Guidance on the use of medication with musculoskeletal conditions
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.
Opioid analgesics including codeine and dihydrocodeine, used for pain relief, are incompatible with flying.
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.
Sulfasalazine is used for maintaining remission in rheumatoid arthritis. Provided there are no significant side effects aeromedical certificate holders can be assessed as fit while taking sulfasalazine for this purpose. Licence holders must report any unexplained bleeding, bruising, purpura, sore throat, fever or malaise whereupon a full blood count will be performed. The medication must be stopped if there is any suspicion of blood dyscrasia.
(Note: Rheumatoid arthritis sufferers are particularly at risk of developing haematological abnormalities. Full blood count and liver function must be checked monthly for the first three months of treatment and then annually. Renal function must be assessed before starting the medication, after three months treatment and then annually. GP reports on the results of blood testing should be obtained by the AME).
Drugs affecting the immune response
Methotrexate is licensed for moderate to severe rheumatoid arthritis. It is associated with blood dyscrasias, liver cirrhosis and pulmonary toxicity. Licence privileges can be restored once therapy has been stabilised, providing symptoms are well controlled.
(Note: Full blood count, serum creatinine, urea and electrolytes and liver function must be checked before initiation of treatment, every two weeks until therapy is stabilised and every three months thereafter. GP reports on the results of blood testing should be obtained by the AME.)
Ciclosporin is licensed for use in severe rheumatoid arthritis. The severity of the underlying disease may preclude medical certification. Provided arthritic symptoms are controlled, there are no significant side effects and the third blood test result is acceptable, licence privileges can be restored four weeks after initiation of treatment.
(Note: As it is nephrotoxic serum creatinine, urea and electrolytes and liver function must be checked before initiation of treatment, every two weeks for the first three months and every four weeks thereafter. GP reports on the results of blood testing should be obtained by the AME.)
Etanercept and adalimumab inhibit the activity of tumour necrosis factor alpha (TNF-α). These are the only medicines in this group that are acceptable for aeromedical certification at present. They are licensed for use in moderate to severe rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis when response to other disease modifying drugs has been inadequate. Flying can resumed (with an OML for Class 1 holders) provided symptoms are satisfactorily controlled, there are no significant musculoskeletal impairments and there are no significant side effects four weeks after initiation of treatment.
Prednisolone is effective in the treatment of inflammatory joint disease. It also has a role in the maintenance of remission and reducing the rate of joint destruction in moderate to severe rheumatoid arthritis of less than two years duration. A pilot requiring steroids will be assessed unfit unless taking the equivalent of no more than 7.5 mg prednisolone daily to reduce the rate of joint destruction in rheumatoid arthritis. All other indications for oral corticosteroids preclude certification.
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.
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.