Driving & Diabetes

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Driving Fitness Decision Aid for Not on Insulin

Adapted from Austroads Medical Standards 2022 – For Private & Commercial Licensing

🔹 Step 1: Determine Licence Type

• ☐ Private
• ☐ Commercial

🔹 Step 2: Assess Diabetes Treatment

• ☐ Diet and lifestyle only
• ☐ Oral agents and/or non-insulin injectables (e.g. metformin, sulfonylureas, SGLT2 inhibitors, GLP-1 receptor agonists)

🔹 Step 3: Assess for Complications

Tick Yes if any of the following are present.
If any are ticked, annual review is required and a conditional licence is usually necessary.

Complication or Risk Factor	Yes	No
Severe hypoglycaemic event (past 12 months)	☐	☐
Increased risk of hypoglycaemia due to medication (e.g. sulfonylureas or GLP-1 RA with sulfonylurea)	☐	☐
Impaired awareness of hypoglycaemia	☐	☐
Recurrent hyperglycaemic crises or recent acute metabolic decompensation	☐	☐
Diabetes-related complications (e.g. peripheral neuropathy, retinopathy)	☐	☐
Comorbidities impairing driving ability (e.g. visual impairment, cardiovascular disease)	☐	☐

🔹 Step 4: Licensing & Review Frequency

Scenario	Licence Type	Conditional Licence	Medical Review Frequency	Notes
Diet and lifestyle only	Private / Commercial	❌ Not required	❌ None required	If well-controlled and no risk factors
Oral/non-insulin injectable therapy, with good control and no complications	Private	❌ Not required	✅ Every 5 years – GP	“A conditional licence may not be required… review every five years.” (Section 3.2.1)
On sulfonylureas or other agents increasing hypoglycaemia risk OR Complications/comorbidities present	Private	✅ Yes	🔁 Annual – GP	“Annual review required… conditional licence usually necessary.” (Section 3.2.1)
Any treatment OR any complications	Commercial	✅ Yes	🔁 Annual – Specialist	“Medical review is required annually for commercial drivers.” (Section 3.2.1) – see below

🔹COMMERCIAL LICENCE (not on Insulin)

Any person with T2DM on glucose-lowering agents (but not insulin) is not eligible for an unconditional commercial licence.

✅ Conditional licence may be considered

Subject to all of the following:

1. Annual review is mandatory
2. Decision must consider:
   • Nature of the driving task
   • A report from an endocrinologist or diabetes specialist
3. The person must meet all 4 criteria below

✅ 4 Clinical Fitness Criteria (All Must Be Met):

1. No recent history of severe hypoglycaemic events
   • Must have at least annual review by an appropriate diabetes specialist.
2. Preserved hypoglycaemia awareness (i.e. recognises early warning signs)
3. On a treatment regimen that minimises hypo risk
   • e.g. metformin alone or GLP-1 RA alone
4. No end-organ complications that could impair driving
   • Vision loss, neuropathy, cardiovascular disease, etc.

🔸 Special Provision for Metformin Alone

• If the patient is on metformin only, and:
  • Has no complications or hypoglycaemia
  • Meets the above 4 criteria

➡️ Then the annual review can be done by the treating doctor (e.g. GP)
👉 But only if all parties agree:

• The treating doctor
• The diabetes specialist
• The licensing authority

❗ However, the initial conditional licence must be granted based on a specialist’s assessment/report.

🔍 Clinical Implication

If you’re the GP:

• You cannot issue the first report for a commercial driver with T2DM on metformin
• You can do annual reviews if:
  • There’s mutual agreement from the relevant specialist and licensing authority
  • The patient is stable and low risk (e.g. on metformin monotherapy)

Access Issues in Remote/Rural Areas:

• Where specialist access is limited:
  • Initial assessment and advice must be from a specialist.
  • Ongoing periodic reviews may be performed by the GP, in cooperation with the specialist.
  • Telemedicine (e.g. videoconferencing) is encouraged to facilitate specialist input.

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Driving Fitness Decision Aid for Treated with Insulin

Adapted from Austroads Medical Standards 2022 – For Private & Commercial Licensing

🔹 Step 1: Determine Licence Type

• ☐ Private
• ☐ Commercial

🔹 Step 2: Actions Based on Licence Type

✅ Private Licence – Conditional Licence Required

A conditional private licence may be granted if all of the following are met, with at least 2-yearly medical review:

1. No history of severe hypoglycaemic episodes in the past 12 months.
   (See Austroads Section 3.2.1 for definition.)
2. On a treatment regimen that minimises hypoglycaemia risk.
3. Either:
   • Intact hypoglycaemia awareness, or
   • A documented management plan in place if awareness is impaired.
4. No diabetes-related end-organ complications affecting driving ability
   (e.g. vision loss from retinopathy, neuropathy affecting pedal control).

If any criteria are not met, a conditional licence may still be considered if:

• A report is provided by an endocrinologist or diabetes specialist, and
• There is evidence of ongoing specialist monitoring.

✅ Commercial Licence – Strict Specialist Requirements

A conditional commercial licence may be granted only if all the following are met, with annual specialist review:

1. No severe hypoglycaemic event in the past 6 weeks.
   (Typically requires at least 6 weeks free of any episodes, confirmed by a specialist.)
2. On a regimen that minimises hypoglycaemia risk.
3. Intact awareness of hypoglycaemia symptoms.
4. No diabetes-related complications that could impair driving safety
   (e.g. retinopathy, neuropathy, cardiovascular instability).

📌 A report must be completed by an endocrinologist or diabetes specialist for all commercial drivers on insulin (Section 3.2.1).

🔹 Step 3: Assess for Additional Risk Factors/Complications

If any of the following are present, a conditional licence is still possible, but specialist review is generally required:

Risk Factor	Present?
Severe hypoglycaemic episode (within past 12 months)	☐ Yes ☐ No
Impaired hypoglycaemia awareness	☐ Yes ☐ No
Acute hyperglycaemic event (e.g. DKA, HHS, marked instability)	☐ Yes ☐ No
End-organ complications (e.g. neuropathy, retinopathy)	☐ Yes ☐ No
Other medical comorbidities (e.g. CVA, visual impairment, arrhythmias)	☐ Yes ☐ No

👉 If any of the above are ticked Yes, consider:

• Specialist assessment and documentation
• Conditional licence
• Annual medical review

🔹 Step 4: Licensing and Review Requirements

Scenario	Licence Type	Conditional Licence?	Review Frequency	Reviewed By
On insulin, stable, no complications	Private	✅ Yes	Every 2 years	GP or Specialist
On insulin, stable	Commercial	✅ Yes	Yearly	Specialist
Insulin-treated with complications or risks	Private or Commercial	✅ Yes	Yearly	Specialist

Access Issues in Remote/Rural Areas:

• Where specialist access is limited:
  • Initial assessment and advice must be from a specialist. – this is a non-negotiable requirement
  • Ongoing periodic reviews may be performed by the GP, in cooperation with the specialist.
  • Telemedicine (e.g. videoconferencing) is encouraged to facilitate specialist input.

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🔹 3.2.1 Hypoglycaemia

🔹Definition: Severe Hypoglycaemic Event

• Defined as hypoglycaemia requiring assistance from another person.
• Includes events causing:
  • Loss of consciousness
  • Seizure
  • Cognitive/motor impairment or abnormal behaviour
• Differs from mild hypoglycaemia, which presents with:
  • Sweating, tremor, hunger, tingling mouth

🔹 Potential Causes of Hypoglycaemia

• Missed/delayed meals
• Medication non-adherence or dose changes
• Unexpected physical activity
• Alcohol intake
• Excessively tight glycaemic control
• Relevant for commercial drivers and shift workers

🔹 Advice to Drivers to Prevent Hypoglycaemia While Driving

• Do not drive after a severe hypoglycaemic event until medically cleared by a doctor.
• Take steps to avoid hypoglycaemia while driving, including:
• General Medical Precautions
  • Comply with medical reviews as advised by GP or specialist.
  • Wear a continuous or flash glucose monitor (CGM/FGM) with hypoglycaemia alert, if possible.
• Before Driving
  • Do not drive if:
    • Blood glucose ≤ 5.0 mmol/L, OR
    • CGM/FGM shows a downward trend into hypoglycaemia range (when vehicle is parked).
  • Check blood glucose before driving.
  • Ensure a main meal is not missed or delayed.
• During Driving
  • Check blood glucose every 2 hours, as reasonably practical.
  • Do not drive for >2 hours without considering a snack.
  • Keep adequate glucose in the vehicle for self-treatment.
• If Mild Hypoglycaemia Occurs While Driving
  • Pull over safely to the side of the road.
  • Turn off the engine and remove keys from ignition.
  • Treat the hypoglycaemia (e.g., with fast-acting carbohydrate).
  • Re-check glucose ≥15 minutes after treatment.
  • Do not resume driving until:
    • Blood glucose is above 5.0 mmol/L, AND
    • At least 30 minutes have passed since BGL rose above 5.0 mmol/L, AND
    • The driver feels well.

🔹 If Mild Hypoglycaemia Occurs While Driving

• Pull over and stop driving safely
• Turn off engine and remove keys
• Treat low BGL immediately
• Recheck BGL after 15 minutes:
  • Ensure BGL > 5 mmol/L
• Resume driving only after feeling well and at least 30 minutes after BGL normalises

🔹 Post-Severe Hypoglycaemic Event – Driving Restriction

• Do not drive for at least 6 weeks
• Requires:
  • Urgent medical assessment
  • Review of cause and management plan
  • Specialist input (esp. for commercial drivers)
  • Documented BGL data over time
• Return to driving based on stability and medical clearance

🔹 Impaired Hypoglycaemic Awareness

• Loss of early warning signs (e.g. sweating, tremor, hunger, headache)
• Increases risk of severe events ×7
• Prevalence:
  • ~10% in T2DM
  • ~20–25% in T1DM
  • Higher in older adults and longer diabetes duration

🔹 Screening & Monitoring

• Use Clarke Hypoglycaemia Awareness Survey
  • Particularly after:
    • Severe hypo
    • Crash
    • Longstanding insulin use
• CGM/FGM do not replace symptom awareness

🔹 Fitness to Drive – Impaired Awareness

• Persistent impaired awareness = generally not fit to drive
• Conditional private licence may be considered if:
  • Effective management strategy in place
  • Specialist supports driving fitness
• Must be under care of endocrinologist or diabetes specialist

🔹 Management Focus

• Reinforce:
  • Hypo avoidance strategies
  • Education on symptoms
  • Diet, exercise, insulin adjustment, and glucose monitoring
• Requires ongoing collaboration between:
  • Medical practitioner
  • Patient

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🔹 3.2.2 Acute Hyperglycaemia

• May impact brain function (e.g. cognition, alertness)
• No conclusive evidence linking acute hyperglycaemia to crash risk
• Driving advice:
  • Do not drive when acutely unwell with metabolically unstable diabetes
  • Patients should be counselled about this during illness episodes

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🔹 3.2.3 Comorbidities and End-Organ Complications

Assessment should be part of routine diabetes review in relation to driving.

➤ Vision

• Annual visual acuity check
• Retinal screening:
  • Every 2 years if no retinopathy
  • More frequently if high risk
• Visual field testing only if clinically indicated
  → Refer to Section 10: Vision and Eye Disorders

➤ Neuropathy and Foot Care

• Assess severity and impact on:
  • Sensation
  • Motor function required to operate pedals
• Refer to:
  • Section 6: Neurological conditions
  • Section 5: Musculoskeletal conditions

➤ Sleep Apnoea

• Common in T2DM; impacts alertness and crash risk
• Screen if:
  • BMI > 35
  • Clinical symptoms (e.g. daytime sleepiness)
• Use Epworth Sleepiness Scale if appropriate
  → Refer to Section 8: Sleep Disorders

➤ Cardiovascular Disease

• No specific driving standards for diabetes-related CVD
• Routine cardiovascular risk assessment advised → Refer to Section 2: Cardiovascular Conditions

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🔹 3.2.4 Gestational Diabetes Mellitus

• Does not affect licensing as a chronic condition
• Consider short-term restrictions if treated with insulin, due to hypo risk
• Severe hypoglycaemia is rare
• Patients should be:
  • Counselled about symptoms
  • Advised not to drive when symptomatic