Diabetes and driving

Trends in the Use of Driving-Impairing Medicines According to the DRUID Category: A Population-Based Registry Study with Reference to Driving in a Region of Spain between 2015 and 2019

The European DRUID (Drive Under the Influence of drugs, alcohol, and medicines) program classifies medications into three categories according to their effect on one’s fitness to drive. The trend in the use of driving-impairing medicines (DIMs) in a region of Spain between 2015 and 2019 was analyzed through a population-based registry study. Pharmacy dispensing records for DIMs are provided. The use of DIMs on drivers was weighted according to the national driver’s license census. The analysis was performed considering the population distribution by age and sex, treatment length, and the three DRUID categories. DIMs were used by 36.46% of the population and 27.91% of drivers, mainly chronically, with considerable daily use (8.04% and 5.34%, respectively). Use was more common in females than in males (42.28% vs. 30.44%) and increased with age. Among drivers, consumption decreases after 60 years of age for females and after 75 years of age for males. There was a 34% increase in the use of DIMs between 2015 and 2019, with a focus on daily use (>60%). The general population took 2.27 ± 1.76 DIMs, fundamentally category II (moderate influence on fitness to drive) (20.3%) and category III (severe influence on fitness to drive) (19.08%). The use of DIMs by the general population and drivers is significant and has increased in recent years. The integration of the DRUID classification into electronic prescription tools would assist physicians and pharmacists in providing adequate information to the patient about the effects of prescribed medications on their fitness to drive.

Population-Based Registry Analysis of Antidiabetics Dispensations: Trend Use in Spain between 2015 and 2018 with Reference to Driving

Insulins and some oral antidiabetics are considered to be driving-impairing medicines (DIM) and they belong to the Driving under the Influence of Drugs, alcohol, and medicines (DRUID) category I (minor influence on fitness to drive). The trend of antidiabetics use in Castilla y León from 2015 to 2018 is presented through a population-based registry study. Treatment duration with these medicines and the concomitant use of other DIMs were observed. An adjustment method was used with information from the drivers' license census. For all calculations, age and gender were taken into account. 3.98% of the general population used at least one antidiabetic, as well as 2.92% of drivers. The consumption of antidiabetics in men was higher than in women (4.35% vs. 3.61%, p = 0.001), and the use increases with age, especially from 35-39 years to 75-79 years in men and 85-89 years in women. Antidiabetics were consumed chronically, specifically 100% in the case of insulins and 95% in the case of oral antidiabetics. In addition to antidiabetics, 2.5 ± 1.86 DIMs were consumed, mainly anxiolytics (25.53%), opioids (23.03%), other analgesics and antipiretics (19.13%), and antidepressants (17.73%). Collaboration between pharmacists and physicians is a priority to clearly transmitting risks to patients. It is necessary that the health authorities include information on DIMs, such as the DRUID classification, in the prescription and dispensing software.

Toxicological evaluations of combined administration of ethanolic stem bark extract of Enantia chlorantha and lisinopril in experimental type 2 diabetes

Background

Enantia chlorantha is a local medicinal plant commonly use in Nigeria for the treatment of diabetes but without support of scientific data. Large percentage of people suffering from diabetes who uses the plant as antidiabetic agent also combine its administration with standard antihypertensive drugs.

Aim

In the present study, we have investigated the possible toxicological effects of combined administration of E. chlorantha bark extract and lisinopril in diabetic model of experimental rats.

Methods

E. chlorantha stem bark was extracted by cold maceration of the pulverised stem bark in 70% ethanol. The acute toxicity effect of the plant was then evaluated in rats following oral administration of single dose of the extract. Diabetes was induced by intraperitoneal administration of 40 mg/kg streptozotocin into fructose fed rat. Diabetic rats were then randomly assigned into 6 groups of 7 rats each. One group was kept as the diabetic model while separate treatments were administered to the other six groups. Seven non diabetic rats were kept as the control group and administered normal saline.

Results

The LD50 of E. chlorantha stem bark was above 5000 mg/kg. Combined administration of lisinopril and E. chlorantha showed synergistic effects in the restoration of renal biomarkers (serum creatinine, urea, Na+ and K+), cardiac function biomarkers (CK-MB and LDH) and hematological parameters (RBC, WBC, HGB and PCV), while antagonistic effects were however observed with some of the liver biomarkers (AST, ALT, ALP, GGT, total protein and total bilirubin). Rats co-administered lisinopril and E. chlorantha also showed fatty liver with cholestasis.

Conclusion

The study concluded that diabetes is associated with kidney and cardiac dysfunction. Combined administration of lisinopril and E. chlorantha though may not aggravate these dysfunctions however, it may antagonize the efficacy of the plant in ameliorating liver dysfunction in diabetics.

Type 2 diabetes can undermine driving performance of middle-aged male drivers through its deterioration of perceptual and cognitive functions

It has been widely agreed that it is risky for patients with diabetes to drive during hypoglycemia. However, driving during non-hypoglycemia may also bring certain safety hazards for some patients with diabetes. Based on previous studies on diabetes-related to early aging effect, as well as gender differences in health belief and driving behavior, we have hypothesized that middle-aged male drivers with type 2 diabetes, compared with the control healthy ones, may experience a decline in driving performance without awareness. And the decline is caused by impaired perceptual and cognitive driving-related functions. To verify these hypotheses, we recruited 56 non-professional male drivers aged between 40 and 60 (27 patients with type 2 diabetes and 29 healthy controls) to perform a simulated car-following task and finish behavioral tests of proprioception, visual search, and working memory abilities during non-hypoglycemia. They also reported their hypoglycemia experience and perceived driving skills. We found that the patients had equal confidence in their driving skills but worse driving performance as shown in larger centerline deviation (t = 2.83, p = .006), longer brake reaction time (t = 3.77, p = .001) and shorter minimum time-to-collision (t = -3.27, p = .002). Such between-group differences in driving performance could be fully mediated by proprioception, visual search ability, and working memory capacity but not by hypoglycemia experience. Regarding the effect sizes of the mediation, the visual search ability played the most important role, and then followed the working memory and the proprioception. This initial study provides original and first-hand evidence demonstrating that the middle-aged male drivers with type 2 diabetes have deteriorated driving performance, but they are unaware of it. We will also discuss the possible measures to identify people of the highest risk and improve their safety awareness by using the findings of the current study.

A systematic review of the risk of motor vehicle collision after stroke or transient ischemic attack

BACKGROUND

Returning to driving after stroke is one of the key goals in stroke rehabilitation, and fitness to drive guidelines must be informed by evidence pertaining to risk of motor vehicle collision (MVC) in this population.

OBJECTIVES

The purpose of the present study was to determine whether stroke and/or transient ischemic attack (TIA) are associated with an increased MVC risk.

METHODS

We searched MEDLINE, CINAHL, EMBASE, PsycINFO, and TRID through December 2016. Pairs of reviewers came to consensus on inclusion, based on an iterative review of abstracts and full-text manuscripts, on data extraction, and on the quality of evidence.

RESULTS

Reviewers identified 5,605 citations, and 12 articles met inclusion criteria. Only one of three case-control studies showed an association between stroke and MVC (OR 1.9, 95% CI 1.0-3.9). Of five cohort reports, only one study, limited to self-report, found an increased risk of MVC associated with stroke or TIA (RR 2.71, 95% CI 1.11-6.61). Two of four cross-sectional studies using computerized driving simulators identified a more than two-fold risk of MVCs among participants with stroke compared with controls. The difference in one of the studies was restricted to those with middle cerebral artery stroke.

CONCLUSIONS

The evidence does not support a robust increase in risk of MVCs. While stroke clearly prevents some patients from driving at all and impairs driving performance in others, individualized assessment and clinical judgment must continue to be used in assessing and advising those stroke patients who return to driving about their MVC risk.

Diabetes and driving recommendations among healthcare providers in Saudi Arabia. A significant gap that requires action

Objectives:

To assess healthcare providers’ knowledge and awareness of the recommendations for drivers with insulin-treated diabetes in Saudi Arabia.

Methods:

A cross-sectional study was conducted among healthcare providers working at 4 tertiary hospitals in Riyadh, Saudi Arabia between April 2016 and December 2016 using a self-administered questionnaire.

Results:

A total of 285 healthcare providers completed the survey (response rate 88.5%). Most (70.2%) were aware of the safe driving recommendations for patients with insulin-treated diabetes. However, the need to check blood glucose levels before driving was underestimated by almost one-third (30.2%). Only one-quarter (24.6%) identified the correct level of blood glucose level that is safe for a patient when driving, and 28.4% identified the recommended time for checking blood glucose before driving. Participants who were aware of the recommendations for safe driving had a significantly higher average knowledge score (68.8%) than those who were not aware (58.8%; p<0.001). There was a significant difference in the average knowledge score among medical specialties (p=0.002) and job levels (p<0.001).

Conclusions:

Most healthcare providers identified the importance of evaluating their patients for ability to drive safely, but we found some important areas of knowledge deficit. Professional intervention to improve healthcare providers’ awareness and knowledge regarding diabetes and driving is the first step in improving detection and reporting high-risk drivers with diabetes to prevent future driving mishaps.

Effect of Variable Lower Extremity Immobilization Devices on Emergency Brake Response Driving Outcomes

The effect of lower extremity pathologic features and surgical intervention on automobile driving function has been a topic of contemporary interest in the orthopedic medical literature. The objective of the present case-control investigation was to assess 3 driving outcomes (i.e., mean emergency brake response time, frequency of abnormally delayed brake responses, and frequency of inaccurate brake responses) in a group of participants with 3 variable footwear conditions (i.e., regular shoe gear, surgical shoe, and walking boot). The driving performances of 25 participants without active right-sided lower extremity pathology were evaluated using a computerized driving simulator. Both the surgical shoe (0.611 versus 0.575 second; p < .001) and the walking boot (0.736 versus 0.575 second; p < .001) demonstrated slower mean brake response times compared with the control shoe gear. Both the surgical shoe (18.5% versus 2.5%; p < .001) and the walking boot (55.5% versus 2.5%; p < .001) demonstrated more frequent abnormally delayed brake responses compared with the control shoe gear. The walking boot (18.0% versus 2.0%; p < .001) demonstrated more frequent inaccurate brake responses compared with the control shoe gear. However, the surgical shoe (4.0% versus 2.0%; p = .3808) did not demonstrate a difference compared with the control shoe gear. The results of the present investigation provide physicians working with the lower extremity with a better understanding on how to assess the risk and appropriately advise their patients who have been prescribed lower extremity immobilization devices with respect to the safe operation of an automobile.

Diabetes and collision risk. A meta-analysis and meta-regression

AIMS

The main objective of this study was to see whether diabetes is associated with an increased collision risk and to test the effect of age and gender on the overall collision risk for diabetes drivers.

MATERIALS AND METHODS

Twenty-eight studies were included in meta-analysis, using mean age, gender, continent and the prevalence of fatal road incidents as covariates.

RESULTS

The collision risk for diabetes drivers was small and not statistically significant - RR = 1.11 (1.01-1.23) with a prediction interval (PI) or 0.77-1.65. Age and gender were not associated with an increased overall risk. Insulin-dependent diabetes patients had a slightly increased effect size compared with the overall diabetes population, but the effect was not statistically significant. European diabetes drivers had a lower collision risk compared with their North American counterparts, the main cause being the difference of collision risk in the countries in which the studies were performed.

CONCLUSIONS

Overall, diabetes patients do not have a statistically significant increased risk for unfavourable traffic events. Old age and insulin-dependent patients tend to have a higher risk. Advances in diabetes care, associated with advances in road safety regulations, and automotive industry have not decreased significantly the collision risk in the last 50 years for drivers with diabetes.

Addition of dipeptidyl peptidase-4 inhibitors to sulphonylureas and risk of hypoglycaemia: systematic review and meta-analysis

OBJECTIVE

To quantify the risk of hypoglycaemia associated with the concomitant use of dipeptidyl peptidase-4 (DPP-4) inhibitors and sulphonylureas compared with placebo and sulphonylureas.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, ISI Web of Science, SCOPUS, Cochrane Central Register of Controlled Trials, and clinicaltrial.gov were searched without any language restriction.

STUDY SELECTION

Placebo controlled randomised trials comprising at least 50 participants with type 2 diabetes treated with DPP-4 inhibitors and sulphonylureas.

REVIEW METHODS

Risk of bias in each trial was assessed using the Cochrane Collaboration tool. The risk ratio of hypoglycaemia with 95% confidence intervals was computed for each study and then pooled using fixed effect models (Mantel Haenszel method) or random effect models, when appropriate. Subgroup analyses were also performed (eg, dose of DPP-4 inhibitors). The number needed to harm (NNH) was estimated according to treatment duration.

RESULTS

10 studies were included, representing a total of 6546 participants (4020 received DPP-4 inhibitors plus sulphonylureas, 2526 placebo plus sulphonylureas). The risk ratio of hypoglycaemia was 1.52 (95% confidence interval 1.29 to 1.80). The NNH was 17 (95% confidence interval 11 to 30) for a treatment duration of six months or less, 15 (9 to 26) for 6.1 to 12 months, and 8 (5 to 15) for more than one year. In subgroup analysis, no difference was found between full and low doses of DPP-4 inhibitors: the risk ratio related to full dose DPP-4 inhibitors was 1.66 (1.34 to 2.06), whereas the increased risk ratio related to low dose DPP-4 inhibitors did not reach statistical significance (1.33, 0.92 to 1.94).

CONCLUSIONS

Addition of DPP-4 inhibitors to sulphonylurea to treat people with type 2 diabetes is associated with a 50% increased risk of hypoglycaemia and to one excess case of hypoglycaemia for every 17 patients in the first six months of treatment. This highlights the need to respect recommendations for a decrease in sulphonylureas dose when initiating DPP-4 inhibitors and to assess the effectiveness of this risk minimisation strategy.

Diabetes and driving

The principal safety concern for driving for people treated with insulin or insulin secretagogues is hypoglycaemia, which impairs driving performance. Other complications, such as those causing visual impairment and peripheral neuropathy, are also relevant to medical fitness to drive. Case control studies have suggested that drivers with diabetes pose a modestly increased but acceptable and measurable risk of motor vehicle accidents compared to non-diabetic drivers, but many studies are limited and of poor quality. Factors which have been shown to increase driving risk include previous episodes of severe hypoglycaemia, previous hypoglycaemia while driving, strict glycaemic control (lower HbA1c) and absence of blood glucose monitoring before driving. Impaired awareness of hypoglycaemia may be counteracted by frequent blood glucose testing. The European Union Third directive on driving (2006) has necessitated changes in statutory regulations for driving licences for people with diabetes in all European States, including the UK. Stricter criteria have been introduced for Group 1 vehicle licences while those for Group 2 licences have been relaxed. Insulin-treated drivers can now apply to drive Group 2 vehicles, but in the UK must meet very strict criteria and be assessed by an independent specialist to be issued with a 1-year licence.

Driving with diabetes: precaution, not prohibition, is the proper approach

Safety issues posed by driving with diabetes are primarily related to severe hypoglycemia, yet some public authorities rely on categorical restrictions on drivers with diabetes. This approach is misguided. Regulation of all drivers with diabetes, or all drivers using insulin, ignores the diversity of people with diabetes and fails to focus on the subpopulation posing the greatest risk. Advances in diabetes care technology and understanding of safety consequences of diabetes have expanded techniques available to limit risks of driving with diabetes. New means of insulin administration and blood glucose monitoring offer greater ease of anticipating and preventing hypoglycemia, and thus, limit driving risk for persons with diabetes. So too do less sophisticated steps taken by people with diabetes and the health care professionals they consult. These include adoption and endorsement of safety-sensitive behaviors, such as testing before a drive and periodic testing on longer trips. Overall, and in most individual cases, driving risks for persons with diabetes are less than those routinely tolerated by our society. Examples include freedom to drive in dangerous conditions and lax regulation of drivers in age and medical cohorts with elevated overall rates of driving mishaps. Data linking specific diabetes symptoms or features with driving risk are quite uncertain. Hence, there is much to recommend: a focus on technological advances, human precautions, and identifying individuals with diabetes with a specific history of driving difficulty. By contrast, available evidence does not support unfocused regulation of all or most drivers with diabetes.

Driving safety: concerns and experiences of parents of adolescent drivers with type 1 diabetes

Driving is a dangerous activity for adolescents, perhaps being even more precarious for adolescents with type 1 diabetes due to the possibility of extreme blood glucose (BG). There is no available data on adolescent driving safety concerns and type 1 diabetes. To begin addressing this issue, we surveyed parents regarding their observations and concerns. Seventy-two parents (87.5% mothers) of adolescent drivers aged 16-19 with type 1 diabetes provided analyzable data. Females comprised 36% of their adolescents, with 74% using pump therapy. In the past year, 13 and 84% of parents reported that their adolescent had experienced severe or moderate disruptive hypoglycemia, respectively. Over half (56%) of the parents reported moderate to extreme worry about how diabetes impacted their adolescent's driving, while only 21% of parents thought their adolescents had similar concerns (p = 0.037). Almost one third (31%) of parents thought their adolescent need not treat low BG until it fell below 70 mg/dL, 13% thought their adolescent could safely drive with BG below 65 mg/dL. And, 31 and 14% of parents, respectively, reported their adolescent had been in a collision or stopped by the police in the past year, which they attributed to both hypo- and hyperglycemia. Adolescents reportedly took steps to prevent hypo- and hyperglycemia while driving, but more aggressively avoided hypoglycemia (p < 0.001). While this data is limited, lacking a non-diabetic control group and randomized sample, it does suggest that driving and adolescent type 1 diabetes deserve further attention and investigation.