Pulmonary Embolism
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Pulmonary Embolism
Hello
I have a colleague that has suffered a DVT after a long haul flight, then suffered a Pulmonary Embolism after clots travelled to his lungs-luckily after 3 days in ICU he survived. From a medical standpoint from you Aviation medicine types out there, how will this affect his Class 1?
I have a colleague that has suffered a DVT after a long haul flight, then suffered a Pulmonary Embolism after clots travelled to his lungs-luckily after 3 days in ICU he survived. From a medical standpoint from you Aviation medicine types out there, how will this affect his Class 1?
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not a medic but know someone that had DVT although without the embolism.
It depends on the reason for the DVT in the first place.
His was due to a injury so eventually got his back.
But there other people that can basically never fly again as a pax never mind as crew.
It depends on the reason for the DVT in the first place.
His was due to a injury so eventually got his back.
But there other people that can basically never fly again as a pax never mind as crew.
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With pulmonary embolism he will be on anti-coagulants for a while, usually not less than 6 months. If he has no residual side effects of the medication, his risk factors are fully controlled, there are no damage done by the initial embolism and his aviation medical examination is 100% normal, he may be considered to be fit by the relevant authority based on a protocol.
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Pulmonary Embolism
Had a PE at the age of 35. No big deal on account I survived. Back flying after 4 months. CAA very good about it. BIG thanks to Coventry Hospital. Message me if you require any further details with regards the process of obtaining your Medical back.
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Hi Leolia, very interested to hear how you went about getting your medical back after your PE. Can I ask when it happened? I have recently suffered a DVT, no PE, but my AME seems to be quite negative about the possibility of Class 1 recertification at all. He believes it was unprovoked, and insists CAA requires a recurrence possibility of less than 1% if on DOAC meds, for Class 1 OML. Does that sound familiar?
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Hi Granny and Skyfall,
I had an unprovoked PE a few years ago and returned to flying after 7 months with an OML. I was placed on warfarin but I believe other forms of anti-coagulant medication is now acceptable.
If I remember correctly the probability of a recurrence without treatment is 5% and with treatment this is reduced to 2%, which seemed to be acceptable to the CAA in my case. At the time I had heard the figure of 1% being quoted too and was pleasantly surprised when I was cleared to return to flying.
The UK CAA protocol is here: https://www.caa.co.uk/Aeromedical-Ex...e-of-warfarin/
Hope that helps.
I had an unprovoked PE a few years ago and returned to flying after 7 months with an OML. I was placed on warfarin but I believe other forms of anti-coagulant medication is now acceptable.
If I remember correctly the probability of a recurrence without treatment is 5% and with treatment this is reduced to 2%, which seemed to be acceptable to the CAA in my case. At the time I had heard the figure of 1% being quoted too and was pleasantly surprised when I was cleared to return to flying.
The UK CAA protocol is here: https://www.caa.co.uk/Aeromedical-Ex...e-of-warfarin/
Hope that helps.
With those restrictions in place, why would anybody hire someone on warfarin in the UK? What happens if the INR is out of range 12hrs before a flight and one is in a far away place with no chance getting another crew member on time? Mind you other EASA countries request one INR value between 2 and 3 once a month just like the FAA. Why invent the wheel new if some other authority has years of experience with thousands of pilots?
There is no longer any need to be on warfarin except in a very few cases. The new tablets need no monitoring. But they are a little more expensive so you may need to ask....or insist....
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Wondering,
My best guess is that you would be in the same position as anyone else who was suddenly taken ill and reported sick. From my own experience, and feedback from others who are/were also on warfarin, you very quickly become adept at controlling the INR within the required range. The actual test is a pain in the rear (in reality it's a finger) when you have to perform it every day, but having survived a potentially fatal condition it's a small price to pay to retain employment and a regular income. The only two occasions that I have been off work with anything INR related have been when my GP has prescribed antibiotics (rapid increase in INR), when I wouldn't have been fit for work anyway, had I not been on warfarin.
I personally don't think being on warfarin makes you any more unreliable than any other member of the flight crew, in terms of fitness to fly, unless you decide to perform a double backflip and land on your head after a sherbet or two.
Probably best though to take Radgirl's advice. Maybe, in time, the CAA will adopt the same requirements as the FAA (when it comes to INR testing)
What happens if the INR is out of range 12hrs before a flight and one is in a far away place with no chance getting another crew member on time?
I personally don't think being on warfarin makes you any more unreliable than any other member of the flight crew, in terms of fitness to fly, unless you decide to perform a double backflip and land on your head after a sherbet or two.
Probably best though to take Radgirl's advice. Maybe, in time, the CAA will adopt the same requirements as the FAA (when it comes to INR testing)
Last edited by Uplifting; 10th May 2016 at 20:53. Reason: Clarification
The CAA are quite happy with dabigatran and the other oral antocoagulants which are licensed for this use. IMHO some doctors are yet to make the change, hence my last post
You do NOT feel unwell if the INR is high or low, you are just at risk of a further clot (low) or a bleed (high). Unfortunately timing is important and lots of things alter the INR if you are on warfarin.
If anyone has been refused these newer drugs in favour of warfarin I would love to hear why....
You do NOT feel unwell if the INR is high or low, you are just at risk of a further clot (low) or a bleed (high). Unfortunately timing is important and lots of things alter the INR if you are on warfarin.
If anyone has been refused these newer drugs in favour of warfarin I would love to hear why....
Warfarin needs to be adjusted because of variability in the way the drug is metabolised. This is also effected by lots of other things. The newer drugs are just a set dose and no monitoring. All drugs have side effects and 30 seconds on Google will be enough to terrify you, but I find these drugs well tolerated. Long term drugs I agree are a separate concern, but if you need long term anticoagulation (not everybody does!) I would rather be off warfarin simply because the risk of under or over medication is far more likely than long term side effects.
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...the risk of under or over medication is far more likely than long term side effects.
With regard to the potential damage to liver, etc., I have annual tests which have always been normal to date, although I admit that I don't know if that will still be the case in another 5 years or whatever. So far, so good!
One of the, dare I say, advantages of warfarin over the other anticoagulant drugs is that it is possible to reverse the affects of warfarin should I require emergency treatment, although I am led to believe that this reversal isn't necessarily immediate. Because I always 'know where I am' with regard to the INR levels I have also been able to undergo a couple of minor operations without coming off warfarin - it's possible to 'manage' the INR at the bottom of the range.
I understand that with the other DOACs I would most likely have to stop taking them a couple of days before any op? I would be interested to hear if there has been any success with reversal agents for these newer drugs. I know that there has been some research with Andexanet Alfa, in 2015, but I'm not aware how that research (or any other) has progressed. I would be interested to find out if there has been any success and, if there has been, how long it might take before it becomes available to the medical profession (if it isn't already)?
I suppose there are pros and cons for everything.
Really good points Uplifting
If you need any operation where there is a risk of bleeding you should consider coming off anticoagulants and we would normally 'bridge' with heparin injections. With warfarin I would stop say 5 days before and demand MORE blood tests to check the INR is back down. With the newer drugs we stop at the same time but no tests
We can reverse warfarin with vitamin K and it is pretty good in an emergency. The good news is that we now have idarucizumab, a monoclonal antibody that reverses the newer anticoagulant dabigatran. Dabigatran can also be removed from the body by dialysis in an emergency. Idarucizumab is not yet freely available in the UK, but this will likely change very quickly and we can get hold of it in a hospital setting within an hour.
We await news of Andexanet Alfa - my understanding is that all these reversals are being fast tracked
However, in studies the newer anticoagulants have been shown to produce less nasties such as strokes and bleeding, although perhaps more common, is not so severe as with warfarin.
If you need any operation where there is a risk of bleeding you should consider coming off anticoagulants and we would normally 'bridge' with heparin injections. With warfarin I would stop say 5 days before and demand MORE blood tests to check the INR is back down. With the newer drugs we stop at the same time but no tests
We can reverse warfarin with vitamin K and it is pretty good in an emergency. The good news is that we now have idarucizumab, a monoclonal antibody that reverses the newer anticoagulant dabigatran. Dabigatran can also be removed from the body by dialysis in an emergency. Idarucizumab is not yet freely available in the UK, but this will likely change very quickly and we can get hold of it in a hospital setting within an hour.
We await news of Andexanet Alfa - my understanding is that all these reversals are being fast tracked
However, in studies the newer anticoagulants have been shown to produce less nasties such as strokes and bleeding, although perhaps more common, is not so severe as with warfarin.
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Radgirl,
That all sounds very positive. With regard to the new anticoagulants, is there a rationale behind the decision as to which one is prescribed by the GP or is it going to be purely down to cost? Presumably a change of medication from warfarin to dabigatran, for example, will require 3 months absence from work in accordance with the protocol to ensure there are no side effects, or have I misunderstood something?
That all sounds very positive. With regard to the new anticoagulants, is there a rationale behind the decision as to which one is prescribed by the GP or is it going to be purely down to cost? Presumably a change of medication from warfarin to dabigatran, for example, will require 3 months absence from work in accordance with the protocol to ensure there are no side effects, or have I misunderstood something?
There is not much between the different drugs - dabigatran cant be used in renal failure and a few other issues. I suspect most doctors stick to one or the other. Of course only a few patients are on permanent anticoagulation - mostly patients with atrial fibrillation. The vast majority are on for 1-3 months.
The CAA website says no ticket for 6 months due to INR stabilisation on warfarin - interesting as I would expect to have a patient stable in 6 weeks - and 3 months for the newer drugs to ensure there are no side effects. Not sure I follow the logic as side effects are usually seen in days. They may mean in case there is a bleed, but perhaps they are just being ultra cautious - new drug syndrome. Would be interested to hear from others
The CAA website says no ticket for 6 months due to INR stabilisation on warfarin - interesting as I would expect to have a patient stable in 6 weeks - and 3 months for the newer drugs to ensure there are no side effects. Not sure I follow the logic as side effects are usually seen in days. They may mean in case there is a bleed, but perhaps they are just being ultra cautious - new drug syndrome. Would be interested to hear from others
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The vast majority are on for 1-3 months.
@Uplifting,
you write you donīt have any deficiency. Have you been checked for coagulation disorders? Your family history might be an indication.
you write you donīt have any deficiency. Have you been checked for coagulation disorders? Your family history might be an indication.
Last edited by wondering; 18th May 2016 at 05:12.
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Wondering,
No genetic or other predispositions were evident in the tests; just unlucky I guess! I haven't been particularly good at hydrating in the past; don't know if that's a potential route to a PE, otherwise it must have been the roll of the dice.
No genetic or other predispositions were evident in the tests; just unlucky I guess! I haven't been particularly good at hydrating in the past; don't know if that's a potential route to a PE, otherwise it must have been the roll of the dice.