By James D. Lakin PhD MD FACP CFI
FAA Senior Aviation Medical Examiner 

You Can Fly With Insulin-Dependent Diabetes


December 1, 2021

There was a time when the diagnosis of diabetes was the prelude to a short life. Then insulin came along in 1922, which gave diabetic patients a reprieve from the immediate effects of a deficiency of that vital hormone.

However, as time passed it become apparent that longstanding diabetes, if not well controlled, caused degeneration of the eyes, kidneys, heart and blood vessels. Also, not all diabetics could control their blood sugars well.

Episodes of low blood sugar (hypoglycemia) would cause unconsciousness and brain damage if prolonged. Likewise, high blood sugars (hyperglycemia) led to confusion, coma and even death if not treated.

As early as 1935 it was recognized that there was a second or Type II diabetes that tended to develop later on in life and be associated with less violent swings in blood sugar levels.

As time went on it was recognized that even Type II Diabetes can be complicated by stroke, heart and kidney disease especially if poorly controlled. As you might surmise, for many years the diagnosis of diabetes was an unequivocal disqualification for an FAA medical certificate.

In the 1950s oral medications were developed to treat Type II diabetes. Freed from insulin, these patients were less likely to have episodes of incapacitating hypoglycemia. Several years later the FAA began granting Special Issuance medical certificates to well-controlled Type II diabetics. As experience grew, the FAA now allows AMEs to grant medical certificates to well-controlled Type II diabetics without going through the Special Issuance process.

The development of glucose meters allowed Type I diabetics to check their blood sugar levels with a finger stick blood sample and better anticipate and prevent episodes of hypoglycemia or hyperglycemia. As the technology became established, the FAA started to grant Special Issuance (SI) medicals to well-controlled Type I diabetics for Third Class Medical Certificates. Flying with Type I diabetes for Part 135 or Part 121 commercial operations continued to be forbidden. This is a good example of the dilemma the FAA’s Medical Certification Division faces: How do you balance granting pilots the freedom to fly with protection of the paying passengers? The protocol which SI pilots had to follow was strict and involved checking blood sugar levels one half-hour before and at hourly intervals during the flight with oral glucose preparations on hand to counteract hypoglycemia.

The development of Continuous Glucose Monitoring (CGM) proved to be a game changer for flying commercially with Type I Diabetes. This marvel of biomedical engineering automatically tracks blood glucose levels throughout the day and night. You can see your glucose level anytime and review how your glucose changes over a few hours or days to see trends. Seeing glucose levels in real time can help you make more informed decisions throughout the day about how to balance your food, physical activity, and medicines to control blood sugar.

It works through a sensor that is placed beneath the skin which transmits blood glucose levels to a monitor every few minutes. Some models are linked to an insulin pump which acts (or doesn’t) on the basis of blood sugar concentrations.

The display can even be routed to your smartphone or iPad with certain models. This system dramatically increases the control a pilot can have over his/her blood glucose during flight.

Recognizing this, in November 2019 the FAA released protocols allowing commercial pilots with insulin-dependent diabetes to fly Part 135 and Part 121. Admittedly the requirements are pretty strict. A board-certified endocrinologist must do lab work and certify that your diabetes is stable and well controlled.

A cardiologist and ophthalmologist must certify that your heart and eyes are OK, respectively. You must submit 6 months of CGM data to back this up. Every 12 months thereafter the FAA will want the specialists to take another look at things. It’s a bit involved but frankly it’s not much more than you would be well-advised to do for good follow-up of insulin dependent diabetes anyway. And the great thing about it is you get to fly the heavy metal!

For more information about this topic, check out this FAA link: Fly wisely. See you next month.


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