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AEROMEDICAL CONCERNS FOR
THERAPEUTICS IN AIRCREWS
87TH ASMA ANNUAL SCIENTIFIC MEETING ATLANTIC CITY - APRIL 22 -
29, 2016
MANEN O, MD, Pr MONIN J, BISCONTE S, HORNEZ AP,
HUIBAN N, GUIU G, BERTRAN PE, PERRIER E
Percy Military Hospital, Clamart, France Aeromedical Center
Cardiology and Aviation Medicine Department
French Military Health Service
Academy
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DISCLOSURE INFORMATION
MANEN Olivier
87TH ASMA ANNUAL SCIENTIFIC MEETING
I have no financial relationships to disclose
The opinions or assertions expressed here in are the private
views of the authors
and are not to be considered as official or as reflecting the
views of
the French Military Health Service, or .
French Military Health Service
Academy
Percy Military Hospital, Clamart, France Aeromedical Center
Cardiology and Aviation Medicine Department
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Medicines : a significant place in the life of aircrews A French
study: 1,329 professional pilots 39 yo, 64% civil, 36% military 15
y experience, 32% monopilots A regular / daily medical treatment
for 12% / 4% Automedication in 56% 44% precise their job to
chemists What is true reality about drug consumption in aircrews ?
Medicines… but other therapeutics
BACKGROUND
Fratus L. Thesis of Medicine, 2010 Med Aero Spat 2011; 195(52):
89-100
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Therapeutics : a responsability written for civil aircrews A new
European medical certificate with a medical information from the
Commission Regulation (EU) n°1128/2011 of 3 November 2011
BACKGROUND
CLASSE 1 / 2 / LAPL CLASS 1 / 2 / LAPL
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In care medicine : the health Molecules / Techniques Protocols
Studies Recommendations : national / international Levels of
evidence
BACKGROUND
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In clinical aviation medicine : the flight safety Recovery,
remission, control, relief New aeromedical situations 3 basic
principles : Flights in all conditions (normal and complex) No
sudden or subtle incapacitation No worse health because of the
flights What specific elements to take into consideration ?
BACKGROUND
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May be more problematic than the treatment itself Natural course
Stage Complications May require a specific decision Temporary fit /
unfit Waiver
1. THE CAUSAL DISEASE
CAD
Sarcoidosis
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A bad cardiovascular prognosis Mortality of patients with Type 2
Diabetes but no Myocardial Infarction = Mortality of patients with
Myocardial Infarction but no Type 2 Diabetes 15% of diabetics in
patients with « primitive » cardiomyopathy 30% of diabetics in
patients with cardiac failure 50% of diabetics will die because of
a heart disease
The heart of type 2 diabetic patients
Coronary Artery Disease
Cardiomyopathy Cardiac Autonomic Neuropathy
Manen O, AsMA 2015
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First, second, third line of treatment Asthma Migraine Crohn’s
disease Spondyloarthropathy Chronic hepatitis C Leukaemia Solid
cancer…
2. TREATMENT AND STAGE OF THE DISEASE
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First, second, third line of treatment Asthma Migraine Crohn’s
disease Spondyloarthropathy Chronic hepatitis C Leukaemia Solid
cancer…
2. TREATMENT AND STAGE OF THE DISEASE
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Tolerance and efficiency in a context of favourable environment
Selected patients (age, comorbidities, sub-groups…) Limited periods
Very regular follow-up, motivation Different conditions than those
in general population Laboratory interests…
3. THE CLINICAL STUDIES
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GLP-1 and GIP activated
Incretin secretion
Glycemic control
Food intake
Pancreas
! Glucose uptake and stocking in the muscles and lipid
tissues
! Insulin secretion Glucose dependence
(GLP-1 and GIP)
" Glucagon secretion Glucose dependence
(GLP-1)
" Glucose production in the liver
β Cells α Cells
Digestive tract
Glucose
DPP-4 enzyme
Inactivated
metabolites
Type 2 diabetes : " GLP-1 secretion
" GIP effect
GLP-1 receptor
agonists
DPP- 4
inhibitors
Diabetes and incretin-based therapies
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Diabetes and incretin-based therapies
DPP- 4
inhibitors
GLP-1 receptor
agonists
They are safe !
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Large population, long period : new data Rare but severe side
effects, a not so good efficiency ? Ureterorenoscopy and stone free
condition Efficiency based on : The procedure (basket ? laser ?)
The imaging technique (echo or TDM ?)
4. THE STUDIES IN THE REAL LIFE
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Cariou B. Diabetes & Metabolism 2013; 39(1): A3
Miller ME. BMJ 2010; 340(7): b 5444
The DIALOG study in France
2 509 Type 2 Diabetics with insulin for ≥ 1 year 40% with 1
injection/day only ≥ 1 confirmed hypoG in 45% : 1,6
episodes/pt/month ≥ 1 severe hypoG in 6,7% : 0,1
episode/pt/month
The ACCORD study
10 209 Type 2 Diabetics with insulin « Patients with poor
glycaemic control (higher baseline HbA1C concentration) had a
greater risk of hypoglycaemia than those with better glycaemic
control, regardless of treatment group »
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What is the real short and long-term benefit ? Primary
spontaneous pneumothorax (first episode)
5. THE NEW COURSE OF THE DISEASE
Treatment Recurrence
Rest, tube 30 - 60%
Old techniques (chemical…) 15 - 20%
Thoracoscopy + talc 5%
Thoracoscopy + pleurectomy ≤ 3%
Thoracotomy + pleurectomy ≤ 1%
Casadio C. J Cardiovasc Surg 2002; 43(2): 259-62 Lang L. Ann
Thorac Surg 2003; 75: 960-5 Gossot D. Surg Endosc 2004; 18(3):
466-71
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What is the real short and long-term benefit ? Ureterorenoscopy
with stone free condition : No immediate risk of renal colic But no
effect on the stone formation (hydration, eating habits, metabolic
troubles, uropathy) High risk of long-term recurrence
5. THE NEW COURSE OF THE DISEASE
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To be fit to fly whatever the means are Ureterorenoscopy to fly
solo ? Pleurectomy to fly as a fighter pilot ? Biological aortic
valve prosthesis to fly as a military French transport pilot ?
Thyroid removal in Basedow’s disease to return to flying duties
rapidly ? What if severe complications ? Advices of the aeromedical
expert Choice of the aircrew
6. SOME « AEROMEDICAL INDICATIONS » ?
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Target organs for the flight safety Cardiovascular and
respiratory system ++ Central nervous system and sense organs ++
Assessment Physical exam (HR, BP, vision, audiogram…)
Investigations (biology, lung function test, echocardiography…)
MEDICAL HISTORY Context of expertise A good relationship required :
same AME or same AeMC ++
7. THE EVIDENCE OF A GOOD TOLERANCE
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Restless leg syndrome and anti-Parkinson drug (Pramipexole)
1% à 10% of each side effects :
Abnormal dreams, insomnia, vertigo, sleepiness, fatigue,
headaches
HISTORY ? / EPWORTH SCALE ? / VIGILANCE TESTS ?
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A particular lifestyle that may interfere with a regular daily
intake Jet lag, night hours, sudden missions… impaired sleep and
meal rhythms Airline Pilot, 54 yo, AD-PKD, renal transplant in
2000, IS drugs 2016 : fatigue ++ by treatment and the wakes-up in
stop-over + + =
8. THE PROFESSIONAL CONSTRAINTS
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A follow-up of the disease in relation to the treatment Sleep
apnea syndrom : CPAP : machine records Mandibular advancement
devices : sleep polygraphy Intra-cranial aneurysm : Endovascular
techniques : regular angio-MRI or arteriography Neurosurgery : no
systematic imaging
9. A SPECIFIC FOLLOW-UP
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What acceptable risk for which aeronautical activity ? Flight
attendant, flight engineer, pilot Professional, private Jet,
helicopter, high-performance, glider Monopilot, multipilot
Offshore, overseas deployment…
10. THE REAL JOB AND EXTREME ENVIRONMENTS
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Cavernoma, bleeding, Broca aphasia Surgery, no sequela but MRI
41 yo female flight attendant
Spine fractures Surgery… cement Ejection ?
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He may not be aware of all the risks in relation to his
treatment Information by GMP, specialist, internet, friends…
Initial under-estimation by the aircrew Final role of the
aeromedical expert He may ask to fly with a treatment not
admissible But also ask not to fly with a treatment admissible
!
11. THE CHOICE OF THE AIRCREW
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Anticoagulant treatment in a flight attendant What if
turbulence, bad fall and head trauma on board ? Flight SQ308
Singapore - London 11 passengers and 1 aircrew injured
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The Light Aircraft Pilot Licence European regulations
A blood sugar testing during operational periods under the
responsability of the diabetic pilot and the safety pilot
120 min before
take-off
30 min before
take-off
No take-off if Gly > 15 mmol/l
10-15 g sugar if Gly < 4.5 mmol/l
+ re-test within 30 min
Every 60 min
30 min before landing
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11. THE CHOICE OF THE AIRCREW
12. THE GOOD SENSE OF THE AEROMEDICAL EXPERT
TODAY
TOMORROW
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Therapeutical innovation… … but unchanging way of thinking in
clinical aviation medicine Information, well-known
molecules/protocols, grounding periods… Be careful of a new
aeromedical philosophy
CONCLUSION
RECOMMENDATIONS FOR THE HEALTH
& THE FLIGHT SAFETY
RECOMMENDATIONS FOR THE JOB
A good choice ?
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To know when to say , why and how
CONCLUSION
An ESAM Working Group about medications in aircrews to be
continued…
Contact: [email protected]
