Medical review and opining in drivers with dysglyce-mia or diabetes is regulated by the Appendix No. 6 to the ordinance of the Minister of Health of July 17, 2014 on medical examinations of driving license applicants and drivers (Journal of Laws 2014, item 949), entitled “Detailed conditions of the medical examinations related to diabe-tes”. The above mentioned ordinance was considered the legal basis for the present Appendix which offers practical recommendations on medical review and opining, based on a guidance prepared by specialists from the Institute of Occupational Medicine.
1. Based on the results of a medical examination, labora-tory tests, and specialist consultations, a physician au-thorized to medically certify drivers evaluates the risk for traffic safety and includes it in the medical opinion.
2. According to the section 4 of the above mentioned Ap-pendix to the ordinance of the Minister of Health, an opinion of a diabetes specialist or another physi-cian engaged in treating diabetes, including a state-ment of no other medical contraindications to driving related to diabetes, is obligatory in subjects:
applying for or holding a category C1, C1+E, C, C+E, D1, D1+E, D, D+E driving license, or a tram driving permit;
— working as road transport drivers;
— working as drivers of emergency vehicles or ar-mored transportation service vehicles.
3. In case of diagnostic or medical opining uncertain-ties, a physician authorized to examine drivers may also order a diabetes consultation if:
— the patient has inadequate knowledge regarding dia-betes, its, treatment, and possible complications;
— the patient does not adhere to medical recommen-dations, in particular does not undertake blood glucose self-monitoring or does not take the pre-scribed drug therapy;
— during documented blood glucose self-monitoring, more than 10% of flood glucose readings are below 70 mg/dL;
— metabolic control of the disease is poor (HbA1c level
> 8%).
4. According to the section 6 of the above mentioned Appendix to the ordinance of the Minister of Health,
a consultation of a diabetes specialist or another physician engaged in treating diabetes should con-clude with issuing a diabetes consultation card, using a template provided in the above mentioned Appendix (see below).
5. During the consultation, a diabetes specialist should:
— evaluate patient knowledge regarding the disease, its treatment, and possible complications, rating it as extensive, satisfactory, or not satisfactory;
— evaluate blood glucose self-management ability, rating it as high, acceptable, or low;
— evaluate hypoglycemia awareness and the patient’s ability to prevent and counteract hypoglycemia, rat-ing it as good or not satisfactory;
— confirm the presence or absence of hypoglycemia prodromes;
— categorize the risk of hypoglycemia as low, accept-able, or high;
— determine the presence of chronic diabetes com-plications involving the eye, nervous system, and cardiovascular system;
— provide additional comments regarding chronic diabetes complications and the health condition of the patient which are important for the assessment of the risk for traffic safety.
6. The consulting diabetes specialist should also assess the patient’s ability to drive, using the respective space provided in the consultation card. Issues related to dysglycemia may have the following effect of the final medical opinion:
— No medical contraindications for driving:
• without time constraints resulting from the investigations for dysglycemia,
• with time constraints resulting from the iden-tified dysglycemia (consistent with a low or in-creased risk for traffic safety);
— Medical contraindications for driving resulting from the identified dysglycemia:
• relative, with indication of a 6-month period after which the patient may undergo a repeat-ed mrepeat-edical assessment (consistent with a high risk for traffic safety, and an option of reassess-ment),
Developed in collaboration with Andrzej Marcinkiewicz, MD, based on: Marcinkiewicz A, Szosland D. Medical examina-tions of drivers with diabetes — methodological guidance for examining driving license applicants and drivers. Institute of Occupational Medicine, Łódź 2012
• absolute medical contraindications for driving (consistent with a high risk for traffic safety and no indication of the timing of a repeated medi-cal assessment).
7. Recommendations regarding medical opining in subjects with dysglycemia have been divided into two categories:
— group I drivers (category AM, A1, A2, B1, B, B+E, or T driving license) (see Tab. 1);
— group II drivers (category C1, C1+E, C, C+E, D1, D1+E, D, D+E driving license, or tram driving per-mit, road transport drivers, emergency vehicle driv-ers, armored transportation services) (see Tab. 2).
8. Absolute contraindications for driving:
— in group I (see Tab. 1):
• recurrent severe hypoglycemia (at least two epi-sodes of severe hypoglycemia during the last 12 months),
• hypoglycemia unawareness;
— in group II (see Tab. 2):
• any history of severe hypoglycemia,
• hypoglycemia unawareness,
• other diabetes-related complications that preclude driving.
9. The consultation card is handed by the diabetes specialist to the patient who presents it to the physician authorized to medically certify drivers. In case of a negative opinion regarding the ability to drive, it is recommended that the opining physician who referred a patient for a diabetes consultation is informed directly by the diabetes specialist.
10. Diabetes consultation should be performed by a physician experienced in diabetes treatment or a physician with other board certification who man-ages diabetes in the consulted patient.
11. Although established regulations and recommenda-tions should always be the basis for medical review and opining, the approach to each diabetic patient should be individualized. Ultimately, the patient’s attitude should be the key factor taken into account when making decisions in case of opining uncertain-ties. Each diabetic patient, regardless of the diabetes type and the management approach, must actively participate in the treatment. Proper patient educa-tion allows adequate disease control and avoidance of hypo- and hyperglycemia by strict adherence to the recommendations regarding drug therapy and diet, and appropriate blood glucose self-monitoring.
Diabetes consultation card for examining driving license applicants and drivers
Patient data Name and surname
PESEL Personal identity card details and
number in non-PESEL holders
Adress: City/town Postal code
Street House/apartment number
Driving license applicant Driver Year driving license obtained
Driving license category A, A1, B, B1, T, B+E (motorcycle, passenger car)
C, C1, D, D1, C+E, D+E, C1+E, D1+E (truck, bus, tram)
Diabetes: Date Type Treating Primary care Diabetes clinic
of diagnosis physician:
Patient knowledge regarding the disease, Extensive Satisfactory Not satisfactory its treatment, and complications:
Blood glucose self-management ability: High Acceptable Low
Hypoglycemia awareness, ability to prevent: Good Not satisfactory and counteract hypoglycemia
Occurrence of hypoglycemia prodromes: Yes No
Risk of hypoglycemia: Low Acceptable High
Presence of chronic diabetes complications No chronic diabetes complications Eye Nervous system Cardiovascular system Comments regarding other diabetes complications:
...
...
Assessment of the ability to drive:
...
...
...
Other remarks:
...
...
Stamp of the healthcare unit or physician’s practice
license) with dysglycemia (Source: Marcinkiewicz A, Diabetes treatmentLaboratory testing
Consultation of a diabetes specialist or other physi
- cian treating diabetes
Other consultations
Medical opinion and timing of the next examination
diabetes; dysglycemiaNone — newly diagnosed diabetesNewly diagnosed diabetes based on laboratory findings (FPG, OG
TT, RBG)1, HbA1c < 8%
Not obligatory
Not obligatory; ophthalmologic consultation recommended, others depending on the patient’s condition
No contraindications to driving, next examination in
6 months to 5 years depending on the presence of chronic diabetes complications diabetes; dysglycemiaNone — newly diagnosed diabetesNewly diagnosed diabetes based on laboratory findings (FPG, OG
TT, RBG)1, HbA1c > 8%
Not obligatory
Not obligatory; ophthalmologic consultation recommended, others depending on the patient’s condition
Recommended relative contrain- dication to driving for 6 months, until adequate metabolic control diabetes; dysglycemiaNone — newly diagnosed diabetesNewly diagnosed diabetes
based on laboratory findings (FPG, OG
TT, RBG)1, HbA1c < 8%
Not obligatory
Not obligatory; ophthalmologic consultation recommended, others depending on the patient’s condition No contraindications to driving, next examination in
6 months to 5 years depending on the presence of chronic diabetes complications diabetes; dysglycemiaNone — newly diagnosed diabetesNewly diagnosed diabetes based on laboratory findings (FPG, OG
TT, RBG)1, HbA1c > 8%
Not obligatory
Not obligatory; ophthalmologic consultation recommended, others depending on the patient’s condition
Recommended relative contrain- dication to driving for 6 months, until adequate metabolic control ; - 3; no hypoglycemia una-
-Oral agents or GLP-1 analogsHbA1c level measurement may be consideredNot obligatory Not obligatory; ophthalmologic consultation recommended, others depending on the patient’s condition No contraindications to driving, next examination in
6 months to 5 years2 depending on metabolic
control and the presence of chronic diabetes complications
; - 3;
-Insulin therapy ± oral agentsHbA1c level measurement may be consideredNot obligatory
Not obligatory; ophthalmologic consultation recommended, others depending on the patient’s condition No contraindications to driving, next examination
in 6 months to 5 years2 depending on metabolic
control and the presence of chronic diabetes complications
; history 3 or
Oral agents and/or insulin therapy
Proceeding with further algo-
algo-rithm steps not warranted due to absolute contraindications to driving
Proceeding with further algo-
algo-rithm steps not warranted due to absolute contraindications to driving
Proceeding with further algo-
algo-rithm steps not warranted due to absolute contraindications to driving Absolute contraindications to driving
3 TT — oral glucose tolerance test; RBG — random blood glucose; HbA1c — hemoglobin A1c. of the Minister of Health of July 17, 2014 on medical examinations of driving license applicants and ere hypoglycemia (at least two episodes during the last 12 months), and in group II drivers (category C1, C1+E, C, C+E, n services), contraindications to driving exist in case of any history of severe hypoglycemia.
license) with dysglycemia (Source: Marcinkiewicz A, Medical historyDiabetes treatmentLaboratory testing
Consultation of a diabetes specialist or other physi
- cian treating diabetes
Other consultations
Medical opinion and timing of the next examination
No history of diabetes; no history of dysglycemiaNone — newly diagnosed diabetesNewly diagnosed diabetes based on laboratory findings (FPG, OG
TT, RBG)1, HbA1c < 8%
Not obligatory
Not obligatory; ophthalmologic consultation recommended, others depending on the patient’s condition
No contraindications to driving, next examination in
6 months to 5 years depending on the presence of chronic diabetes complications No history of diabetes; no history of dysglycemiaNone — newly diagnosed diabetesNewly diagnosed diabetes based on laboratory findings (FPG, OG
TT, RBG)1, HbA1c > 8%
Not obligatory
Not obligatory; ophthalmologic consultation recommended, others depending on the patient’s condition
Recommended relative contrain- dication to driving for 6 months, until adequate metabolic control No history of diabetes; history of dysglycemiaNone — newly diagnosed diabetesNewly diagnosed diabetes
based on laboratory findings (FPG, OG
TT, RBG)1, HbA1c < 8%
Not obligatory
Not obligatory; ophthalmologic consultation recommended, others depending on the patient’s condition No contraindications to driving, next examination in
6 months to 5 years depending on the presence of chronic diabetes complications No history of diabetes; history of dysglycemiaNone — newly diagnosed diabetesNewly diagnosed diabetes based on laboratory findings (FPG, OG
TT, RBG)1, HbA1c > 8%
Not obligatory
Not obligatory; ophthalmologic consultation recommended, others depending on the patient’s condition
Recommended relative contrain- dication to driving for 6 months, until adequate metabolic control History of diabetes; no history of severe hypogly- cemia3; no hypoglycemia una- wareness; no diabetes-relates complica- tions precluding driving
Oral agents or GLP-1 analogsHbA1c level measurement may be consideredNot obligatory Not obligatory; ophthalmologic consultation recommended, others depending on the patient’s condition No contraindications to driving, next examination in
6 months to 5 years2 depending on metabolic
control and the presence of chronic diabetes complications
History of diabetes; no history of severe hypogly- cemia3 ;
no hypoglycemia unawareness; no diabetes-relates complica
- tions precluding driving
Insulin therapy ± oral agentsHbA1c level measurement may be consideredNot obligatory
Not obligatory; ophthalmologic consultation recommended, others depending on the patient’s condition No contraindications to driving, next examination
in 6 months to 5 years2 depending on metabolic
control and the presence of chronic diabetes complications
History of diabetes; history of severe hypoglycemia3 or hypoglycemia unawareness or diabetes-relates complications precluding driving Oral agents and/or insulin therapy
Proceeding with further algo-
algo-rithm steps not warranted due to absolute contraindications to driving
Proceeding with further algo-
algo-rithm steps not warranted due to absolute contraindications to driving
Proceeding with further algo-
algo-rithm steps not warranted due to absolute contraindications to driving Absolute contraindications to driving
3 TT — oral glucose tolerance test; RBG — random blood glucose; HbA1c — hemoglobin A1c. of the Minister of Health of July 17, 2014 on medical examinations of driving license applicants and ere hypoglycemia (at least two episodes during the last 12 months), and in group II drivers (category C1, C1+E, C, C+E, n services), contraindications to driving exist in case of any history of severe hypoglycemia. iving permit, road transport drivers, emergency vehicle , Szosland D. Medical examinations of drivers with diabetes – methodological guidance for examining nal Medicine, Łódź 2012, modified according to the current regulations — Journal of Laws 2014, item 949.) Diabetes treatmentLaboratory testingConsultation of a dia-
dia-betes specialist or other physician treating dia
- betes
Other consultations
Medical opinion and timing of the next examination
history of diabetes; history of dysglycemiaNone — newly diagnosed diabetesNewly diagnosed diabetes based on laboratory findings (FPG, OG
TT, RBG)1, HbA1c < 8%
Not obligatory
Obligatory ophthalmologic consultation
4, others depending on the patient’s condition
No contraindications to driving, next examination in 6 months to 1 year depending on the presence of chronic diabetes complications history of diabetes; history of dysglycemiaNone — newly diagnosed diabetesNewly diagnosed diabetes based on laboratory findings (FPG, OG
TT, RBG)1, HbA1c > 8%
Not obligatory
Obligatory ophthalmologic consultation
4, others depending on the patient’s condition
Recommended relative contrain- dication to driving for 6 months, until adequate metabolic control history of diabetes; dysglycemiaNone — newly diagnosed diabetesNewly diagnosed diabetes based on laboratory findings (FPG, OG
TT, RBG)1, HbA1c < 8%
Not obligatory
Obligatory ophthalmologic consultation
4, others depending on the patient’s condition
No contraindications to driving, next examination in 6 months to 1 year depending on the presence of chronic diabetes complications history of diabetes; dysglycemiaNone — newly diagnosed diabetesNewly diagnosed diabetes based on laboratory findings (FPG, OG
TT, RBG)1, HbA1c > 8%
Not obligatory
Obligatory ophthalmologic consultation
4, others depending on the patient’s condition
Recommended relative contrain- dication to driving for 6 months, until adequate metabolic control ; - 3;
-Oral agents or GLP-1 analogsHbA1c level measurement may be consideredObligatory
Obligatory ophthalmologic consultation
4 , others depending on the patient’s condition
No contraindications to driving, next examination in
6 months to 3 years2 depending on metabolic
control and the presence of chronic diabetes complications
; - 3;
-Insulin therapy ± oral agentsHbA1c level measurement may be consideredObligatory Obligatory ophthalmologic consultation
4, others depending on the patient’s condition
No contraindications to driving, next examinations in 6 months to
1 year2
depending on metabolic control and the presence of chronic diabetes complications
; history of 3 or or complications
Oral agents and/or insulin therapy
Proceeding with further algo-
algo-rithm steps not warranted due to absolute contraindications to driving
Proceeding with further al-
al-gorithm steps not warranted due to absolute contraindica
- tions to driving
Proceeding with further algo-
algo-rithm steps not warranted due to absolute contraindications to driving
Absolute contraindications to driving3 TT — oral glucose tolerance test; RBG — random blood glucose; HbA1c — hemoglobin A1c. of the Minister of Health of July 17, 2014 on medical examinations of driving license applicants and vere hypoglycemia (at least two episodes during the last 12 months), and in group II drivers (category C1, C1+E, portation services), contraindications to driving exist in case of any history of severe hypoglycemia.