Implications for Medical Reporting Priya Narula CCPA Manager Medical Services Ronnie Aronson MD FRCPC FACE Executive Director LMC Diabetes Objectives Define hypoglycemia and severe hypoglycemia and review treatment of each ID: 928018
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Slide1
Hypoglycemia & DrivingImplications for Medical Reporting…
Priya Narula, CCPA
Manager, Medical Services
Ronnie Aronson MD, FRCPC, FACE
Executive Director, LMC Diabetes
Slide2ObjectivesDefine hypoglycemia and severe hypoglycemia and review treatment of eachReview current process of license suspension in OntarioUnderstand and differentiate the 3 supporting documents: CCMTA, CDA and the CMA Driver’s GuideDiscuss the duty to report across CanadaDefine “fitness to drive”Summarize the Ombudsman report: Better Safe than Sorry
Slide3SourcesDetermining Driver Fitness in Canada: CCMTA, Ed. 13. August 2013. Canadian Council of Motor Transport AdministratorsBetter
Safe than
Sorry
Ombudsman
Report, April
2014
CMA Driver’s Guide: Determining Medical Fitness to Operate Motor Vehicles, 8
th
edition
Canadian Medical Association
CDA CPG’s for Diabetes and Private and Commercial Driving.
Begg
et al, CJD 2003;27(2):128-140
The
Practice
Guide.
CPSO
College of Physicians and Surgeons of Ontario
Slide4Mild HypoglycemiaSevere HypoglycemiaHypoglycemia UnawarenessDefinitions of Hypoglycemia
Slide5Case Study # 1 54 y/o male with T1D for 30 years using MDI therapy. Generally very well-controlled glycemia with minimal mild hypoglycemic event and no hypoglycemia unawareness.
Slide6He had a severe hypoglycemic episode overnight as he mistakenly took his bolus insulin as his basal. His wife tried to provide him Dextrose tabs however he had passed out and instead paramedics were called. He is otherwise healthy with no co-morbidities and this is the first severe hypoglycemic episode.Case Study # 1
Slide7Question:Will you report to the Ministry of Transportation or not?Case Study # 1
Slide858 year old male with 25 years of well controlled T1D using Lantus and Humalog. He has hypoglycemia unawareness however has never had a severe hypoglycemic episode. He checks his blood sugars before he drives.Case Study # 2
Slide9He comes to see you and you notice multiple hypoglycemic episodes, as low as 1.7 which you start to question. He was at the airport, waiting for his flight home. He explains that he did not have any classic symptoms of hypoglycemia however a passenger noticed him sweating profusely which prompted him to check his blood sugar.Case Study # 2
Slide10He immediately asked the passenger to call for help as he did not have any fast-acting carbohydrates. He was unable to take anything by mouth and there fore was given glucagon by paramedics.Case Study # 2
Slide11While in your office now, you notice him slightly disoriented and again profusely sweating. When you check his blood sugar it is 1.9. You treat as per your clinic protocol and his sugars after 30 min are at 5.6. What are your next steps?Case Study # 2
Slide1267 year old male with type 2 diabetes using Apidra and Lantus. In general, he has not been controlled well due to much variation in his diet.He would have mild hypoglycemic events which he would treat appropriately and these events were related to delayed meal.Case Study # 3
Slide13He comes to you for a follow up and explains he was in a car accident with no casualties or injuries. When paramedics arrived his blood sugar was 2.7. He does not recall any warning symptoms. Prior to driving he checked his blood sugar which was 7.8, however 1 hour before driving.Case Study # 3
Slide14What would you do?Case # 3
Slide15Facts - Hypoglycemia2011: 723 reports (police and physicians)only 32 resulted in MTO asking for more information2012: 730
reports (police and physicians)
only
31
resulted in MTO asking for more information
96%
immediate license suspension
References:
Better Safe than Sorry, Ombudsman Report, April 2004
Slide16License Disruption Timelines - OntarioReport to Response = 30 days by MTORegain license: 4+ monthsRequires a 3-month stability period (CCMTA)MTO - Medical Advisory CommitteeMedical experts including 2 endocrinologists
Jan 2010 to Mar 2012:
126
files reviewed by MAC
40%
required further follow up through
MTO
to ensure
fitness
to drive.
References:
Better Safe than Sorry, Ombudsman Report, April 2014
Slide17Conditions & Guidelines
Slide18CCMTA Conditions - Non commercialInsulin useStop driving especially if BG is < 4.0Do not drive if BG is 4.0-5.0 unless treated with fasting acting CHODo not drive for 45 min if treated BG of 2.5-4.0If driving for longer period then test BG ~ every 4 hours and carry a fast acting CHO
Resource:
Determining Driver Fitness in Canada: CCMTA, Ed. 13. August 2013
Slide19CCMTA Conditions - Non commercialSevere hypoglycemiaNeed a stability period with no further “hypoglycemia” within 6 monthsNeed stability in overall glycemic controlTest before driving and every hour while drivingIf BG is <6.0 stops driving and doesn’t resume until BG is > 6.0
Resource: Determining Driver Fitness in Canada: CCMTA, Ed. 13. August 2013
Slide20CCMTA Conditions - Non commercialHypoglycemia Unawareness within the past yearDocumented no episode in the past 3 monthsGlycemic awareness is regainedThere is stability in glycemic controlIf BG is < 6.0 stops driving and only resumes if BG is > 6.0
Resource: Determining Driver Fitness in Canada: CCMTA, Ed. 13. August 2013
Slide21CCMTA Conditions - CommercialInsulin useNeed a certificate of competencyExclusions – A1c > 12.0%; or 10% of BG < 4.0Stability (not defined) in insulin therapy & monitoring
Tests BGs
frequently
and has knowledge of causes, symptoms and treatment of hypos
Carries fast acting CHO
Tests BGs 1 hour or less before driving and every 4 hours while driving
Does not drive
if BG < 6
Slide22CCMTA Conditions - commercialSevere hypoglycemiaStability in glycemic control re-establishedNo further episodes within the last 6 monthsChecks BGs at least 4/day for the last 30 days; < 5% of readings are <4.0Tests before driving and every hour while drivingDoesn’t drive if BG is < 6.0
Resource: Determining Driver Fitness in Canada: CCMTA, Ed. 13. August 2013
Slide23CDA Guidelines for Driving - based on 2003 CDA CPG & derivative of CCMTA ConditionsAll patients with Diabetes:Are required to take an active role in determining if they are fit to drive.Should not drive if BG < 4.0 and should administer a fast acting carbohydrate if BG 4.0-5.0Should stop driving if they suspect hypoglycemia or have impaired driving. The patient should not resume driving for the next 45-60 min.
CDA Guidelines: Guidelines for Diabetes and Private and Commercial Driving
Slide24CMA Driver’s GuideDerivative of CCMTA and 2003 CDA GuidelinesNon-commercial VehiclesFit to drive if:Under a regular medical supervisionDemonstrate appropriate management of hypoglycemia if using insulinCommercial Vehicles:All reference is to the CDA Guidelines
only
CMA Driver’s Guide: Determining Medical Fitness to Operate Motor Vehicles, 8
th
edition
Slide25Duty to Report “Fitness to Drive”
CCMTA – silent on duty to report
CDA Guidelines – silent on duty to report
other than to refer to provincial legislation:
Manitoba, NB, Newfoundland, Ontario, PEI, Saskatchewan, NWT – “reporting is mandatory”
BC – mandatory if driver refuses to heed MD’s advice to stop driving
Alberta – discretionary for patient & physician
Nova Scotia & Quebec – discretionary for physician
What is “dangerous”?
undefined
Slide26Duty to Report “Fitness to Drive” (MTO - Highway Traffic Act)(CPSO – The Practice Guide)
Non-Commercial
Commercial
Severe hypoglycemia
re-established stable glycemic control
- no further
hypoglycemic
episode w/in
past 6m
Hypoglycemia unawareness
within the last year
re-established stable glycemic control
- no further
hypoglycemic
episode w/in
past 3m
Persistent hypoglycemic unawareness
same
not eligible to drive
Slide27Better Safe than SorryOmbudsman ReportApril 2014
Slide28Case Review by the OmbudsmanMr. Maki is a 40 year old male with type 1 DMseveral prior episodes of severe hypoglycemia - unknown if his physicians were awareDay of incident:BG tested before driving was hypo - treateddid not wait to retest
BG
MVA -
3
fatalities
Concern
at hand: delay of suspending license by
Ministry
June 2009
October 2010
References:
Better Safe than Sorry, Ombudsman Report, April 2004
Slide29Slide30Recommendations- Summary
Slide31REVISIT CASE STUDIES
Slide32Case Study # 1 54 y/o male with T1D for 30 years using MDI therapy. Generally very well-controlled glycemia with minimal mild hypoglycemic event and no hypoglycemia unawareness.
Slide33He had a severe hypoglycemic episode overnight as he mistakenly took his bolus insulin as his basal. His wife tried to provide him Dextrose tabs however he had passed out and instead paramedics were called. He is otherwise healthy with no co-morbidities and this is the first severe hypoglycemic episode. What are your next steps?Case Study # 1
Slide3458 year old male with 25 years of well controlled T1D using Lantus and Humalog. He has hypoglycemia unawareness however has never had a severe hypoglycemic episode. He checks his blood sugars before he drives.Case Study # 2
Slide35He comes to see you and you notice multiple hypoglycemic episodes, as low as 1.7 which you start to question. He was at the airport, waiting for his flight home. He explains that he did not have any classic symptoms of hypoglycemia however a passenger noticed him sweating profusely which prompted him to check his blood sugar.Case Study # 2
Slide36He immediately asked the passenger to call for help as he did not have any fast-acting carbohydrates. He was unable to take anything by mouth and there fore was given glucagon by paramedics.Case Study # 2
Slide37While in your office now, you notice him slightly disoriented and again profusely sweating. When you check his blood sugar it is 1.9. You treat as per your clinic protocol and his sugars after 30 min are at 5.6. What are your next steps?Case Study # 2
Slide3867 year old male with type 2 diabetes using Apidra and Lantus. In general, he has not been controlled well due to much variation in his diet. He would have mild hypoglycemic events which he would treat appropriately and these events were related to delayed meal.Case Study # 3
Slide39He comes to you for a follow up and explains he was in a car accident with no casualties or injuries. When paramedics arrived his blood sugar was 2.7. He does not recall any warning symptoms.Prior to driving he checked his blood sugar which was 7.8, however 1 hour before driving.Case Study # 3
Slide40What would you do?Case # 3
Slide41Thank you!Priya Narula, BSc, CCPAManager, Medical ServicesLMC Diabetes & EndocrinologyPriya.narula@lmc.caFor further informationwww.lmc.ca
www.Diabetessource.ca
Contact details