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DVLA Petition- Action for Diabetic Drivers
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<blockquote data-quote="gpwsi" data-source="post: 691566" data-attributes="member: 143986"><p><strong>Hypoglycaemia: </strong></p><p></p><p>Nocturnal hypoglycaemia is not a phenomenon that is easy to explain, and yes the context of the problem of hypoglycaemia itself needs to be considered before DVLA should make a judgement on the issue. I am a GP and my family suffer a condition called Reactive Hypoglycaemia, hence my interest on this topic. My family also have a strong history of diabetes, usually reverting to Type 1 following a diagnosis of Type 2.</p><p></p><p></p><p>It has been well established that intensive insulin therapy (lower HbA1c) can cause a progressive increase in hypoglycaemic episodes in Type 1 diabetics (DCCT: <em>N Eng J Med 1993; 329:977</em>).</p><p></p><p></p><p>Considering this premise, it should not be too difficult to understand the physiology of hypoglycaemia in the Type 1 diabetic or strategies to reduce the risk. This should form the context for DVLA decisions on fitness to drive in Type 1 diabetics.</p><p></p><p></p><p>Put simply, in laymen terms, insulin causes the potential for hypoglycaemia and therefore all Type 1 diabetics are at risk regardless of documented episodes requiring outside assistance as I will explain below. There is debate on the cut-off value to diagnose hypoglycaemia. I would assume, in the home at least, a blood glucose measurement will be possible, but that is not always the case.</p><p></p><p></p><p>Whilst Type 1 diabetics have been trained to identify the early warning signs of hypoglycaemia, nocturnal hypoglycaemia is in a different category altogether. You are asleep, therefore it becomes irrelevant as you are not awake to identify the early warning signs. This is why I have started off with the physiologic basis of hypoglycaemia. Recently the Somogyi hypothesis has been disputed and it has been suggested that the reverse is true in that nocturnal hypoglycaemia is associated with morning hypoglycaemia and vice versa. With nocturnal hyperglycaemia (and morning hyperglycaemia) this often forms the basis for Type 2s converting to Type 1s (known as Type 2s treated with Insulin) etc.</p><p></p><p></p><p>During night time, most people will be asleep. If they were awake and developed hypoglycaemia requiring outside assistance, then the situation changes. The DVLA must be concerned with people who ‘lose awareness to hypoglycaemia’ and not ‘hypoglycaemia’ per se. Most people sleep on a night time and sleep hypoglycaemia should not fall under this category as no one who is asleep can have ‘awareness’ of hypoglycaemia and therefore be deemed to have ‘lost’ this awareness that is so critical for driving. The danger is if they fell asleep due to hypoglycaemia, as opposed to going to bed normally and then suffering a hypoglycaemic episode during night time which required assistance, would also result in a call to the paramedics etc. If you have been aroused and requested glucose gel from your partner, that forms the ‘assistance’ or even requested glucagon (if you have it prescribed), this is <strong>NOT</strong> reportable because this still suggests you <strong>have </strong>awareness.</p><p></p><p></p><p>The danger on the roads comes from diabetics who are not aware of hypoglycaemia. It is assumed that they are awake, hence the conscious decision to drive, but have lost the awareness to hypoglycaemia and therefore deemed high risk were they to become unconscious and become a danger to themselves as well as others.</p><p></p><p></p><p><strong><em>“DVLA: </em></strong></p><p></p><p><strong><em>What is a reportable hypoglycaemic episode?</em></strong></p><p></p><p><em>Hypoglycaemia requiring assistance from another person at any time of day or night constitutes an episode for reporting purposes. The requirement of assistance <strong>would</strong> include:</em></p><p></p><p><em>- admission to Accident and Emergency,</em></p><p></p><p><em>- treatment from paramedics,</em></p><p></p><p><em>- assistance from a partner/friend who has to administer <strong>glucagon</strong> or <strong>glucose</strong> because the person <strong>cannot</strong> do so themselves </em>(the important point is ‘cannot’)</p><p></p><p></p><p><strong><em>It does not include another person offering or giving assistance</em></strong><em>, in circumstances where the person was aware of his/her hypoglycaemia and able to take appropriate action independently. </em></p><p></p><p></p><p><em>ABCD2 recommends that primary care teams should consider referral to the specialist team for patients who have suffered a single hypoglycaemic attack requiring assistance, especially where a second episode might result in loss of employment.</em></p><p></p><p></p><p><strong><em>What about nocturnal hypoglycaemia?</em></strong></p><p></p><p><em>A significant change in the assessment criteria for fitness to drive is the inclusion of episodes of severe nocturnal hypoglycaemia. <strong>If it is suspected that severe nocturnal hypoglycaemia is present, but not witnessed or treated, this would not necessarily constitute an episode for reporting.</strong> However, if the clinician had concerns it may be appropriate to advise the person to notify the DVLA. Similarly, data gathered while using continuous glucose monitoring devices or other evidence of hypoglycaemia may not constitute evidence to stop driving in the absence of symptoms unless the clinician has concerns</em><strong><em>”</em></strong></p><p></p><p></p><p>The DVLA has provisions for reinstating licenses once it can be proved that the risk has been adequately treated (we can never say the risk has been removed).</p><p></p><p></p><p>The ADA (American Diabetes Association) defines <strong>Severe Hypoglycaemia</strong> as an event requiring the assistance of another person to actively administer carbohydrate, glucagon etc. Whilst plasma glucose measurements may not be available during such an event, neurologic recovery attributable to restoration of glucose to normal is considered sufficient evidence that the event was caused by low plasma glucose concentration.</p><p></p><p></p><p>On the other hand documented symptomatic hypoglycaemia is defined by the fact that the plasma glucose has been monitored and the levels coincide with the local or national guidance on the cut-off for diagnosing hypoglycaemia. Other forms of hypoglycaemia consist of asymptomatic, probable symptomatic and pseudo-hypoglycaemia.</p><p></p><p></p><p>The UK Hypoglycaemia Study Group (Diabetologia. 2007;50(6):1140) as well as other studies have documented the fact that hypoglycaemia occurs frequently in Type 1 diabetics. The average patient suffers countless numbers of episodes of asymptomatic hypoglycaemia, two episodes of symptomatic hypoglycaemia per week, and one episode of temporary disabling hypoglycaemia per year. The category in which ‘outside help’ is sought, i.e. severe hypoglycaemia, represents a small fraction of the total hypoglycaemic experience.</p><p></p><p></p><p><strong>Nocturnal Hypoglycaemia:</strong></p><p></p><p>Prevention of nocturnal hypoglycaemia can be through snacks containing protein (J Clin Endocrinol Metab. 1996;81(4):1508). I note you are on an insulin pump, however a Sensor-augmented CSII using an insulin pump that stops infusing insulin for up to two hours when the sensor detects a predetermined low glucose level has been shown to reduce nocturnal hypoglycaemia (N Eng J Med. 2013 Jul;369(3):224-32).</p><p></p><p></p><p>Exercise – interestingly – is linked to hypoglycaemia unawareness by reducing autonomic symptom responses. Post-exercise hypoglycaemia can occur hours after exercise. Simple monitoring of blood glucose post-exercise and using the approach of protein snacks can help.</p><p></p><p></p><p>For insulin-dependent diabetics having pure glucose and perhaps a glucagon kit is essential to recovery. In severe hypoglycaemia (that which requires assistance) an ambulance must always be called.</p><p></p><p></p><p><strong>Finally:</strong></p><p></p><p>The question you need to answer is: <strong>How</strong> was this assistance given during the night? (using the DVLA guidance above). If you had woken up and asked for assistance, that is not the same as what DVLA should be recommending. In my opinion people who are asleep may develop asymptomatic hypoglycaemia but not necessarily severe hypoglycaemia – how would anyone know in time to give the ‘sleeping’ person with severe hypoglycaemia, glucose? Unless that person was not rousable for some reason and assistance had to be given in the context of the affected person not asking for such assistance. If your context is not indicative of severe hypoglycaemia because you asked your partner, then you did not require the assistance that is associated with the definition of severe hypoglycaemia requiring your driving license to be revoked. Usually, in such circumstances it would be the clinician (see guideline above) that would advise you to inform DVLA based on the history you provided. It appears that the Consultant disagrees with DVLA, so it may be that you have not filled the form in correctly by assuming you had a reportable episode of hypoglycaemia, when it may be that you did not have such a reportable episode. In such an instance, DVLA will send you a form to advise you to make your case – or state the context. Again, I will refer to the DVLAs own guidance again: <em>The requirement of assistance <strong>would</strong> include: admission to <strong>Accident and Emergency</strong>, treatment from <strong>paramedics</strong>, assistance from a <strong>partner/friend</strong> who has to administer <strong>glucagon</strong> or <strong>glucose</strong> because the person <strong>cannot</strong> do so themselves.</em></p><p></p><p></p><p>In treating such people, often it is misunderstood that oral food containing sugar can be given, there is a risk of aspiration and hence dextrose GEL or even cake frosting in the space between the teeth and buccal mucosa keeping the patient’s head tilted slightly to the side is the safest method of administering glucose to a Type 1 diabetic (or a Type 2 on Insulin) suffering from hypoglycaemia. However lack of a dextrose gel should <strong>not </strong>prevent use of any type of sugary product available.</p></blockquote><p></p>
[QUOTE="gpwsi, post: 691566, member: 143986"] [B]Hypoglycaemia: [/B] Nocturnal hypoglycaemia is not a phenomenon that is easy to explain, and yes the context of the problem of hypoglycaemia itself needs to be considered before DVLA should make a judgement on the issue. I am a GP and my family suffer a condition called Reactive Hypoglycaemia, hence my interest on this topic. My family also have a strong history of diabetes, usually reverting to Type 1 following a diagnosis of Type 2. It has been well established that intensive insulin therapy (lower HbA1c) can cause a progressive increase in hypoglycaemic episodes in Type 1 diabetics (DCCT: [I]N Eng J Med 1993; 329:977[/I]). Considering this premise, it should not be too difficult to understand the physiology of hypoglycaemia in the Type 1 diabetic or strategies to reduce the risk. This should form the context for DVLA decisions on fitness to drive in Type 1 diabetics. Put simply, in laymen terms, insulin causes the potential for hypoglycaemia and therefore all Type 1 diabetics are at risk regardless of documented episodes requiring outside assistance as I will explain below. There is debate on the cut-off value to diagnose hypoglycaemia. I would assume, in the home at least, a blood glucose measurement will be possible, but that is not always the case. Whilst Type 1 diabetics have been trained to identify the early warning signs of hypoglycaemia, nocturnal hypoglycaemia is in a different category altogether. You are asleep, therefore it becomes irrelevant as you are not awake to identify the early warning signs. This is why I have started off with the physiologic basis of hypoglycaemia. Recently the Somogyi hypothesis has been disputed and it has been suggested that the reverse is true in that nocturnal hypoglycaemia is associated with morning hypoglycaemia and vice versa. With nocturnal hyperglycaemia (and morning hyperglycaemia) this often forms the basis for Type 2s converting to Type 1s (known as Type 2s treated with Insulin) etc. During night time, most people will be asleep. If they were awake and developed hypoglycaemia requiring outside assistance, then the situation changes. The DVLA must be concerned with people who ‘lose awareness to hypoglycaemia’ and not ‘hypoglycaemia’ per se. Most people sleep on a night time and sleep hypoglycaemia should not fall under this category as no one who is asleep can have ‘awareness’ of hypoglycaemia and therefore be deemed to have ‘lost’ this awareness that is so critical for driving. The danger is if they fell asleep due to hypoglycaemia, as opposed to going to bed normally and then suffering a hypoglycaemic episode during night time which required assistance, would also result in a call to the paramedics etc. If you have been aroused and requested glucose gel from your partner, that forms the ‘assistance’ or even requested glucagon (if you have it prescribed), this is [B]NOT[/B] reportable because this still suggests you [B]have [/B]awareness. The danger on the roads comes from diabetics who are not aware of hypoglycaemia. It is assumed that they are awake, hence the conscious decision to drive, but have lost the awareness to hypoglycaemia and therefore deemed high risk were they to become unconscious and become a danger to themselves as well as others. [B][I]“DVLA: [/I][/B] [B][I]What is a reportable hypoglycaemic episode?[/I][/B] [I]Hypoglycaemia requiring assistance from another person at any time of day or night constitutes an episode for reporting purposes. The requirement of assistance [B]would[/B] include:[/I] [I]- admission to Accident and Emergency,[/I] [I]- treatment from paramedics,[/I] [I]- assistance from a partner/friend who has to administer [B]glucagon[/B] or [B]glucose[/B] because the person [B]cannot[/B] do so themselves [/I](the important point is ‘cannot’) [B][I]It does not include another person offering or giving assistance[/I][/B][I], in circumstances where the person was aware of his/her hypoglycaemia and able to take appropriate action independently. [/I] [I]ABCD2 recommends that primary care teams should consider referral to the specialist team for patients who have suffered a single hypoglycaemic attack requiring assistance, especially where a second episode might result in loss of employment.[/I] [B][I]What about nocturnal hypoglycaemia?[/I][/B] [I]A significant change in the assessment criteria for fitness to drive is the inclusion of episodes of severe nocturnal hypoglycaemia. [B]If it is suspected that severe nocturnal hypoglycaemia is present, but not witnessed or treated, this would not necessarily constitute an episode for reporting.[/B] However, if the clinician had concerns it may be appropriate to advise the person to notify the DVLA. Similarly, data gathered while using continuous glucose monitoring devices or other evidence of hypoglycaemia may not constitute evidence to stop driving in the absence of symptoms unless the clinician has concerns[/I][B][I]”[/I][/B] The DVLA has provisions for reinstating licenses once it can be proved that the risk has been adequately treated (we can never say the risk has been removed). The ADA (American Diabetes Association) defines [B]Severe Hypoglycaemia[/B] as an event requiring the assistance of another person to actively administer carbohydrate, glucagon etc. Whilst plasma glucose measurements may not be available during such an event, neurologic recovery attributable to restoration of glucose to normal is considered sufficient evidence that the event was caused by low plasma glucose concentration. On the other hand documented symptomatic hypoglycaemia is defined by the fact that the plasma glucose has been monitored and the levels coincide with the local or national guidance on the cut-off for diagnosing hypoglycaemia. Other forms of hypoglycaemia consist of asymptomatic, probable symptomatic and pseudo-hypoglycaemia. The UK Hypoglycaemia Study Group (Diabetologia. 2007;50(6):1140) as well as other studies have documented the fact that hypoglycaemia occurs frequently in Type 1 diabetics. The average patient suffers countless numbers of episodes of asymptomatic hypoglycaemia, two episodes of symptomatic hypoglycaemia per week, and one episode of temporary disabling hypoglycaemia per year. The category in which ‘outside help’ is sought, i.e. severe hypoglycaemia, represents a small fraction of the total hypoglycaemic experience. [B]Nocturnal Hypoglycaemia:[/B] Prevention of nocturnal hypoglycaemia can be through snacks containing protein (J Clin Endocrinol Metab. 1996;81(4):1508). I note you are on an insulin pump, however a Sensor-augmented CSII using an insulin pump that stops infusing insulin for up to two hours when the sensor detects a predetermined low glucose level has been shown to reduce nocturnal hypoglycaemia (N Eng J Med. 2013 Jul;369(3):224-32). Exercise – interestingly – is linked to hypoglycaemia unawareness by reducing autonomic symptom responses. Post-exercise hypoglycaemia can occur hours after exercise. Simple monitoring of blood glucose post-exercise and using the approach of protein snacks can help. For insulin-dependent diabetics having pure glucose and perhaps a glucagon kit is essential to recovery. In severe hypoglycaemia (that which requires assistance) an ambulance must always be called. [B]Finally:[/B] The question you need to answer is: [B]How[/B] was this assistance given during the night? (using the DVLA guidance above). If you had woken up and asked for assistance, that is not the same as what DVLA should be recommending. In my opinion people who are asleep may develop asymptomatic hypoglycaemia but not necessarily severe hypoglycaemia – how would anyone know in time to give the ‘sleeping’ person with severe hypoglycaemia, glucose? Unless that person was not rousable for some reason and assistance had to be given in the context of the affected person not asking for such assistance. If your context is not indicative of severe hypoglycaemia because you asked your partner, then you did not require the assistance that is associated with the definition of severe hypoglycaemia requiring your driving license to be revoked. Usually, in such circumstances it would be the clinician (see guideline above) that would advise you to inform DVLA based on the history you provided. It appears that the Consultant disagrees with DVLA, so it may be that you have not filled the form in correctly by assuming you had a reportable episode of hypoglycaemia, when it may be that you did not have such a reportable episode. In such an instance, DVLA will send you a form to advise you to make your case – or state the context. Again, I will refer to the DVLAs own guidance again: [I]The requirement of assistance [B]would[/B] include: admission to [B]Accident and Emergency[/B], treatment from [B]paramedics[/B], assistance from a [B]partner/friend[/B] who has to administer [B]glucagon[/B] or [B]glucose[/B] because the person [B]cannot[/B] do so themselves.[/I] In treating such people, often it is misunderstood that oral food containing sugar can be given, there is a risk of aspiration and hence dextrose GEL or even cake frosting in the space between the teeth and buccal mucosa keeping the patient’s head tilted slightly to the side is the safest method of administering glucose to a Type 1 diabetic (or a Type 2 on Insulin) suffering from hypoglycaemia. However lack of a dextrose gel should [B]not [/B]prevent use of any type of sugary product available. [/QUOTE]
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