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Aetiology and pathogenesis .................................................................. III-4-15
Symptoms ............................................................................................. III-4-15
Diagnosis .............................................................................................. III-4-15
Glycosuria ............................................................................................ III-4-16
Biochemical criteria for diagnosis ........................................................ III-4-16
Associated manifestations .................................................................... III-4-17
Classification ........................................................................................ III-4-17
Treatment .............................................................................................. III-4-17
Operational implications of diabetes .................................................... III-4-17
Cardiovascular disease ............................................................................. III-4-18
Nephropathy .............................................................................................. III-4-18
Visual problems ......................................................................................... III-4-18
Hypoglycaemia .......................................................................................... III-4-19
Type 1 Diabetes .................................................................................... III-4-19
Type 2 Diabetes .................................................................................... III-4-20
Aeromedical considerations ................................................................. III-4-21
Criteria for satisfactory control for aviation duties ............................... III-4-21
References .................................................................................................. III-4-23
Appendix 1.─ Assessment of Type 2 insulin-treated
diabetic applicants under the provisions of
Standard 1.2.4.8 (“flexibility Standard”) ....................................... III-4A1-1
Appendix 2.─ Protocol for certification of applicants
with insulin treated Type 2 diabetes .............................................. III-4A2-1
References to Appendices 1 and 2
————————
ICAO Preliminary Unedited Version — March 2010 III-4-1
INTRODUCTION
In the introductory chapters of this Manual the basic principles for the assessment of an applicant's
medical fitness for aviation duties are outlined.
The general medical provisions of Annex 1, 6.2.2, state that an applicant shall be required to be free from
any abnormality, disability, etc., such as would entail a degree of functional incapacity which is likely to
interfere with the safe operation of an aircraft or with the safe performance of duties.
The provisions of Annex 1, 6.3.2.15, state, for all classes of licences and ratings, that applicants with
metabolic, nutritional or endocrine disorders that are likely to interfere with the safe exercise of their
licence and rating privileges shall be assessed as unfit.
THE ENDOCRINE SYSTEM
The endocrine system is controlled by the hypothalamus, which is subject to regulatory influences from
other parts of the brain, especially the limbic system. A number of releasing hormones from the
hypothalamus cause stimulating hormones to be released from the anterior pituitary gland
(adenohypophysis) to act on specific end organs. The resulting hormone production from the end organs
acts as a complex system of feedback to inhibit further production.
In such a finely tuned homeostatic environment any disturbance of secretion of the trophic hormone or of
the end organ itself may result in clinical disease.
In aircrew, the most important question the aeromedical examiner must ask is whether the disease or its
treatment will affect performance.
DISEASES OF THE THYROID
The production of triiodothyronine (T3) and thyroxine (T4) in the thyroid gland is stimulated by
thyrotrophin (Thyroid Stimulating Hormone, TSH) which is released from the pituitary in response to
thyrotrophin releasing hormone from the hypothalamus. There is negative feedback by the thyroid
hormones on thyrotrophin to ensure homeostasis. It is self-evident that any upset in this mechanism may
result in under- or over-activity of the thyroid gland.
Hyperthyroidism - Thyrotoxicosis
Thyrotoxicosis is common with a prevalence of 1-2 per cent in women in countries which do not have
iodine deficiency; men have a 5-10 fold lower incidence. The commonest cause is auto-immune thyroid
disease (Grave’s disease1 or Basedow’s disease2). More rarely thyrotoxicosis is caused by multinodular
　
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