

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QUESTIONS
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New VFSO Names

• GATOR- Global Aeromedical Tracking Online Record
  System
• APEX- Aviation Physical Examination
• GRAPE- Global Recording of Aviation Physical
  Examinations
• FSFOS- Flight Surgeons From Outer Space
• FRED- Flight Records Entry Database

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And a few more

• AERO- Aeromedical Electronic Resource Office
• MADCOW- Medical Aviation Data Collection
  OperationWebserver
• SPAMER- Special Program for Aviation Medicine
  Electronic Repository
• FINGER- Flight Information Network Gathering of
  Examination Results
• WOMENS- Worldwide Operational Medical Exam
  Network Server