Hypoglycemia. Hypoglycemia. Hypoglycemia. That may be (just about) all you need to know about diabetes and FMCSA safety concerns.
While it is true that hyperglycemia can be associated with mental status changes and effects on physical functioning that increase driver safety risk, such concerns are unlikely to manifest suddenly and with immediate concern. Hypoglycemic reactions, on the other hand, often occur quickly and are often associated with immediate effects on cognition, alertness, and even consciousness.
It is for this reason that insulin dependent diabetes mellitus (IDDM) is the diabetic condition of greatest concern for driver safety, since insulin use is far more likely to be associated with sudden hypoglycemia than use of oral medications used for glycemic control. Drivers with IDDM may not be certified except by waiver or exemption, and the requirements for waiver and exemption are stringent and complex. These include requirements to maintain glucose monitoring logs, to check blood sugar before and during driving at specified intervals, to have annual ophthalmology and endocrinology consultation, and to complete waiver and exemption application requirements at least every two years.
Driver education is crucial, and medical examiners should document discussion with all drivers with diabetes regarding issues related to hypoglycemia, diet, and exercise. Fingerstick blood sugar should be checked at each examination. Although there are no specific requirements with respect to hemoglobin A1c level, most examiners will require that this is being monitored and may place upper end limits the examiner considers acceptable for driver certification.
Drivers with diabetes often have comorbid conditions, especially cardiovascular issues. Diabetes is a coronary heart disease risk-equivalent condition, which should be considered when monitoring a driver with, or at high risk for, cardiovascular disease. Obesity, so often attendant to diabetes and a significant risk factor for diabetes, should be addressed. Medical examiners should recognize the broad leeway granted them by the Federal Motor Carrier Safety Administration to monitor and place limits on driver medical conditions such as diabetes – although medical examiners should not certify drivers with insulin dependent diabetes, medical examiners may also choose not to certify drivers with diabetes, even if not insulin dependent, if the medical examiner considers the driver to be at significant risk for a safety related event that could have serious consequences.
Steven St. Clair, MD, MPH
Dr. St. Clair is a medical consultant to the NRCME Training Institute, LLC. The NRCME Training Institute, LLC provides an affordable 100% online DOT medical examiner training program which meets and exceeds FMCSA requirements.