Diabetes mellitus: assessing fitness to drive

✘- Must not drive

! - May continue to drive subject to medical advice and/or notifying DVLA

✓- May continue to drive and need not notify DVLA

Diabetes mellitus

Information sent to drivers

Insulin-treated drivers are sent a detailed letter from DVLA explaining the licensing requirements and driving responsibilities.responsibilities (see the INF294 leaflet in Appendix E).

All drivers with diabetes must follow the information provided in ‘Information for drivers with diabetes’, which includes a notice of when they must contact DVLA (see Appendix E).

Insulin-treated diabetes

Adequate awareness of hypoglycaemia

The Secretary of State’s Honorary Medical Advisory Panel on Driving and Diabetes has defined adequate awareness of hypoglycaemia as beingwhether able‘the licence holder/applicant [is] capable of bringing their vehicle to recognisea safe controlled stop’.

This is a matter of professional judgement and as a guide the duration of hypoglycaemic symptoms inexperienced timeshould be compatible with bringing a vehicle to safelya stopsafe thecontrolled vehicle.stop.

The reliance on alarms on glucose monitoring devices shouldare supplement, not replaceaccepted theas individual’sa ownsubstitute awarenessfor andadequate activesymptomatic self-monitoringor practices.physiological Theyawareness should be set at appropriate levels of abovehypoglycaemia 4.0mmol/Lexperienced whileby driving.the driver.

IfShould a driver becomesbecome dependentreliant on these alarms to recogniseadvise lowthem glucose,that they are hypoglycaemic they must stop driving and notify DVLA.

Impaired awareness of hypoglycaemia

ForThe Group 1 drivers, the Panel has also defined impaired awareness of hypoglycaemia asfor beingGroup unable1 todrivers recogniseas when‘an theinability glucoseto leveldetect isthe lowonset orof startinghypoglycaemia tobecause fall,of due to a total absence of warning symptoms.symptoms’.

Group 2 drivers must have full awareness of hypoglycaemia.

Severe hypoglycaemia

The law defines ‘severe’ as an episode of hypoglycaemia requiring the assistance of another person.

For Group 1 drivers,drivers hypoglycaemia- thatepisodes happensof hypoglycaemia occurring during established sleep isare no longer considered relevant for licensing purposes, unless there are concerns aboutregarding thetheir driver’shypoglycaemia ability to recognise low glucose.awareness.

Group 2 drivers - must report all episodes of severe hypoglycaemia requiring the helpassistance of another person, including sleep episodes.

ContinuousInterstitial glucose monitoring systems (CGM)

DriversThese shoulddevices useare amore devicewidely thatknown isas medicallyflash approvedglucose formonitoring non-adjunctivesystems use,(Flash meaningGM) itand isreal-time approvedcontinuous forglucose makingmonitoring treatmentsystems decisions based on CGM readings. This ensures the monitor meets the required safety and quality standards.(RT-CGM).

Group 1 and Group 2

These systems may be used for monitoring glucose at times relevant to driving in Group 1 and Group 2 vehicles. Users of these systems must carry finger prick capillary glucose testing equipment for driving purposes as there are times when a confirmatory finger prick blood glucose meterlevel asis required.

If using an interstitial fluid continuous glucose monitoring system (Flash GM or RT-CGM), the blood glucose level must be confirmed with a backup.finger Thisprick isblood essentialglucose reading in casethe following circumstances:

• when the CGMglucose stopslevel workingis 4.0 mmol/L or below
• when symptoms of hypoglycaemia are being experienced
• when the glucose monitoring system gives readingsa reading that dois not matchconsistent howwith the personsymptoms feelsbeing experienced (for example, symptoms of hypoglycaemia butand nothe lowsystem reading shown).

  Fordoes morenot details,indicate this) - see the INF294 leaflet in Appendix E. for further details

Group 2

There is a legal requirement for Group 2 drivers to monitor their blood glucose for the purpose of Group 2 driving.

Flash GM and RT-CGM interstitial fluid glucose monitoring systems are not permitted for the purposes of Group 2 driving and licensing.

Group 2 drivers who use these devices must continue to monitor finger prick capillary blood glucose levels with the regularity defined below.

Group 1 Car and motorcycle

Group 2 Bus and lorry

! - Must meet the criteria to drive and must notify DVLA. All the following criteria must be met for DVLA to license the person with insulin-treated diabetes for 1, 2 or 3 years: ■ adequate awareness of hypoglycaemia (being(see able to recognise symptoms in time to safely stop the vehicle - see above) ■ hasno notmore experiencedthan 21 orepisode more episodes of severe hypoglycaemia while awake in the preceding 12 months and the most recent episode occurred more than 3 months ago (see recurrent severe hypoglycaemia guidance below) ■ practises appropriate glucose monitoring as defined below ■ not regarded as a likely risk to the public while driving ■ meets the visual standards for acuity and visual field (see the (guidancesee onChapter 6, visual disorders) ■ no disqualifying complications of diabetes ■ under regular medical review

! - Must meet the criteria to drive and must notify DVLA. All the following criteria must be met for DVLA to license the person with insulin-treated diabetes for 1 year (with annual review as indicated last below): ■ full awareness of hypoglycaemia ■ no episode of severe hypoglycaemia in the preceding 12 months ■ practises blood glucose monitoring with the regularity defined below ■ must use a blood glucose meter with sufficient memory to store 46 weeks of readings as detailed below ■ demonstrates an understanding of the risks of hypoglycaemia ■ no disqualifying complications of diabetes that would mean a licence being refused or revoked, such as visual field defect (see the (guidancesee onChapter 6, visual disorders) ■ under regular medical review

Group 1 and Group 2 requirements for insulin-treated drivers licensed on review

The Secretary of State’s Honorary Medical Advisory Panel on Driving and Diabetes has defined the glucose self-monitoring requirements for licensing as follows.

Group 1 car and motorcycle

Glucose

• glucose testing mustno takemore place:
  • atthan 2 hours before the start of the first journey
    and
  • at least every 2 hours duringafter thedriving journeyhas started

  A

• a maximum of 2 hours should pass between the pre-driving glucose test and the first glucose check performed after driving has started.

  Applicantsstarted

• applicants will be asked to sign an undertaking to comply with the directions of the healthcare professionals treating their diabetes and to report any significant change in their condition to DVLA immediately.
  immediately

More frequent self-monitoring may be required with any greater risk of hypoglycaemia (such(physical asactivity, physical activity or altered meal routine).

Group 2 bus and lorry

Glucose testing must take place:

• regular blood glucose testing – at least twice daily,daily including on days when not driving
  and
• atno more than 2 hours before the start of the first journey
  and
• at least every 2 hours duringafter thedriving journeyhas started

A

a maximum of 2 hours should pass between the pre-driving glucose test and the first glucose check performed after driving has started.

started

More frequent self-monitoring may be required with any greater risk of hypoglycaemia (such(physical asactivity, physicalaltered activitymeal orroutine), alteredin mealwhich routine).case Aa bus or lorry driver may be licensed if theythey:

• use needone toor use more thanblood one glucose metermeters with a memory functionfunctions to ensure 46 weeks of readings whilewhilst on insulin arethat will be available for assessment.
  assessment

How DVLA checks diabetes management requirements for insulin-treated Group 2 bus and lorry licensing

DVLA takes the following measures to ensure the requirements are met for the licensing of insulin-treated Group 2 bus and lorry drivers. Applicants must:drivers:

• applicants must stop driving Group 2 vehicles when they commence insulin,insulin until DVLA has made a licensing decision
• havearranges aan stableexamination medicalto conditionbe forundertaken at least one month before starting a driving licence application
• attend an examination every 12 months by an independent consultant specialist in diabetes

At

at the examination, the consultant will require sight of blood glucose self-monitoring records for the previous 46 weeks stored on the memory of a traditional blood glucose meter.

Applicantsmeter (not Continuous Glucose Monitoring System)

the licence application process cannot start until an applicant’s condition has been stable for at least one month, and they can provide 6 weeks of blood glucose readings taken whilst on insulin

applicants will be asked to sign an undertaking to comply with the directions of the healthcare professionals treating their diabetes and to report any significant change in their condition to DVLA immediately.

immediately

Recurrent severe hypoglycaemia guidance

Advice for Group 1 drivers who have had 2more orthan moreone episodesepisode of severe hypoglycaemia while awake in the last 12 months

✘- Must not drive and must notify DVLA.

DVLA will then carry out medical enquiries before a licensing decision is made.

Advice for Group 2 drivers after every episode of severe hypoglycaemia in the last 12 months

✘- Must not drive and must notify DVLA following all episodes of severe hypoglycaemia.

Severe hypoglycaemia whilst driving

All Group 1 and Group 2 drivers who experience an episode of severe hypoglycaemia whilst driving must not drive and must notify DVLA.

Impaired awareness of hypoglycaemia – ‘hypoglycaemia unawareness’

For Group 1 drivers, the Panel has also defined impaired awareness of hypoglycaemia as being unable to recognise when the glucose level is low or starting to fall, due to a total absence of warning symptoms. 

Group 2 drivers must have full awareness of hypoglycaemia.

Group 1 Car and motorcycle	Group 2 Bus and lorry
✘- Must not drive and must notify DVLA. Driving may resume after a clinical report by a GP or consultant diabetes specialist confirms that adequate hypoglycaemia awareness has been regained.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked. Refer to the requirements for insulin-treated diabetes.

Diabetes complications

Visual complications – affecting visual acuity or visual field

Group 1 Car and motorcycle	Group 2 Bus and lorry
! - May need to stop driving and notify DVLA. SeeRefer theto guidanceChapter on6, visual disordersdisorders. .	!✘- -Must Maynot needdrive to stop driving and must notify DVLA. SeeThe thelicence will be refused or revoked. Refer to insulin-treated diabetes and guidanceChapter on6, visual disordersdisorders..

Renal complications

Group 1 Car and motorcycle	Group 2 Bus and lorry
! - May need to stop driving and notify DVLA. See theRefer to guidance on renalChapter 7, renal and respiratory disorders.	! - May need to stop driving and notify DVLA. SeeRefer theto guidance on renalChapter 7, renal and respiratory disorders.

Limb complications – including peripheral neuropathy

	Group 1 Car and motorcycle	Group 2 Bus and lorry
Any complication such as peripheral neuropathy that means a driver must meet requirements (such as vehicle adaptations) for disabilities	! - May need to stop driving and notify DVLA. See Appendix G, disabilities and vehicle adaptations. Limb problems or amputations are of themselves unlikely to prevent driving since they may be assisted by suitable vehicle adaptations. The ability to safely control a vehicle at all times is the essential requirement.	! - May need to stop driving and notify DVLA. See Appendix G, disabilities and vehicle adaptations. Limb problems or amputations are of themselves unlikely to prevent driving since they may be assisted by suitable vehicle adaptations. The ability to safely control a vehicle at all times is the essential requirement.

Temporary insulin treatment – including gestational diabetes or post-myocardial infarction

	Group 1 Car and motorcycle	Group 2 Bus and lorry
Trial participants for oral or inhaled insulin are also examples to be included as receiving temporary insulin treatment	! - May drive and need not notify DVLA, provided: ■ under medical supervision ■ not advised by clinician as at risk of disabling hypoglycaemia ! - May continue to drive but must notify DVLA if: ■ disabling hypoglycaemia occurs ■ treatment continues for more than 3 months – or in gestational diabetes, continues for 3 months after delivery	✘- Must notify DVLA and meet the above standards.

Diabetes treated by medication other than insulin

Severe hypoglycaemia

The law defines ‘severe’ as an episode of hypoglycaemia requiring the assistance of another person.

All Group 1 and Group 2 drivers who experience an episode of severe hypoglycaemia whilst driving must not drive and must notify DVLA.

Managed by tablets carrying hypoglycaemia risk

	Group 1 Car and motorcycle	Group 2 Bus and lorry
Including sulphonylureas and glinides (for example Repaglinide, Nateglinide)	! - May drive and need not notify DVLA, providedprovided: the driver: ■ hasno adequatemore awarenessthan of1 hypoglycaemiaepisode (being able to recognise symptoms in time to safely stop the vehicle) ■ has not experienced 2 or more episodes of severe hypoglycaemia while awake in the last 12 months and the most recent episode occurred more than 3 months ago ■ isshould underpractise regularappropriate reviewglucose monitoring ■at hastimes norelevant disqualifyingto complicationsdriving of ■ diabetesunder regular review It is advisableappropriate to practiseoffer appropriate glucose monitoring at times relevant to driving to enable the detection of hypoglycaemia. If the above requirements and those set out in Appendix E are met, DVLA need not be informed. DVLA must be notified if clinical information indicates the agency may need to undertake medical enquiries.	! - May drive but must notify DVLA. All the following criteria must be met for DVLA to issue a licence for 1, 2 or 3 years: ■ no episode of severe hypoglycaemia in the last 12 months ■ full awareness of hypoglycaemia ■ regular self-monitoring of blood glucose – at least twice daily and at times relevant to driving, suchi.e. asno atmore than 2 hours before the start of the first journey and at least every 2 hours duringafter thedriving journeyhas started ■ demonstrates an understanding of the risks of hypoglycaemia ■ under regular medical review ■ has no disqualifying complications of diabetes that mean a licence will be refused or revoked, such as visual field defect

Managed by other medication - such medication includes Metformin, DPP-4 inhibitors (gliptins), SGLT2 inhibitors, GLP-1 agonists and non-insulin injectables

	Group 1 Car and motorcycle	Group 2 Bus and lorry
	! - May drive and need not notify DVLA, provided the requirements set out in Appendix E are met and the driver is under regular medical review. Must! have- noMay disqualifyingdrive complicationsbut ofmust diabetes.notify DVLA if clinical information indicates the agency may need to undertake medical enquiries.	! - May drive but must notify DVLA. DVLA may issue a licence if the requirements set out in Appendix E are met and the driver is under regular medical review. Must haveA nolicence is refused or revoked if relevant disqualifying complications ofhave diabetes.developed, such as diabetic retinopathy affecting visual acuity or visual fields. A short-term licence may be issued if diabetes complications have developed but the required medical standards have been met.

Diabetes managed by dietdiet/lifestyle or lifestyle alone

Group 1 Car and motorcycle	Group 2 Bus and lorry
✓- May drive and need not notify DVLA,DVLA. providing ✘- theMust drivernot meetsdrive theand requirementsmust setnotify outDVLA inif, Appendixfor E.example: Must■ haverelevant no disqualifying complications ofdevelop diabetes.such as diabetic retinopathy affecting visual acuity or visual fields ■ insulin treatment is required (see the requirements for insulin-treated diabetes).	✓- May drive and need not notify DVLA,DVLA. providing ✘- theMust drivernot meetsdrive theand requirementsmust setnotify outDVLA inif, Appendixfor E.example: Must■ haverelevant no disqualifying complications ofdevelop diabetes.such as diabetic retinopathy affecting visual acuity or visual fields ■ insulin treatment is required (see the requirements for insulin-treated diabetes).

Severe hypoglycaemia due to causes other than diabetes management

Examples include hypoglycaemia post-bariatric surgery or in association with eating disorders, and the restriction applies for both car and motorcycle, and bus and lorry drivers.

Severe hypoglycaemia

The law defines ‘severe’ as an episode of hypoglycaemia requiring the assistance of another person.

✘- If there are episodes of severe hypoglycaemia from any cause other than diabetes treatment driving must stop and the driver must notify DVLA.DVLA

Group 1 Car and motorcycle

Group 2 Bus and lorry

The following criteria must be met for DVLA to licenselicence the person experiencing severe hypoglycaemia due to causes other than diabetes management: ■ adequate awareness of hypoglycaemia (being able to recognise symptoms in time to safely stop the vehicle) ■ practices appropriate glucose monitoring as defined in the sectiontext below ■ demonstrates an understanding of the risks of hypoglycaemia ■ not regarded as a likely risk to the public when driving ■ remains under regular clinical review for the management of the underlying medical condition

The following criteria must be met for DVLA to licenselicence the person experiencing severe hypoglycaemia due to causes other than diabetes management: ■ full awareness of hypoglycaemia ■ no episode of severe hypoglycaemia in the preceding 12 months ■ practices appropriate glucose monitoring aswith the regularity defined in the sectiontext below ■ demonstrates an understanding of the risks of hypoglycaemia ■ not regarded as a likely risk to the public when driving ■ remains under regular clinical review for the management of the underlying medical condition

Group 1 car and motorcycle

Glucose

• glucose testing mustno takemore place:
  • atthan 2 hours before the start of the first journey
    and
    
  • atevery least2 everyhours after driving has started
  • a maximum of 2 hours duringshould pass between the journeypre-driving glucose test and the first glucose check performed after driving has started

  More frequent self-monitoring may be required with any greater risk of hypoglycaemia (such(physical asactivity, physical activity or altered meal routine).

  Group 2 bus and lorry

  Glucose testing must take place:

  • regular blood glucose testing – at least twice daily,daily including on days when not driving
    and
    
  • atno more than 2 hours before the start of the first journey
    and
    
  • at least every 2 hours duringafter thedriving journeyhas started

  A

• a maximum of 2 hours should pass between the pre-driving glucose test and the first glucose check performed after driving has started.
  started

More frequent self-monitoring may be required with any greater risk of hypoglycaemia (such(physical asactivity, physical activity or altered meal routine).

Pancreas transplant

Group 1 Car and motorcycle	Group 2 Bus and lorry
! - May drive but must notify DVLA. Licensing is on the provision that the patient has no disqualifying condition. If the patient is on insulin, refer to insulin-treated diabetes.	! - May drive but must notify DVLA. Licensing is on the provision that the patient has no disqualifying condition. If the patient is on insulin, refer to insulin-treated diabetes.

Islet cell transplantation

Group 1 Car and motorcycle	Group 2 Bus and lorry
! - May drive but must notify DVLA. Licensing is on the provision that the patient has no disqualifying condition. If the patient is on insulin, refer to insulin-treated diabetes.	! - May drive but must notify DVLA. Licensing is on the provision that the patient has no disqualifying condition. If the patient is on insulin, refer to insulin-treated diabetes.

Seizures provoked by hypoglycaemia

Seizures provoked by hypoglycaemia now require a period off driving due to the prospective risk of a further seizure.

Group 1 Car and motorcycle	Group 2 Bus and lorry
✘ - Must not drive and must notify DVLA. See ‘Provoked seizures’ under Epilepsy and seizures.	✘ - Must stop driving and must notify DVLA. See ‘Provoked seizures’ under Epilepsy and seizures.