Okay, so we're going to diabetes. And I hope we're going to go fast. There's lots of people in the US who have diabetes, mostly are type 2. We worry a lot about the long-term risks when we're doing general primary care. In this class, we only care about the short-term risks, especially loss of consciousness or function. That's my focus here, because if you're passed out, you can't drive the truck well or my bus or whatever. And I work a little bit about variability and vision for people that are poorly controlled. That sometimes is also a problem. So blood glucose control, there's a lot of things about being a driver and traveling across time zones and eating regularly and all that stuff that can mess with your ability to control your diabetes well. Hyperglycemia can be a problem, but not usually a big problem. For drivers, it takes a really long time to get sick because your sugar is going up. 6, 7, 800. I mean, you can get in DKA, but even DKA doesn't incapacitate you. You'll feel like crap, but it doesn't make you pass out right away. We worry about hypoglycemia. That's the one we're worried about. Far more immediate health concerns. Some people are lucky and have symptoms before they get all the way to seizure, loss of consciousness, impaired function, and need for assistance, but those are the ones we worry about. If they're lucky enough to have symptoms where they know their sugar is getting low, that's awesome. I encourage them to keep track of that, and if they start noticing those symptoms, they need to do something about it. You may have your favorite rib place that's another two hours along, but maybe you have to stop sooner to get something to eat if you start having symptoms. Another problem with history is you can't have anything that suggests undiagnosed or uncontrolled diabetes, inadequately controlled diabetes, or evidence of hypoglycemic episodes. Those are the problems. On the history forum, there's stuff about insulin and being a driver and your diabetes. I encourage you to check that out. Make sure you ask a whole bunch more questions. So how do we assess control? My big question is about hypoglycemic episodes. This does require that the patient is not lying to me, but if they've had hypoglycemic episodes, I'm concerned about that. If they're on insulin, the fun part is if they're on insulin, I kind of transfer this risk to the treating clinician who fills out the special form. If they're not on insulin, then it comes back to me because there is no form for that. I will do a DIPUA, might do a finger stick. You can ask them for an A1C if you're concerned. So we have our own definition for a severe hypoglycemic episode. If you have a seizure, loss of consciousness, or need for assistance from another person, you have a severe hypoglycemic episode. That's the FMCSA definition. So if they've had one, I want to know when the last hypoglycemic episode was and how many episodes in the last five years. And do document well how they're doing in their thing, write a decent little micro note. So everybody's going to get a DIPUA, looking for glucose, urea, and protein urea. And I also need to think about target organ damage in somebody with diabetes. If they have glucose, urea, I would recommend a finger stick. The FMCSA normal range is 100 to 400. If they're in that range and they're just perfectly okay, I do realize that making people be over 100 and not using some other bottom number is probably not necessarily helpful for everybody. So my personal spin on this is if they go down to 80 and they're just fine, then I'll let them go down to 80 and count that as okay. I don't really like them a lot below 80 because then you start getting into the land where some people get in trouble. But if they're well-controlled diabetic and their sugars, you know, typically are in the 70 to 100 range, I don't want to tell them you can't do that. Because that's going to mess up their long-term treatment. A1c is not required, but if you do one, they want it less than 10%. That's in the guideline? Yes. It used to be hard and fast. It's no longer. Yeah, but you don't need one now. But if you get one, we'd like it less than 10%. If you're not on insulin, insulin's different. Go ahead. The surgeons will, and they're requesting glucose. just so you know, if you do primary care, surgeons won't do surgery unless the hemoglobin A1C is eight or less, because they don't heal. Yes. As you mentioned, people don't heal with a hemoglobin A1C of 10. They need to be, most, many surgeons want it to be eight or less, which is fine. So we're gonna document whatever we know. I recommend that this is the time when you talk to the person. We have a plan for how they're gonna deal if they have a low sugar sensation while they're driving, that they've got food, and how to stop, that they have to stop, and that sort of thing. So if somebody's not on insulin, so that's us, right? Then we certify them based upon determining that we don't think there's a significant risk of a low sugar episode. I do continue to hate sulfonylureas. They cause this problem far more than any other class of drugs. Just, if they get on anything else, they're better off. But they're cheap. Sulfonylureas are dirt cheap, but they have issues, especially if people don't eat enough. So recommend not to certify. If they've had a hypoglycemic reaction in the last 12 months, or more than two or more in the last five years, that's evidence of poor control. If they've had, and so that, if they've had seizure, loss of consciousness, needing assistance from other persons, that's the one you clap a couple of times for, stomp our feet, or whatever the right way to do this is, or any periods of impaired cognitive functioning. So if you're not on insulin, impaired cognitive functioning is an important thing to know. That seems to, that's not a thing for, if you're on insulin, which makes no sense. So don't certify people with proprioceptive defects, especially with their feet. Like if they can't tell where their feet are on the pedals, that's a problem. This person's got a little bit of burning in the bottom of one foot, it's not a big deal. Resting tachycardia, orthostatic, or if they're getting the autonomic neuropathies, and that's a problem. So I'm not gonna certify them, maximum certification for one year if I think everything's cool. And what about the incretin mimetics? Well, they're not insulin, even though they're injected. You don't need the exemption. They follow the same rules as oral hypoglycemics, and that would be all the other diabetes medicines that aren't some flavor of insulin. Even if they're injected. Doesn't matter if it's injected, if anything, as long as it's, I mean, insulin, when I was, back when I was a resident, all the things that were insulin had the word insulin in their name. That is not true anymore. They've got things that are really insulin that they don't call, insulin's not in the name anywhere. And so you just gotta be mindful of those things that are hiding. What about the SGL-2 inhibitors, like Traciga and Vokana, and they'll make the glucose dipstick really positive and use finger sticks to just adequate control. So drivers using insulin, this we've now, we're now leaving non-insulin controlled diabetes, and we're going into insulin control, a whole different world. This is the way, this is exactly what I would have told you two years, three years ago. If you're on insulin, you're not qualified. That's not true anymore. That's gone after 2018. So we got new rules for people on insulin. The grandfathered insulin people went away. There's no more grandfathering for insulin. There was a bunch of those hearing and insulin people in 1996, that were given a get out of jail free card as a research study. And that's those people, that's done. We actually, I had one of those, one of each of those in my prior clinic. And so if they're on insulin, the treating physician has to evaluate them and they must use the MCSA 5870 form. Whoever's prescribing their insulin is a treating clinician. Now, Liz is shaking her head that the endocrinologist won't be able to do it. The endocrinologist won't fill out the form. That's probably- They won't certify this person as able to drive. Right, and that's probably good medical, the sound medical decision-making. If the endocrinologist doesn't think they're safe to drive, probably not safe to drive. And then I don't have to worry about making that decision, right? So the treating clinician is whoever prescribes their insulin. So if it's a PA in their clinic, that's fine. That's who it is. On that form, they'll testify to their status regarding their insulin. The form itself is good for 45 days after it's completed. So they have to go see their treating person and they've got to come see you within 45 days. Bringing your form from four months ago is not adequate. It's got to be within the last 45 days. They have to have a glucometer capable of storing and electronically storing and recalling their values, preferably one where usually the ones that can do that, the $40 one that I bought in my office doesn't do that. It stores like the last 10, but that's not the same thing. They've got one that can store it for a long time. And usually when you get those, which these are the $100 glucometers, or they've got one of those pod things with their phone, any of those things, usually they can print your report and you can see like the last three months because you need a three-month report from this person's glucometer. So they've got to have a special glucometer to do that with. Unstable is defined as severe hypoglycemic episodes, loss of consciousness, seizures, or coma, but impaired cognition is not on this list anymore. So the fact that they needed somebody else's assistance is irrelevant if they're on insulin, whereas it was very important when they were not on insulin. At least that's what the writing on paper from FMCSA says today. Same target organ damage concerns. They can't have neuropathy. And I really worry, I said about fetal position sense, because it's really hard to control the pedals if you can't tell where your feet are. They can't have severe either proliferative or non-proliferative retinopathy. The words are severe and retinopathy are important. What comes in between doesn't matter. That would be disqualifying. Okay, so the question was asked, since I'm an internist, I am likely to be one of the patient's primary care physicians. Can I, the trained DO, complete the form myself? And the answer is absolutely. You are permitted to be the person that fills out that form as long as you fill out the form. And it says, then can I subsequently disqualify the patient? Yes, you can. So if you're the prescriber, you can be both a TC, the treating clinician, and you can also be their CDME person, their medical examiner. You can be both of those people. That's just fine. You have to have electronic recording glucometer, has to have three months of electronic records. Handwritten records are not acceptable. And if somebody doesn't have this the first time you see them, you can give them a three month card to get a recording glucometer. But when they come back after that three month card, one of the rules for three month emergency cards is they never repeat. So if they come back, they better have that glucometer that can give them three months worth of electronic records. So if they have a hypoglycemic episode, because this will happen to somebody on insulin maybe. So what they have to do is stop driving, consult their treating clinician. They'll reevaluate them. Hopefully they'll adjust their medications. Give them a new MCSA 5870 and they can get back on the road with just the 5870. They don't have to come back and see you. I personally wrote to FMCSA about this because this is stupid. But it is the way the rules are. I wrote to them and ACOM wrote to them about this exact point of when somebody who's had a hypoglycemic episode, just go back to your experienced clinician who says, yeah, I think you're okay. Let's decrease your sulfonylurea from 10 milligrams to five milligrams and sends back out on the road. Then 10 minutes later, probably not safe. Say earlier hypoglycemia in the last 12 months. I'm so sorry. That was if you're not on insulin. Once you're on insulin, you've passed through the mirror and into wonderland. So if you're not on insulin, then there's some, I think, pretty reasonable rules. Once you're on insulin, we've got these weird rules with the treating clinician making all the decisions. But you can still disagree with the treating clinician if they think they're safe and you think they aren't. But this person that just had a hypoglycemic episode, they never come back. They just get a new form from their doctor and drive for the next four months or a year or whatever it is. Aren't they supposed to stop if they've had two or more episodes of hypoglycemia? So the question was, do they have to stop if there's two or more episodes? The answer is no, they just need a second form. So if the treating clinician keeps adjusting their medicine and gives them a new form, they can go back and start driving that afternoon. It makes no sense. I'm not gonna, this does not make sense. You've heard me say that before in this class, but that, it doesn't make sense. I would be, if I had somebody that had two hypoglycemic episodes while driving, because remember, you've got some liability here if you let them go back to driving, I wouldn't let them go back. I'd fix it first, but that's not the law. The rule, the rule is that fill a new form. If they fill it out and say they're safe to drive, they can go drive. You're right, it makes no sense. So then when they come, so they've had the hypoglycemic episode, they went to see the treating clinician, they got a new 58-70 form. They're gonna bring that one from when they got adjusted and the current one, right, to you for your next exam. So they're gonna come in with two forms, because that one from four months ago or six months ago isn't adequate. It doesn't meet the 45-day criteria. It says you're gonna need a new one from the treating clinician when they come back to see you for the next exam, and then you can reassess. But they've been driving for four months and passing out, and that's apparently okay, as long as you adjust their medicine. So it has to be committed by the treating clinician. There's no waiting period for being on insulin or making treatment adjustments. Severe, you have to, the form does require them to address the consequence of your hypoglycemic episodes. If they decided to get an A1C within the last 90 days, you should attach it. It's not required that they do that, but if they do it, they need to attach it. And is there a target organ damage? Those are questions asked of the treating clinician. When was their last comprehensive eye exam? These are things that are on the form, okay? Any evidence for the proliferative and non-proliferative retinopathy? Other eye diseases? And then an attestation of proper control of their diabetes by the treating clinician. I like this, because this way, we're gonna share, we'll both get to be in the defendant's box when we end up in court. Grandfathered exempted people. There were some of these people around. They are no longer exist, and there's also no waivers. So the waiver program went away. There were banishing a few people in the waiver program, like 10 nationally. There were a couple hundred people that were grandfathered in that experimental thing in the past. But all that went away by 2019, because those people would have had, they got, until the next time they had to be reevaluated, then they would have switched over to this program. If the driver has a problem, they can call. Let's see, so we talked, okay. So glucose needs to be in the 100 to 400 level. That's the official safe driving range per FMCSA. And the A1C, if they did want, they're supposed to attach the results or write it in. This is the form. I'm not gonna spend a lot of time on it. It does have about the 45 calendar days, time limit, and the electronically downloaded results. Talks about complications, severe hypoglycemic episodes, diabetes complications, progressive eye diseases, and then they attest. So, you know, with their name and their address and their, all that stuff. So who's the decider? So the Drink Coalition offers their opinion. You remain the decider. You're the person certifying the person. If you don't think they're safe, do not certify them. Okay. You still possess that power. 100% of the time. So case by case evaluation, as always, 100% of the time you need to have the 5870 form. A letter doesn't replace it. A note on their script pad doesn't replace it. Some other form that the Drink Coalition wants to use doesn't replace it. And remember that if you've got the testing results, 100 to 400 is acceptable numbers for glucose control, and A1C less than 10. Some scenarios. So guy comes in, he's on metformin, no troubles, good blood pressure. I can certify this guy for one year because he's had a, because he has diabetes condition that could become less stable. And he's on a good treatment. Number two, so they're on glipizide and lisinopril. And they had a hypoglycemic episode requiring assistance about six weeks ago. The doctor turned down their glipizide dose. A1C is 6.5, UA is negative. And everything else is just hunky dory. Certify? Do not certify. No, this guy's, this is a do not certify because they're on insulin and they are, they're, I'm sorry, they're not on insulin, no insulin. And they had a hypoglycemic episode six weeks ago. That's not a year. So it's a difficult call. She meets the examination criteria, but the hypoglycemic episode would be disqualifying. So I recommend not to certify because they had the hypoglycemic episode in the last 12 months. So that's a do not certify. Scenario two, she comes back 11 months later, doing well on her low-dose of glipizide, no further hypoglycemic episodes. And now her A1C is 7.1. Everything else is normal. Certify, one year maximum from today, right? And this counts as a new exam because it's this like partial exam thing that's just gone. Every time I touch them, it's a new exam unless I did determination pending. And then that one thing counts, but they don't get a card. So Mrs. Bird comes for recertification, diabetic for the last seven years. She's been a metformin and rosiglitazone, which I pray is still a medicine in the United States. No good, okay. No hypoglycemic episodes. She's having trouble with control. So her pre-inflation added a PIDRA with great results. A1C is great. Everything else looks wonderful. Okay, so the answer in the room here is do not certify because they're missing the form. And I agree with you. So the metformin and rosiglitazone are fine. The glulisine is insulin, even though the word insulin doesn't occur anywhere in the name of the drug. So you give them the form, tell them to take it to the treating clinician, explain the new process to the driver because they may not know this. And the FMCSA specifically prohibits giving them a decision pending for this scenario because they're on insulin and should have had the form. And because they didn't have the form, they can't do decision pending. I have to actually fail this person and give them the form and say, you can come back, go get your doctor, fill this out, and you can come back and we'll start over again. All right. Okay, Mr. Smyth comes to clinic for certification. He has diet controlled diabetes and he's on the center pull to protect his kidneys. No hypoglycemia ever. Everything else looks fine. UA is positive for glucose, negative for protein. Certify for? He doesn't want any more information because he's supposedly on diet controlled diabetes, but now he's spilling sugar. So you've got a couple of options with him. I need more information. I do a finger stick glucose, it's 270. So now he's got uncontrolled diabetes. That's not okay to certify. So I could do him a determination pending for his uncontrolled diabetes, let him go see his doctor, pray to God that they start him on metformin, not anything else, and he'll probably be fine. And I will sometimes whisper in their ears, say, ask your doctor about metformin and I'll write it down for them. You know, I won't prescribe it, but I'll encourage strongly that that's the right drug to use for this. For our pilots, just so you guys know this, for our pilots, if they're on metformin for pre-diabetes in quotes, and just metformin and nothing else, I can issue them under a khaki. That's new. So the FAA is so comfortable with metformin, they'll let me certify somebody. Just keep that in mind. That not any of the other medicines, just metformin. Yes, sir. So under the 100 to 400, he's not uncontrolled, but he's uncontrolled because he's not being treated? Correct. Okay. It's not that he's, if he was being treated, then that would be okay. Diet, like watch your diet is not treated. But if he was on medication, then that would be, then 100 to 400 applies. Okay. So he comes back five weeks later, he's doing well. PCP added metformin. I whispered loud enough in his ear that the doctor could hear me. No hypoglycemic episodes. A1C is 9.5, which is a little higher than you'd like for treatment, but he just started treatment, so that's okay. That should come down. Finger 6105 certification. One year. Which one year? B or C. Oh, that's B. No, it's actually one year from the initial exam because he was decision pending. So we just said you pended him. So I used the original date, one year from whenever I saw him the first time. So part two, what is it? Maximum one year cert, but it would be because it was decision pending, it would be from the initial decision date, initial exam date. Any questions about diabetes?

diabetes management

commercial drivers

hypoglycemia risks

blood glucose control

driver certification

FMCSA 5870