Medication used for musculoskeletal conditions

Guidance on the use of medication with musculoskeletal conditions

Medication used in musculoskeletal conditions

Although some medications may be acceptable while flying or controlling, the underlying medical condition may be disqualifying. Aeromedical advice must be sought following a new diagnosis or recurrence/flare up of a medical condition.


Analgesics
Paracetamol (acetaminophen) is similar in analgesic efficacy to aspirin but has no anti-inflammatory activity. It has less irritant effect on the stomach and is preferable to non-steroidal anti-inflammatory drugs for relief of mild to moderate pain.  Paracetamol is acceptable for pilots provided the underlying reason for requiring pain relief has been considered and is compatible with flying.

Analgesic opiate medications such as codeine and dihydrocodeine, are incompatible with flying. While using this type of medication the pilot will be assessed unfit and the medical certificate will be temporarily suspended.

Non-steroidal anti-inflammatory drugs
NSAIDs,in single doses, have similar analgesic activity to paracetamol.  When used regularly they also have an anti-inflammatory effect.  Pilots may fly unrestricted while taking NSAIDs provided the condition for which they are being taken is adequately controlled without side effects.  Proton pump inhibitors can be used to control dyspepsia and for prevention of peptic ulceration in licence holders requiring long term NSAIDs.

Selective cyclo-oxygenase-2 inhibitors (eg, celecoxib, etoricoxib) are licensed for the relief of pain in osteoarthritis, rheumatoid arthritis and ankylosing spondylitis.  Etoricoxib is also licensed for use in gout.  These medications are as effective in relieving pain as non-selective NSAIDs such as diclofenac and naproxen with less risk of upper gastrointestinal bleeding. These medications are acceptable for flying with the proviso that the degree of underlying pain and mobility should be assessed prior to, and be satisfactory for, certification.

Other medication
Glucosamine is licensed for mild to moderate osteoarthritis of the knee.  It is acceptable for aviators to use although there is limited evidence of its effectiveness.

Corticosteroids (Prednisolone, Beclomethasone, Budesonide and Hydrocortisone)
Local corticosteroid injections may be given intra-articularly in inflammatory joint disease and directly into the soft tissues in conditions such as tennis or golfer’s elbow or compression neuropathies. Flying can be resumed a minimum of 48 hours after the injection provided the condition being treated is adequately controlled. Clinical examination by an AME may be required to assess range of movement, strength and dexterity.

Corticosteroids administered orally or rectally, can be effective in the treatment of active inflammatory disease.  The use of oral steroids is disqualifying therefore, while using this type of medication, the pilot will be assessed unfit and the medical certificate will be temporarily suspended.  (Note: certification may in exceptional cases be considered where no more than 7.5 mg prednisolone daily has been prescribed to reduce the rate of joint destruction in rheumatoid arthritis; such cases should be assessed in consultation with the AMS).  Recertification can be considered when the certificate holder has been off oral steroid therapy for a minimum of two weeks with no recurrence of symptoms and the condition is confirmed quiescent.

Aminosalicylates, Medications Affecting the Immune Response, and Cytokine Modulators
The certificate holder is unfit on each occasion that a ‘flare up’ of the condition occurs and must seek aeromedical advice following any change in clinical condition, or medication.

• Aminosalicylates (Mesalazine, Balsalazide and Olsalazine)
• Medication affecting the immune response (Ciclosporin, Mercaptopurine Azathioprine and Methotrexate)
• Cytokine Modulators (Adalimumab and Infliximab)*

If indicated for the treatment of active inflammatory disease these medications are disqualifying.  These medications may be acceptable for maintaining remission of the disease provided the disease is quiescent, the certificate holder does not experience side-effects and regular review is undertaken.

Aeromedical Certification - Aminosalicylates, Medications Affecting the Immune Response, and Cytokine Modulators* 

ACCEPTABLE MEDICATIONMesalazine, Balsalazide and Olsalazine
Ciclosporin, Mercaptopurine Azathioprine and Methotrexate
Adalimumab and Infliximab*
ACTIONUnfit after flare up of condition or starting medication or an increase in dose until:
Minimum of 2 weeks on a stable maintenance dose of medication
The disease is demonstrated to be stable and well controlled
Unfit after flare up of condition or starting medication or an increase in dose until:
Minimum of 4 weeks on a stable maintenance dose of medication
The disease is demonstrated to be stable and well controlled
INVESTIGATIONSMedical reports and up to date blood test results within normal parameters will be required for aeromedical assessment (Guidance for medical reports – Musculoskeletal)
Ensure satisfactory symptom control and free of side-effects of medication
Medical reports and up to date blood test results within normal parameters will be required for aeromedical assessment (Guidance for medical reports – Musculoskeletal)
Ensure satisfactory symptom control and free of side-effects of medication 
CERTIFICATION   Class 1 Unrestricted/OML
Class 2 Unrestricted/OSL
Class 1 OML
Class 2 Unrestricted/OSL/OPL
FOLLOW UPThe result of each clinical review should be copied to the AME on an ongoing basis.
To continue to maintain certification an assessment of the clinical condition and up to date blood test results must be included in the follow up report/letter.
The result of each clinical review should be copied to the AME on an ongoing basis.
To continue to maintain certification an assessment of the clinical condition and up to date blood test results must be included in the follow up report/letter.
ADDITIONAL NOTES

Applicants will be having periodic blood testing (pre-treatment, bi-weekly, monthly, three monthly, and annual), of blood count, liver and renal functioning to identify bone marrow suppression/blood dyscrasis, hepatic or renal impairment, liver cirrhosis and pulmonary toxicity.
The results of blood tests which are not within normal parameters must be notified to the AME immediately.

Limitations
Some medications are likely to require a longer period of grounding (*up to 4 weeks) to demonstrate stability and for professional pilots an OML limitation (permitting flights as or with a qualified co-pilot), and for private pilots an OSL (operational safety pilot) limitation may be required.