herbal medication and Flying

Commentary, by Donato J. Borrillo, MD

 "When having an alternate is not a good thing."

In aviation, it is usually good practice for a pilot to have an alternate, such as an alternate airfield, routing, or aircraft. The use of so-called alternative remedies may not, however, be similarly "a good thing."

The aviation medical examiner (AME) should remember, "it is the medical condition, not necessarily the treatment (herbal or otherwise), that may influence the safety of flight."

The Food and Drug Administration (FDA) has little or no authority over the estimated 15 million Americans that take herbal medication, nor does the AME.

The AME should simply regard all purported benefits of an herbal medication as being "true" and disqualify based on the underlying disease or side effects. The AME should not debate the "medical legitimacy" of an herbal medication but should consider the possible underlying disease.

Addressing the disease, not the treatment modality, fosters a more informative relationship with the applicant airman.

First, there are herbal medications that treat a specific underlying condition. These include ginseng, saw palmetto, ginko, St. John's Wort, and echinacea. Asian ginseng (Panax Ginseng) is used to increase stamina. The AME should inquire, "Why is the pilot tired?" A flier that is tired may have a chronic illness or depression. In addition, Ginseng should be avoided by hypertensives and can cause anxiety, irritability, nervousness, and insomnia.

Saw palmetto (Serenoa Repens) is a berry product used to treat benign prostatic hyperplasia; its use should spark queries about urinary tract problems.

Ginko biloba is an antioxidant, used to increase blood circulation and oxygenation. It is commonly used to improve memory; however, it may also be used to treat the disqualifying conditions of tinnitus, asthma, and depression. Furthermore, ginko has a profound effect upon platelet function and should not be used with blood thinners.

St. John's Wort (Hypericum Perforate) promotes a healthy mood and helps to relieve mild to moderate depression. Both of these conditions require an evaluation prior to medical certificate issuance. Similarly, echinacea (Echinacea Purpurea) stimulates the immune system to fight colds and flu; a pilot should not be flying with these symptoms.

Second, the AME should be aware of herbal medications that prevent illness. These include cranberry, goldenseal, and garlic. Cranberry (Vaccinium Macrocarpon) is marketed to prevent urinary tract infections and should not be considered disqualifying; however, one caveat: Is the use of cranberry to prevent kidney stones (which may be disqualifying)? Similarly, goldenseal (Hydrastis Canadensis) is marketed as an antiseptic for the bowel. As a preventive measure, it is not disqualifying; however, if used for acute gastroenteritis, it may be disqualifying. Garlic cloves (Allium Sativum) have been used to lower cholesterol and should alert the AME to possible cardiac disease.

In sum, the AME should be ever vigilant for the airman using alternative medicinal therapies, whether folk, herbal, diet, homeopathy, faith, new age, chiropractic, acupuncture, naturopathy, massage, or music therapy. The AME can make up for the lack of FDA authority, and once again make an alternative "a good thing," by simply considering the underlying disease.