Expert Advice: Avoiding a Low While Behind the Wheel

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By : Suvarna Sheth

Of the nearly 100 million Americans living with diabetes or prediabetes, a large percentage will seek a driver’s license or are already driving.

For most, driving is a part of daily life and so understanding how diabetes could affect it is important.

There are various facets to diabetes that could potentially impair the ability of someone to drive including hypoglycemia, retinopathy, cataract formation and neuropathy.

We spoke to Linda Kerr, RN, DNP, FNP-BC, CDE, director of the diabetes program at MemorialCare Long Beach Medical Center, to get the most up-to-date information on having diabetes and driving.

Q: Can people with diabetes drive safely?

A: The answer is yes and no. For many people living with diabetes, there is a minimal safety risk for driving — the safety risk would be equivalent to that of other drivers on the road. Simply by virtue of having diabetes, it doesn’t necessarily mean there is any additional risk.

Now, the risk is elevated in the presence of certain medications and certain complications of diabetes. But we have to make sure that we appreciate the fact that many people live healthfully with diabetes without taking any medications or having complications.

If a person is living with diabetes and taking oral anti-diabetic medications that can cause hypoglycemia, taking insulin or have certain complications of diabetes that would raise the risk of driving — such as retinopathy, which would affect the vision, or neuropathy, which would affect the ability to feel or sense the pedals with the feet — then the risk is a little bit higher.

Q: What will the DMV ask?

A: If you go to the DMV, you will be asked a series of questions. Typically, drivers will be asked whether they have diabetes, declare what medications they are taking and whether they are taking medications that would put you at a heightened safety risk.

They also may be asked whether they have had any episodes of hypoglycemia and whether they are taking insulin or an oral anti-diabetic medication that can cause low blood sugars.

In the state of California, drivers are asked if they have diabetes and whether they are taking medication that may cause an increased safety risk. It is possible to say “Yes,” they have diabetes or, “No,” they are not taking any medication that would cause an increased safety risk.

And from there, depending on what the response is to the questions, then they would be subjected to the additional requirement or they would just be passed on to get your license without any restrictions or issues.

Certain states will be more detailed about those questions than others. If you are a commercial driver, a bus driving, or if you are driving state-to-state, then there is more intense interest in the background in the medications that are related to diabetes.

Interstate driving from state-to-state is federally regulated, so individuals would need to meet guidelines and regulations at the federal level.

Typically, an individual will go through a physical every two years and have to answer questions relating to their diabetes, medication and whether or not they’ve had episodes of hypoglycemia.

Q: What’s the prevalence of hypoglycemia for those who drive?

A: I will refer to the ADA position statement that was released in 2014. In that, they asked that very question: What is the prevalence of hypoglycemia for people who are driving?

What they found is that most of the cases of severe hypoglycemia occur in only about 20 percent of Type 1s.

With that said, what is severe hypoglycemia? Severe hypoglycemia is an incidence where your blood sugar goes so low that you need someone else to help you in order to get better to get your sugars back up. Severe is defined by the ADA as two or more incidences in a year.

A very small percent with Type 2 is living with insulin and would be at risk as well. But, the ADA is very careful to say even moderately low blood sugars, say between 50-70, does pose a risk of being able to drive safely and could impair judgment.

Q: What are your recommendations?

A: All of our recommendations for people living with diabetes, whether you are at high, moderate or low risk, is that you have an education on a few of the points below:

  1. You must always have your supplies with you. In the event where you feel like you might be having a low, you can easily reach into your backpack, purse or compartment in the car, and have access to use a simple, quick acting sugar source to get you quick elevation in blood sugar.
  2. This should be followed by a snack that has carbohydrate and protein sources, which will hold your sugars up until the next meal. You should have those two things at your disposal at all times and especially in your car.
  3. Having said that, the things that do not do well in heat and should not be left in the car are insulin and your testing supplies strips. If you’re going to have a little emergency kit, keep it inside something that’s with you at all times. If you’re comfortable, then your insulin, your testing supplies are comfortable as well.

Q: What are simple sugar choices that travel well?

A: Typically I tell people to have something handy that will dissolve in the mouth because it will absorb the fastest through your mucous membranes and get your blood sugar up fast, say in 10-15 minutes, as opposed to something you would eat or drink.

Sugar tablets, found in any pharmacy absorb quickly. Three to four sugar tablets is one serving of carbohydrates or 15 grams, which will raise the sugar 50 points.

Some people like to carry a roll of Lifesavers with their testing supplies.

One Skittle or Jelly Belly will make your blood sugar go up one point. So I often tell people to count out 15-20 Skittles or Jelly Bellies and put those in a little baggie.

The reasons all the choices above are good is because they don’t melt or get gummy if they sit around for a long time or if they sit in a hot car.

A good follow-up snack would be a peanut butter cracker or cheese cracker, or some kind of snack bar that’s not covered in chocolate. Like a crunchy snack bar or a protein bar.

Q: How do you educate your patients?

A: The first thing we teach an individual with diabetes, and particularly patients taking medication that would cause low sugars, is to keep blood glucose testing supplies handy and always test before driving.

If they feel like they have a low sugar before they get in the car, stop and correct the low sugar and to allow enough time for the sugars to come up and then to demonstrate that they are going to stay up.

If you’re feeling symptoms while you’re driving, pull over. People get in trouble when they think they can get a little further. If you’re not feeling well, immediately, get off the freeway, you might be low, you need to pull off the freeway or the road and make sure you are testing your sugar.

Well, what does that mean? You’re going to do your pure sugar correction, and 15 minutes later you recheck the sugar and you have your snack. You would like your sugar to be over 100, but you have to allow time, you have to be patient, and slow down and give yourself the time.

The ADA finds it takes 40-60 minutes to demonstrate your blood sugars can stay up, and that you’re safe to get in the car. You want to slow down, make sure you’re taking the time.

Stock your car or your bag with all the supplies we talked about and make sure your insulin and testing strips are not exposed to heat. Always carry your ID and make sure you have that information with you.

Q: Should drivers with diabetes consider CGMs?

A: Continuous glucose monitors are getting more popular. There are several good ones that are straightforward to use. There are some that are integrated with the insulin pump, and some stand-alone without an insulin pump.

All insurances with the exception of MediCal are covering CGMs, and they should be becoming more accessible for those living with diabetes.

A CGM will typically have a sensor and a monitor, like your phone, which will immediately tell you what your blood sugar is. It will give you an alarm that will let you know if you’re dropping fast or if your sugars are going up fast.

They are so sensitive and accurate now that the very latest sensors do not need calibration. And the number on the meter is accurate enough to dose insulin. Patients don’t need to do a finger stick to double check, they can simply look at the monitor on the sensor.

CGMs are also good options for commercial drivers, those working in law enforcement or driving a school bus, etc. The CGM would allow them to monitor their blood sugars while on the road and therefore help them, and their employer, feel more in control and relaxed.

If people can have access to a CGM it can be a really good thing. As we become more sophisticated in our understanding of people with diabetes, the devices that are available will mitigate the risks of driving even further.

Special thanks to MemorialCare Long Beach Medical Center in Long Beach, California.

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