Date of preparation: April 2012Job bag number: UK/DB/0412/0176Date of preparation: April 2012Job bag number: DVLA Guidance & Diabetes Janet Bellis

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Driving licensing, Diabetes & Hypoglycaemia Diabetes is a medical condition which, dependent upon treatment, may require notification by law to the Driver and Vehicle Licensing Agency (DVLA) Hypoglycaemia is the main hazard when driving and can occur with diabetes treated with insulin or tablets or both Many of the road accidents caused by hypoglycaemia are because drivers ignore or are unaware of the warning signs of hypoglycaemia DVLA 2011 At a glance Guide to the current Medical Standards of Fitness to Drive

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Hypoglycaemia-related road traffic accidents in the UK Approximately 5 fatal hypoglycaemic road traffic accidents per year 25–30 serious hypoglycaemia related road traffic events per month (information from police notifications to DVLA, 2009) Last accessed 4 th April 2012

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Hypoglycaemia Defined Documented symptomatic hypoglycaemia An event during which typical symptoms of hypoglycaemia are accompanied by a measured plasma glucose concentration ≤3.9 mmol/l Asymptomatic hypoglycaemia An event not accompanied by typical symptoms of hypoglycaemia but with a measured plasma glucose concentration ≤3.9 mmol/l American Diabetes Association Workgroup on Hypoglyceamia Diabetes Care May 2005 vol. 28 no

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Hypoglycaemia Defined Relative hypoglycaemia An event during which the person with diabetes reports any of the typical symptoms of hypoglycaemia, and interprets those as indicative of hypoglycaemia, but with a measured plasma glucose concentration >3.9 mmol/l. American Diabetes Association Workgroup on Hypoglyceamia Diabetes Care May 2005 vol. 28 no

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 What is a reportable severe hypoglycaemic episode? Hypoglycaemia requiring the assistance from another person at any time of day or night The requirement of assistance includes –Admission to A&E –Treatment from paramedics –Assistance from 3 rd party who has to administer glucagon/glucose because the person cannot do so themselves. It does NOT include another person giving assistance in circumstances where the person was aware of his/her hypoglycaemia and able to take appropriate action independently. Diabetes UK 2011 Driving and the new medical standards for people with diabetes

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Common symptoms of hypoglycaemia McAulay. Diabetic Medicine 2001;18:690–705 Edinburgh Hypoglycaemia Scale in which the 11 most commonly reported symptoms were incorporated AutonomicNeuroglycopenicGeneral malaise SweatingConfusionHeadache PalpitationsDrowsinessNausea ShakingOdd behaviour HungerSpeech difficulty Incoordination

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Hypoglycaemia & cognitive function Cognitive function can start to deteriorate when blood glucose levels drop below the region of 3.0 mmol/l Complex tasks are consistently impaired – Memory & attention – Concentration/abstract thought – Rapid decision making – Hand-eye coordination Cognitive function does not fully recover for at least 45 minutes after hypoglycaemia Warren and Frier. Diabetes, Obesity and Metabolism, 7, 2005, 493–503

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Hypoglycaemic Unawareness Impaired awareness of hypoglycaemia has been defined by the Secretary of State's Honorary Medical Advisory Panel on Driving and Diabetes as, 'an inability to detect the onset of hypoglycaemia because of a total absence of warning symptoms'. DVLA Swansea, Dec At a glance: Guide to the current Medical Standards of Fitness to Drive p.29

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Driving Regulations 1st January 1998 – New driving restrictions introduced in the UK, to bring UK in line with other European countries People with diabetes on insulin had a licence requiring revalidation a maximum of every 3 years Normal licence ran until the age of 70 years Since 15 th November 2011, new driving regulations have been implemented

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 There are two groups of licence holders and the medical standards differ according to each group: Group 1 includes motorcars and motorcycles –Aged years Group 2 concerns vocational vehicles and includes large lorries (category C) and buses (category D) –Aged years, then every 5 years to 65 years Driving Licences: Classification in Europe

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Group 1: managed by diet alone Need not notify DVLA unless develop relevant disabilities e.g. diabetic eye problems affecting visual acuity or visual field or if insulin required. DVLA 2011 At a glance Guide to the current Medical Standards of Fitness to Drive

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Group 1: Managed by tablets associated with a risk of hypoglycaemia (includes SUs & glinides) If all of the following requirements are met DVLA does not require notification: Must not have had more than one episode of hypoglycaemia requiring the assistance of another person within the preceding 12 months. Must not suffer a single severe hypoglycaemia event while driving. Must not have hypoglycaemic unawareness DVLA 2011 At a glance Guide to the current Medical Standards of Fitness to Drive

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Must have no other debarring complications of diabetes such as a visual field defect. Must not be considered at high risk of developing severe hypoglycaemia by self or medical team. It is advised but not required to monitor blood glucose regularly and at times relevant to driving to enable the detection of hypoglycaemia. A medication review should also take place. Group 1: Managed by tablets associated with a risk of hypoglycaemia (includes SUs & glinides) DVLA 2011 At a glance Guide to the current Medical Standards of Fitness to Drive

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Group 1: managed by tablets other than those on the previous page or by non- insulin injectable medication If all the following requirements are met, and they are under regular medical review, DVLA does not require notification: Must not have had more than one episode of hypoglycaemia requiring the assistance of another person within the preceding 12 months. Must not suffer a single severe hypoglycaemia event while driving. DVLA 2011 At a glance Guide to the current Medical Standards of Fitness to Drive

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Group 1: managed by tablets other than those on the previous page or by non- insulin injectable medication Must not have hypoglycaemic unawareness Must have no other debarring complications of diabetes such as a visual field defect. DVLA 2011 At a glance Guide to the current Medical Standards of Fitness to Drive

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Group 1: Insulin treated Drivers treated with any insulin preparation MUST inform the DVLA. However, they can apply for and be granted a 1, 2, or 3 year Group 1 licence if the following criteria are met: Must have awareness of hypoglycaemia. Must not have had more than one episode of hypoglycaemia requiring the assistance of another person in the preceding 12 months. Must not be regarded as a likely source of danger to the public while driving. Must meet the visual standards for acuity & visual field DVLA 2011 At a glance Guide to the current Medical Standards of Fitness to Drive

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Group 1 : Insulin treated Must not be considered at high risk of developing severe hypoglycaemia by self or medical team. Must not have a single episode of severe hypoglycaemia while driving MUST have appropriate blood glucose monitoring –Must always carry glucose meter & blood glucose strips. –Must check blood glucose before driving and every two hours whilst driving. –If blood glucose is 5.0mmol/l or less, take a snack. If less than 4.0mmol/l or feel hypoglycaemic, do not drive. DVLA 2011 At a glance Guide to the current Medical Standards of Fitness to Drive

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Group 2: managed by diet alone Need not notify DVLA unless develop relevant disabilities e.g. Diabetic eye problems affecting visual acuity or visual field or if insulin required. DVLA 2011 At a glance Guide to the current Medical Standards of Fitness to Drive

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Group 2: Managed by tablets which carry a risk of inducing hypoglycaemia (includes SUs & glinides) Need to inform the DVLA but can be issued a 1, 2 or 3 year group 2 licence if meets the following criteria: No episode of hypoglycaemia requiring the assistance of another person has occurred in the preceding 12 months. Has full awareness of hypoglycaemia. Has sufficient understanding of the risks of hypoglycaemia. No other debarring complications of diabetes such as a visual field defect. Required by law to monitor blood glucose at least twice daily and at times relevant to driving. DVLA 2011 At a glance Guide to the current Medical Standards of Fitness to Drive

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Group 2: managed by tablets other than those on the previous page or by non- insulin injectable medication Drivers need to inform the DVLA but will be issued a group 2 licence unless they develop relevant disabilities e.g. diabetic eye problem affecting visual acuity or visual fields, in which case either refusal, revocation or short period licence. Drivers are advised to monitor their blood glucose regularly and at times relevant to driving. They must be under regular medical review. DVLA 2011 At a glance Guide to the current Medical Standards of Fitness to Drive

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Group 2: Insulin treated Drivers taking any insulin preparation MUST inform the DVLA. However, they can apply for and be granted a Group 2 licence for a maximum of 12 months if the following criteria are met: No episode of hypoglycaemia requiring the assistance of another person has occurred in the preceding 12 months. Has full awareness of hypoglycaemia. Has sufficient understanding of the risks of hypoglycaemia. Is not considered at high risk of developing severe hypoglycaemia by self or medical team. Has no episode of severe hypoglycaemia while driving DVLA 2011 At a glance Guide to the current Medical Standards of Fitness to Drive

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Group 2: Insulin treated Must also have no other debarring complications of diabetes such as a visual field defect. Required by law to monitor blood glucose at least twice daily and at times relevant to driving using a glucose meter with a memory function. Must have an annual examination by an independent Consultant Diabetologist –3 months of blood glucose readings must be available. DVLA 2011 At a glance Guide to the current Medical Standards of Fitness to Drive

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Police, Ambulance and Health Service Vehicle Driver Licensing The Secretary of State’s Honorary Medical Advisory Panel on Diabetes and Driving has recommended that drivers with insulin treated diabetes should not drive emergency vehicles This takes account of the difficulties for an individual, regardless of whether they may appear to have exemplary glycaemic control, in adhering to the monitoring processes required when responding to an emergency situation. DVLA 2011 At a glance Guide to the current Medical Standards of Fitness to Drive

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Group 1 license holders: key changes A group 1 driver who has had two or more episodes of hypoglycaemia requiring assistance from another person at any time (including when sleeping) in a year, must inform the DVLA and be advised not to drive. Previously a single hypoglycaemic event would ban the person from driving until satisfactory control certificate obtained from GP. DVLA 2011 At a glance Guide to the current Medical Standards of Fitness to Drive

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Group 2 license holders: key changes DVLA have now removed the ban for people on insulin driving Group 2 vehicles and people can now undergo individual medical assessment to assess their fitness to drive these vehicles. Good news for Group 2 however: –Must demonstrate 3 months of blood glucose monitoring before applying –Additional requirement: using a blood glucose meter with a memory function –Must not experience one or more hypoglycaemic episode(s) requiring assistance of another person in the previous 12 months. DVLA 2011 At a glance Guide to the current Medical Standards of Fitness to Drive

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 What to do if your licence is taken away If a driving licence is revoked the DVLA can be asked to reconsider their decision. Must appeal within 6 months of the decision to revoke your licence. To succeed, court must be convinced that the incident was due to most unusual circumstances and that the onset of another uncontrolled hypoglycaemic episode whilst driving is unlikely. If you have had your licence revoked due to having more than one disabling hypoglycaemic event in 12 months, you can reapply for your licence when 12 months have passed since the penultimate (last-but-one) hypoglycaemic event. Diabetes UK 2011 Driving and Diabetes Information Sheet

Date of preparation: April 2012Job bag number: UK/DB/0412/0176 Summary Diabetes and its treatments can adversely affect the ability to drive safely. New regulations issued in 2011 regarding driving licence standards to bring UK in line with EU Member States Key changes: –Group 1 drivers with two or more episodes of severe hypoglycaemia (requires the assistance of another person) in a 12 month period MUST inform DVLA and be advised not to drive –Group 2 drivers with one or more episodes of hypoglycaemia (requires the assistance of another person) in a 12 month period MUST inform DVLA and be advised not to drive –DVLA have now removed the ban for people on insulin driving Group 2 vehicles and people can now undergo individual medical assessment to assess their fitness to drive these vehicles.