AC 91.11 - 1 Cancelled Guide to 91-11-A DRUG
HAZARDS
AVIATION
MEDICINE
FEDERAL AVIATION AGENCY
AVIATION MEDICAL SERVICE
GUIDE TO
DRUG HAZARDS IN
AVIATION MEDICINE Prepared by Windsor C. Cutting, M.D.
Stanford University AÃO SEATES OF A 1962
FEDERAL AVIATION AGENCY Aviation Medical Service For sale by the Superintendent of Documents, U.B. Government Printing Office Washington, D.C., 20402 - Price 85 cente
Foreword To Each Aviation Medical Examiner:
The need for a manual on pharmacology in aviation prompted the Aviation Medical Service of the Federal Aviation Agency to make this handbook available for your guidance.
The author, Windsor C. Cutting, M.D., an individual with much passenger flying experience, was for many years Professor of Pharmacology and Therapeutics at Stanford University and now is Professor of Experimental Therapeutics there. Also, he was until 1962 Vice Chairman of the Council on Drugs, American Medical Association.
Incorporated are comments submitted by the following consultants who were kind enough to review the manual in preliminary form:
Walter Modell, M.D.
Associate Professor of Pharmacology and Director of Clinical Pharmacology Cornell University Medical College Herbert S. Kupperman, M.D., Ph.D.
Associate Professor of Medicine Department of Therapeutics New York University Medical Center School of Medicine Richard W. Payne, M.D.
Associate Professor of Pharmacology and Instructor in Medicine University of Oklahoma School of Medicine H. George Mandel, Ph.D.
Professor of Pharmacology.
The George Washington University School of Medicine Throughout the manual, Dr. Cutting has confined himself primarily to pharmacological considerations important in evaluating airmen for aviation duties either at the time of routine certification examinations or during treatment for ailments occurring during periods of participation in airmen duties. He has purposely avoided detailed discussions of individual drugs, clinical consideration of pathological states, and policy aspects of the Federal Aviation Agency's certification procedures, except in special instances.
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The manual is, of course, provided only for your guidance, and the individual examiner must consider the details of each case-specific pathology involved, nature of airman's duties, specific drug, exact dosage, individual patient response, and existing regulatory or policy guidelines. After such considerations, the examiner should find himself well prepared to advise patients concerning limitation of airman activities during periods of drug therapy and better able to determine medical qualifications at the time of certification examinations.
Necessarily, in any questionable case involving airman certification, the final decision will rest with the Civil Air Surgeon.
In conclusion, I wish to express sincere appreciation to Dr. Cutting and the reviewing consultants for their efforts in preparing this manual for your guidance.
H. D. ESTEs, M.D., Acting Civil Air Surgeon.
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Preface Probably the best general recommendation for flying personnel and others directly associnted with flight control is abstinence from all drugs. However, some illnesses and symptoms may not preclude flying or ground traffic control work, but may be benefited by appropriate drugs. The question therefore arises as to whether use of the required drugs in such instances may be safe and in fact advantageous. This has led to the preparation of this book for Aviation Medical Examiners. It lists drugs, the toxic effects relevant to aviation that they may produce, and a conservative estimate of their allowable use.
The drugs named in this book are arranged so that related drugs are grouped under general therapeutic headings. Individual drug names will be found alphabetically in the index. Mixtures of drugs have not ordinarily been included, but, infrequent synergism aside, the hazards of mixtures may be considered the same as those of their individual components.
To simplify the text, salt or ester designations such as hydrochloride or propionate are omitted; their dangers may be assumed to be the same as the free compound. For ease of identification, trade names are given parenthetically after the nonproprietary name.
The symptoms listed under the heading &Undesirable effects in aviation" include only those that might be considered important to flying. It is presumed that the examining physicians will ordinarily have access to the name of the drug under question, and will not be faced with a problem of identifying the drug from the symptoms of the patient. Discussion of the latter is beyond the limited scope of this book.
Under the heading "Use in aviation personnel" the statement usually reads&Airman duty contraindicated for so many hours or days after use," often with qualifications or exceptions. Customary or usual dosage is assumed. The time limits are intended to be conservative;
that is, to indicte the time at which undesirable effects would be presumed to be absent even in sensitive or reactive persons. In only a few instances has it been thought possible to distinguish between the dangers of air duty as opposed to ground duty.
It should be stressed that although the likelihood of a drug reaction may disappear after n porticular time, this does not mean that the person is fit for duty. In many instances, it is, of course, inconceivable
that a person ill enough to have required a drug would be well enough to work by the time the chance of toxicity from the drug has disappeared. In other instances, the need of a particular drug would of itself indicate a disease state permanently incompatible with flying, ground work, or both. The general medical condition of the patient is always of overriding concern.
It should be stressed that the function of the Medical Examiner is to determine the airman's fitness for duty. The first consideration must be to determine whether the disease process of itself, treated or untreated, contraindicates duty; the consideration of the effects of a drug are then secondary in determining final fitness.
I am most appreciative of the comments and refinements of Drs.
James H. Britton, H. D. Estes, Herbert S. Kupperman, H. George Mandel, Walter Modell, Richard W. Payne, and Homer I. Reighard in their consideration of the text.
-WINDSOR C. CUTTING, M.D.
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CONTENTS Page Foreword Preface.
1. ANTIBACTERIAL AND RELATED AGENTS Sulfonamides, systemic and urinary...
Sulfonamides, alimentary and others_.
Penicillins.
Penicillin inhibitor.
Erythromycin group.
Reserve penicillin substitutes.
Tetracyclines- Chloramphenicol Streptomycin group- Streptomycin alternatives.
Sulfones.
Antituberculosis aynthetica.
Nitrofuran derivatives.
Urinary antiseptica. 5 Polypeptide antibiotics- 6
2. ANTIFUNGAL AGENTS Nystatin Amphotericin Griseofulvin
3. ANTIPROTOZOAL AGENTS. 8 Quinine 8 Chloroquine group- Chlorguanide group- Primaquine group Emetine. 9 Glaucarubin 9 Oxyquinoline group.
Fumagillin_ Metronidazole- Arsenicals_ 10 Bismuth and mercury compounds.
Gold compounds.. 10
4. METAL BINDING AGENTS (ANTIDOTES)- Dimercaprol.
Ethylenediamine tetraacetic acid salts- Penicillamines.
5. AGENTS IN TROPICAL DISEASES.
Antimonials.
Synthetica_
6. ANTHELMINTICS.
Flatworm agente..
Chlorinated hydrocarbons
6. ANTHELMINTICS--Continued Pape Phenol derivatives 13 Cyanine dyes. 13 Piperazines_ 14 Bephenium 14 Other anthelmintics 14
7. ANTICANCER AGENTS. 15 Alkylating agenta_ 15 Folic acid antagonists. 15 Purine and Pyrimidine Antagonista. 15 Others_. 16
8. TOPICAL AGENTS 17 Insecticides_ 17 Insect repellante. 17 Antiseptics: Phenols, metale, halogens, oxidizing agents, alcohola, dyes 17 Fungicides.. 18 Surface active compounda 18 Sclerosing agents_ 19 Protectives, Emollients, Cosmetics. 19 Sun tan and depigmenting preparations 19
9. CARDIOVASCULAR AGENTS 20 Cardiac glycosides 20 Antiarrhythmics. 20 Agents in heart block 20 Diuretics, osmotic and acidifying.. 21 Diuretics, xanthines. 21 Diuretics, mercurials 21 Diuretics, carbonic anhydrase inhibitora. 22 Diuretice, thiazide and related.. 22 Diuretics, aminouracil derivatives. 22 Diuretice, aldosterone antagonists. 22 Diuretics, catfonic exchange resins 23 Agents inhibiting renal tubules 23 Agents in atherosclerosis 23 Hypotensives, central. 24 Hypotensives, ganglion blockers. 24 Hypotensives, sympatholytics. 25
10. SMOOTH MUSCLE AGENTS 26 Nitrites and nitrates. :6 Xanthines.
Papaverine and similar agenta.
Ergot alkaloids. 27 Posterior pituitary preparations- 27
11. AGENTS IN BLOOD DISEASES. 28 Iron preparations. 28 Vitamin B,, liver, folic acid preparations 28 Heparin preparations 28 Heparin antagoniste 29 Coumarin and indandione derivatives.. 29 Proteolytic and other enzymes.
Vitamin K preparations.
INTARY AGENTS.
regice_
30. TRANQUILIZERS-Continued Page Antipruritica 70 Reserpine group - 71 Diphenylmethane group- 71 Propanediol-carbamate group- 71 Chlordiazeposide 72 Others_. 72
31. STIMULANTS 73 Nikethamide group- 73 Other medullary stimulants. 73 Reflex stimulants 78
32. PSYCHIC STIMULANTS 74 Xanthine group. 74 Sympathomimetic group- 74 Diphenylmethane group- 74 Amine oxidase inhibitors 74 Dibenzazepine group- 75
33. AGENTS IN ALCOHOLISM. 76 Metabolic inhibitors.. 76
GUIDE TO DRUG HAZARDS IN
AVIATION MEDICINE
1. ANTIBACTERIAL AND RELATED AGENTS
SULFONAMIDES, SYSTEMIC AND URINARY acetylsulfisoxazole (Gantrisin Acetyl) methylsulfanilamidoisoxazole (Gantanoi) sulfacetamide (Sulfamyd) sulfadiazine sulfadimethoxine (Madribon) sulfaethidole (Sul-spansion) sulfamerazine sulfamethazine sulfamethizole (Thiosulfil) sulfamethoxazole (Azo-Gantanol) sulfamethoxypyridazine (Kynex) sulfamidine sulfamonomethoxine sulfamoxole (Nuprin, Sulfuno) sulfaphenazole (Orisul) sulfapyridine sul fasomizole sulfisomidine (Elkosin) sulfisoxazole (Gantrisin) Undesirable effects in aviation: Early: nausea, vomiting, dizziness. Late: dermatitia, rash, agranulocytosis, hepatitis.
Use in aulation personnel: Airman duties contraindicated for 24 hours after use. Medical surveillance advisable for 2 weeks, alert to the appearance of late bone marrow and liver damage, which would preclude work.
SULFONAMIDES, ALIMENTARY AND OTHERS para-nitrogulfathiazole (Nisulfazole) phthalyleulfathiazole (Sulfathalidine) 1
salicylazosulfapyridine (Salazopyrin) succinylsulfathiazole (Sulfasuxidine) Undesirable effects in aviation: Toxicity minimal but effects like those from systemic sulfonamides may appear occasionally.
Use in aviation personnel: Airman duties contraindicated for 1 week after use. A patient needing such agents must be presumed to be too sick for duty.
PENICILLINS ampicillin (Penbritin) benzathine penicillin G (Bicillin; Neolin; Permapen) benzathine phenoxymethyl penicillin benzylpenicillin (penicillin G) chlorprocaine penicillin O (Depo-Cer-O-Cillin) diphenicillin (Ancillin) hydrabamine phenoxymethyl penicillin (Compocillin V Hydrabamine) levophenethicillin (L-Maxipen) oxacillin (Prostaphlin) penicillin O (Cer-O-Cillin) phenethicillin (Syncillin) phenoxymethylpenicillin (penicillin V; Pen-Vee Suspension;
V-Cillin) potassium phenoxymethyl penicillin (Compocillin VK) procaine penicillin G (Aquacillin; Crysticillin; Duracillin; Eskacillin; Hypercillin) sodium methicillin (Staphcillin) Undesirable effects in aviation: Early and late allergic reactions, including anaphylaxis, urticaria and angioneurotic edema, asthma and dermatitis.
Use in aviation personnel: Airman duties contraindicated within 12 hours of use. Duty may be permitted after that time if there is no evidence of late toxicity and examination indicates infection is cured.
PENICILLIN INHIBITOR penicillinase (Neutrapen) Undesirable effects in aviation: Fever, local pain, tenderness, allergic reactions.
Use in aviation personnel: Airman duties contraindicated for 8 days after use, but in any case patient must be presumed to be too sick for duty.
ERYTHROMYCIN GROUP carbomycin (Magnamycin) (withdrawn from market) erythromycin (Ilotycin; Erythrocin) ; free or various esters oleandomycin (Matromycin) spiramycin staphylomycin triacetyloleandomycin (Cyclamycin; TAO) tylosin Undesirable effects in aviation: Relatively free from serious toxic effects. Doses over 0.5 gm. may cause nausea, vomiting and diarrhea. Late: liver damage reported after erythromycin estolate and triacetyloleandomycin.
Use in aviation personnel: Airman duties contraindicated for 12 hours after use. Frequent medical examinations indicated for the next 2 weeks.
RESERVE PENICILLIN SUBSTITUTES novobiocin (Albamycin; Cathomycin) ristocetin (Spontin) vancomycin (Vancosin) Undesirable effects in aviation: Severe toxic effects, including variously: skin rashes, urticaria, fever, thrombophlebitis, neutropenia, ototoxicity, nephrotoxicity.
Use in aviation personnel: Airman duties contraindicated for 1 week after use; additionally, it must be presumed that an illness requiring these drugs precludes duty.
TETRACYCLINES chlortetracycline (Aureomycin) demethylchlortetracycline (Declomycin) oxytetracycline (Terramycin) rolitetracycline (Syntetrin) tetracycline (Achromycin; Panmycin; Polycycline; Steclin;
Sumycin; Tetrabon; Tetracyn; Tetrex) Undesirable effects in aviation: Larly: nausea, vomiting, diarrhea, light-headedness, photosensitivity (especially to demethylchlortetracycline). Late: glossitis, diarrhea, superinfection with monilia.
Use in aviation personnel: Airman duties contraindicated within 12 hours of use, or if any of the listed toxic effects are present, including late or continuing photosensitivity reactions. Frequent medical examinations indicated for the next 2 weeks.