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Policies,Guidelines and Consensus StatementsDiabetes and Driving:2015 Canadian Diabetes Association UpdatedRecommendations for Private and Commercial DriversRobyn L.Houlden MDa,*,Lori Berard RNb,Alice Cheng MDc,Anne B.Kenshole MBd,Jay Silverberg MDe,Vincent C.Woo MDf,Jean-Franois Yale MDgaDivision of Endocrinology and Metabolism,Department of Medicine,Queens University,Kingston,Ontario,CanadabWinnipeg Regional Health Authority,Health Sciences Centre Winnipeg,Winnipeg,Manitoba,CanadacDivision of Endocrinology and Metabolism,Department of Medicine,University of Toronto,Mississauga,Ontario,CanadadMedicine and Obstetrics and Gynecology,University of Toronto,Toronto,Ontario,CanadaeDivision of Endocrinology,Department of Medicine,University of Toronto,Toronto,Ontario,CanadafSection of Endocrinology and Metabolism,John Buhler Research Centre,University of Manitoba,Winnipeg,Manitoba,CanadagMcGill Nutrition and Food Science Centre,McGill University,Montral,Quebec,Canadaa r t i c l e i n f oArticle history:Received 17 August 2015Accepted 17 August 2015IntroductionFor many Canadians,driving is an essential part of daily livingand is often a requirement of employment.Diabetes can affectdriving performance because of chronic complications that impairsensory or motor functions(retinopathy,neuropathy,amputation,vascular disease)and because of transient cognitive dysfunction orloss of consciousness resulting from antihyperglycemic medication-induced hypoglycemia(related primarily to insulin or insulin se-cretagogues).The presence and extent of these factors vary fromperson to person,so the fitness of persons with diabetes to driveshould be assessed on an individual basis.These recommendations represent an update of the 2003Canadian Diabetes Association s guidelines on diabetes and driving(1).Changes have been made to clarify and expand the older rec-ommendations.A MEDLINE search was performed in October 2014and did not reveal new compelling evidence that would requiremajor modifications.Guidelines from other countries were alsoreviewed(26).All recommendations are Grade D and representthe consensus of a national expert panel.The revised recommendations highlight the active role thatpersons with diabetes should play in assessing their fitness to drive.They identify the important roles for healthcare professionals in edu-cating patients with diabetes in strategies to reduce their risks forhypoglycemia while driving.Healthcare professionals also play criti-cal roles in identifying and informing individuals with diabetes athigh risk for motor vehicle accidents.Currently,10 Canadian provinces and territories have manda-tory reporting systems that oblige legally qualified medical prac-titioners to report to the appropriate regulatory body those patientswho have conditions that impair their driving abilities(5)(Table 1).Federal organizations,such as the Canadian Council of Motor Trans-portation Administrators,should have consistent,clear and easilyaccessible reporting mechanisms for physicians and nurse practi-tioners;in addition,provincial and territorial ministries of trans-portations should include information on their websites aboutdiabetes and driving.Driving Risks Associated with DiabetesCase control studies have suggested that drivers with diabetespose a modestly increased but acceptable and measurable risk formotor vehicle accidents compared to drivers without diabetes,butmany studies are limited and of poor quality(7).Older studies mayno longer be relevant due to changes in road conditions,vehiclesand diabetes management(8).Unrecognized hypoglycemia is the most relevant driving hazardfor drivers with diabetes.A number of studies have examined drivingperformance by using driving simulators during induced hypogly-cemia in individuals with type 1 diabetes,and they demonstratedthat performance starts to deteriorate at blood glucose levels below3.8 mmol/L(9,10).Only 1 in 3 drivers self-treated their low bloodglucose levels,and the treatments occurred only when the bloodglucose levels were 2.8 mmol/L or lower.Less than 25%were awarethat their driving performance was impaired(10).Studies have dem-onstrated that cognitive function may not recover until 45 minutesor more after restoration of euglycemia(1113).Hypoglycemia is not a problem for drivers with diabetes whoare treated by lifestyle and dietary measures alone;nor is it a*Address for correspondence:Robyn L.Houlden,MD,Division of Endocrinologyand Metabolism,Kingston General Hospital,76 Stuart Street,Kingston,Ontario K7L2V7,Canada.E-mail address:houldenrqueensu.caCan J Diabetes 39(2015)347353Contents lists available at ScienceDirectCanadian Journal of Diabetesjournal homepage:1499-2671 2015 Canadian Diabetes Association.Published by Elsevier Inc.All rights reserved.http:/dx.doi.org/10.1016/j.jcjd.2015.08.011 problem for drivers with diabetes treated with most non-insulinsecretagogue medications,when used as monotherapy or in com-bination with each other.Treatment with insulin secretagogueantihyperglycemic medication(sulfonylureas,meglitinides)mayprovoke higher rates of hypoglycemia when used alone or in com-bination with other non-insulin antihyperglycemic medications(15).Studies of rates of motor vehicle accidents in drivers with diabe-tes have consistently described the highest ratesoccurring inindividuals treated with insulin(1620).Factors that have been shown to increase driving risk includeprevious episodes of severe hypoglycemia(21,22),with risk greaterin those with lower glycated hemoglobin(A1C)levels(23);previ-ous hypoglycemia while driving(21)and absence of blood glucosemonitoring before driving(16,21).Impaired awareness of hypo-glycemia is a recognized risk factor for severe hypoglycemia.Thisrisk may be mitigated by frequent blood glucose testing(24)or useof a continuous glucose monitoring device(25).Use of a memoryglucose meter is recommended so that measurements can beassessed by the healthcare team and by driving authorities,ifindicated.RecommendationsPrivate drivers1.Private drivers treated with nutritional therapy alone orantihyperglycemic agents with minimal risk of severehypoglycemiaa)Fitness of persons with diabetes to drive should be as-sessed on an individual basis.b)All drivers with diabetes should undergo a medical exami-nation at least every 2 years by a physician or nurse prac-titioner competent in managing patients with diabetes.Thisshould include an assessment of glycemic control;fre-quency and severity of hypoglycemia;symptomatic aware-ness of hypoglycemia and the presence of retinopathy,neuropathy,nephropathy,amputation and/or vasculardisease.A decision should be made on whether any of thesefactors could significantly increase the risk of a motorvehicle accident.c)Persons with diabetes who are well controlled by nutri-tional therapy alone or by a combination of nutritionaltherapy and antihyperglycemic medication that carries aminimal risk of a severe hypoglycemic episode(Table 2)may usually drive all types of motor vehicles withrelative safety provided they remain under regular medicalsupervision.2.Private drivers treated with insulin secretagoguesa)Fitness of persons with diabetes to drive should beassessed on an individual basis.b)All drivers with diabetes should undergo a medical exami-nation at least every 2 years by a physician or nurse prac-titioner competent in managing patients with diabetes.Thisshould include an assessment of glycemic control;fre-quency and severity of hypoglycemia;symptomatic aware-ness of hypoglycemia and the presence of retinopathy,neuropathy,nephropathy,amputation and/or vasculardisease.A decision should be made on whether any of thesefactors could significantly increase the risk of a motorvehicle accident.c)Persons with diabetes treated with insulin secretagoguesmay usually drive private vehicles if they are under regularmedical supervision.d)Persons with diabetes treated with insulin secretagoguesshould take an active role in assessing their ability to drivesafely by maintaining a log of their self-monitored bloodglucose(BG)measurements by using either a memory-equipped BG meter or an electronic record of BG measure-ment performed at a frequency deemed appropriate by theperson with diabetes and their healthcare team.BG logsshould be verifiable on request.e)Persons with diabetes treated with insulin secretagogueswho experience any episode of severe hypoglycemia whileawake(defined as hypoglycemia of sufficient severity torequire corrective intervention by another person or pro-ducing loss of consciousness,even if spontaneous recov-ery occurs)must refrain from driving immediately andnotify their healthcare provider of the event immediately(no longer than 72 hours).f)Persons with diabetes should know how to avoid,recog-nize and treat hypoglycemia.g)Persons with diabetes treated with insulin secretagoguesshould consider measuring their BG level immediatelybefore and at least every 4 hours while driving or wear areal-time continuous BG monitoring device.h)Persons with diabetes treated with insulin secretagoguesshould always have BG monitoring equipment and sup-plies of rapidly absorbable carbohydrate within easy reach(e.g.attached to the driver s-side visor or in the centreconsole).i)Persons with diabetes treated with insulin secretagoguesshould not drive when their BG level is 4.0 mmol/L.If theBG level is 4.0 mmol/L,persons should not drive until atleast 45 minutes after ingestion of a carbohydrate and theirBG level is at least 5.0 mmol/L.j)Persons with diabetes should stop driving,test and treatthemselves as soon as hypoglycemia and/or impaired drivingare suspected.They should not resume driving until at least45 minutes after ingestion of carbohydrate has increasedtheir BG levels to at least 5.0 mmol/L.Table 1Canadian regulations for reporting medically unfit drivers(14)Province/TerritoryReportingaAlbertaDiscretionaryBritish ColumbiaMandatory(only if the driver has been warnedof the dangers of driving and still continuesto drive)ManitobaMandatoryNew BrunswickMandatoryNewfoundland and LabradorMandatoryNorthwest TerritoriesMandatoryNova ScotiaDiscretionaryNunavutMandatoryOntarioMandatoryPrince Edward IslandMandatoryQuebecDiscretionarySaskatchewanMandatoryYukonMandatoryaFor more information regarding reporting processes in Canada,please see theCanadian Medical Association Driver s Guide.Table 2Antihyperglycemic agents and risk for hypoglycemiaAntihyperglycemic agents associated with minimal risk for severe hypoglycemia:Alpha-glucosidase inhibitorsIncretin agents:DPP-4 inhibitorsGLP-1 receptor agonistsMetforminSGLT2 inhibitorsTZDsTZD,glitazones.R.L.Houlden et al./Can J Diabetes 39(2015)347353348 k)Healthcare professionals should inform persons with dia-betes treated with insulin secretagogues to no longer driveand should report their concerns about the person s fitnessto drive to the appropriate driving licensing body if any ofthe following occur:1)Any episode of severe hypoglycemia while driving2)More than 1 episode of severe hypoglycemia whileawake but not driving.l)Persons with diabetes should immediately self-report totheir driving licensing body if they experience any episodeof severe hypoglycemia while driving or if they experi-ence more than 1 episode of severe hypoglycemia whileawake but not driving.m)Persons with diabetes treated with insulin secretagogueswho have had their license suspended due to an episodeof severe hypoglycemia or hypoglycemia unawareness maybe considered for reinstatement of their license if the fol-lowing criteria are met:1)No episode of severe hypoglycemia in last 6 months2)No evidence of hypoglycemia unawareness in last6 months.n)Persons with diabetes treated with insulin secretagogueswith severe hypoglycemia that occurs while asleep shouldbe assessed by their physician or nurse practitioner to de-termine their fitness to drive based on the circumstancessurrounding the severe hypoglycemic episode and its like-lihood to recur while awake and driving.3.Private drivers treated with insulina)Fitness of persons with diabetes to drive must beassessed on an individual basis.b)All drivers with diabetes should undergo a medical exami-nations at least every 2 years by a physician or nurse prac-titioner competent in managing patients with diabetes.Thisshould include an assessment of glycemic control;fre-quency and severity of hypoglycemia;symptomatic aware-ness of hypoglycemia and the presence of retinopathy,neuropathy,nephropathy,amputation and/or vasculardisease.A decision should be made on whether the sever-ity of any of these complications could significantly in-crease the risk of a motor vehicle accident.c)Persons with diabetes treated with insulin may driveprivate vehicles if they are under regular medicalsupervision.d)Persons with diabetes treated with insulin should take anactive role in assessing their ability to drive safely by main-taining a log of their self-monitored BG measurement,eitherby using a memory-equipped BG meter or electronic recordof BG measurement performed,on average,at least oncea day.BG logs should be verifiable on request.e)Persons with diabetes treated with insulin who experi-ence an episode of severe hypoglycemia(defined as hypo-glycemia of sufficient severity to require correctiveintervention by another person or producing loss of con-sciousness,even if spontaneous recovery occurs)mustrefrain from driving immediately and notify their health-care provider of the event immediately(no longer than 72hours).f)Persons with diabetes should know how to avoid,recog-nize and treat hypoglycemia.g)Persons with diabetes treated with insulin should con-sider measuring their BG level immediately before and atleast every 4 hours while driving or wear a real-time con-tinuous BG monitoring device.h)Persons with diabetes treated with insulin with any of thefollowing risk factors for severe hypoglycemia must measuretheir BG levels immediately before and at least every 2 hourswhile driving or wear a real-time continuous BG monitor-ing device:1)Recurrent severe hypoglycemia2)Prior history of severe hypoglycemia or hypoglycemiaunawareness resulting in license suspension and sub-sequent reinstatement.i)Persons with diabetes treated with insulin should alwayshave BG monitoring equipment and supplies of rapidlyabsorbable carbohydrate within easy reach(e.g.attachedto the driver s-side visor or in the centre console).j)Persons with diabetes treated with insulin should not drivewhen their BG level is 4.0 mmol/L.If the BG level is4.0 mmol/L,persons should not drive until at least45 minutes after ingestion of carbohydrate and their BGlevel is at least 5.0 mmol/L.k)Persons with diabetes should stop driving,test and treatthemselves as soon as hypoglycemia and/or impaired drivingare suspected.They should not resume driving until at least45 minutes after ingestion of carbohydrate has increasedtheir BG levels to at least 5.0 mmol/L.l)Healthcare professionals should inform persons with dia-betes treated with in
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