NPC Archive Item: What are the DVLA blood glucose monitoring requirements for people with diabetes?

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19th March 2012

This Rapid Review aims to clarify the DVLA requirements and advice for the monitoring of blood glucose in people with diabetes. It is based on the DVLA publication ‘At a glance guide to the current medical standards of fitness to drive’ (which is due to be updated in late spring 2012) and additional correspondence between the DVLA and NPC. There is a section summarising the DVLA advice, and a section answering questions that healthcare professionals may have.

Action
Healthcare professionals involved in the care of people with diabetes should be aware of these recommendations from the DVLA around the monitoring of blood glucose, in order to best advise patients about their own particular requirements.

Summary of DVLA advice
Adapted from table on pages 29 and 30 of ‘At a glance guide’ December 2011
© Driver and Vehicle Licensing Agency Swansea SA6 7JL

Diabetes mellitus	Group 1 entitlement (cars and motorcycles)*	Group 2 entitlement (lorries and buses)*
INSULIN-TREATED Drivers are sent a detailed letter of explanation about their licence and driving by DVLA.See sample of this letter (DIABINF) below	Must have awareness of hypoglycaemia. Must not have had more than one episode of hypoglycaemia requiring the assistance of another person in the preceding twelve months. There must be appropriate blood glucose monitoring. Must not be regarded as a likely source of danger to the public while driving. The visual standards for acuity and visual field must be met Impaired awareness of hypoglycaemia has been defined by the Secretary of State’s Honorary Medical Advisory Panel on Driving and Diabetes as ‘an inability to detect the onset of hypoglycaemia because of a total absence of warning symptoms’. If meets the medical standard a 1, 2 or 3 year licence will be issued.	May apply for any Group 2 licence. Must satisfy the following criteria: No episode of hypoglycaemia requiring the assistance of another person has occurred in the preceding 12 months. Has full awareness of hypoglycaemia. Regularly monitors blood glucose at least twice daily and at times relevant to driving using a glucose meter with a memory function to measure and record blood glucose levels. At the annual examination by an independent Consultant Diabetologist, 3 months of blood glucose readings must be available. Must demonstrate an understanding of the risks of hypoglycaemia. There are no other debarring complications of diabetes such as a visual field defect. If meets the medical standards a 1 year licence will be issued.
TEMPORARY INSULIN TREATMENT e.g. gestational diabetes, post-myocardial infarction, participants in oral/inhaled insulin trials.	Provided they are under medical supervision and have not been advised by their doctor that they are at risk of disabling hypoglycaemia, need not notify DVLA. If experiencing disabling hypoglycaemia, DVLA should be notified. Notify DVLA if treatment continues for more than 3 months or for more than 3 months after delivery for gestational diabetes.	As above
MANAGED BY TABLETS WHICH CARRY A RISK OF INDUCING HYPOGLYCAEMIA. THIS INCLUDES SULFONYLUREAS AND GLINIDES See additional information on this (INF188/2) below	Must not have had more than one episode of hypoglycaemia requiring the assistance of another person within the preceding 12 months. It may be appropriate to monitor blood glucose regularly and at times relevant to driving to enable the detection of hypoglycaemia. Must be under regular medical review. If the above requirements and all of those set out in the attached information on INF188/2 are met, DVLA does not require notification. This information leaflet can be printed and retained for future reference.Alternatively, if the information indicates that medical enquiries will need to be undertaken, DVLA should be notified.	Must satisfy the following criteria: No episode of hypoglycaemia requiring the assistance of another person has occurred in the preceding 12 months. Has full awareness of hypoglycaemia. Regularly monitors blood glucose at least twice daily and at times relevant to driving. Must demonstrate an understanding of the risks of hypoglycaemia. There are no other debarring complications of diabetes such as a visual field defect. If meets the medical standards 1, 2 or 3 year licence will be issued.
MANAGED BY TABLETS OTHER THAN THOSE ABOVE OR BY NON-INSULIN INJECTABLE MEDICATION See additional information on this (INF188/2) below	If all the requirements set out in the attached information on INF188/2 are met, and they are under regular medical review, DVLA does not require notification. This information leaflet can be printed and retained for future reference.Alternatively, if the information indicates that medical enquiries will need to be undertaken, DVLA should be notified.	Drivers will be licensed unless they develop relevant disabilities e.g. diabetic eye problem affecting visual acuity or visual fields, in which case either refusal, revocation or short period licence.Drivers are advised to monitor their blood glucose regularly and at times relevant to driving. They must be under regular medical review.
MANAGED BY DIET ALONE	Need not notify DVLA unless develop relevant disabilities e.g. diabetic eye problems affecting visual acuity or visual field or if insulin required.	Need not notify DVLA unless develop relevant disabilities e.g. Diabetic eye problems affecting visual acuity or visual field or if insulin required.
Impaired awareness of hypoglycaemia	If confirmed, driving must stop. Driving may resume provided reports show awareness of hypoglycaemia has been regained, confirmed by consultant/GP report.	See insulin treated section above. Refusal or revocation.

*Licence Groups

Group 1 includes motorcars and motorcycles.

Group 2 includes large lorries (category C) and buses (category D). The medical standards for Group 2 drivers are very much higher than those for Group 1 because of the size and weight of the vehicle. This also reflects the higher risk caused by the length of time the driver may spend at the wheel in the course of his/her occupation.

All drivers who obtained entitlement to Group 1, category B (motor car) before 1 January 1997 have additional entitlement to category C1 and D1. C1 is a medium size lorry of weight between 3.5 and 7.5 tonne. D1 is a minibus of between 9 and 16 seats, not for hire or reward.

Holders of C1 and D1 entitlement retain the entitlement until their licence expires or it is medically revoked. On subsequent renewal the higher medical standards applicable to Group 2 will apply.

Under certain circumstances volunteer drivers can drive a minibus of up to 16 seats without having to obtain category D1 entitlement. Individuals should consult DVLA for a detailed fact sheet.

Questions

What are the DVLA blood glucose monitoring requirements for people with insulin-treated diabetes driving buses or lorries?

From November 2011, people with insulin-treated diabetes have been able to apply for a group 2 vehicle driving licence to drive lorries and buses (see MeReC Rapid Review No. 4593). In the interest of road safety, strict medical criteria apply, including a requirement to show adequate control of the condition by regular blood glucose monitoring.

The requirement is that people in this category should regularly monitor their blood glucose at least twice daily and at times relevant to driving using a glucose meter with a memory function to measure and record blood glucose levels. At the annual examination by an independent Consultant Diabetologist, three months of blood glucose readings must be available. Three months of readings must also be available before people in this category can submit their application.

In the letter (DIABINF: A guide to insulin treated diabetes and driving, see below) sent by the DVLA to all insulin-treated diabetic drivers (whether they have a group 1 or group 2 vehicle driving licence), drivers with insulin-treated diabetes are advised to take the following precautions:

You must always carry your glucose meter and blood glucose strips with you. You must check your blood glucose before driving and every two hours whilst you are driving.
In each case if your blood glucose is 5.0mmol/l or less, take a snack. If it is less than 4.0mmol/l or you feel hypoglycaemic, do not drive.
If hypoglycaemia develops while driving, stop the vehicle as soon as possible..
You must switch off the engine, remove the keys from the ignition and move from the driver’s seat.
You must not start driving until 45 minutes after blood glucose has returned to normal. It takes up to 45 minutes for the brain to recover fully.
Always keep an emergency supply of fast-acting carbohydrate such as glucose tablets or sweets within easy reach in the vehicle.
You should carry personal identification to show that you have diabetes in case of injury in a road traffic accident.
Particular care should be taken during changes of insulin regimens, changes of lifestyle, exercise, travel and pregnancy.

You must take regular meals, snacks and rest periods on long journeys. Always avoid alcohol.

NICE guidance advises that SMBG should be available to patients with type 2 diabetes who are treated with insulin, and should be available to ensure safety during activities, including driving.

For group 2 drivers with diabetes who are receiving temporary insulin treatment, e.g. for gestational diabetes, post-myocardial infarction, or participants in oral/inhaled insulin trials, the same requirements around blood glucose monitoring, as outlined above for insulin-treated people, apply.

What are the DVLA blood glucose monitoring requirements for people with insulin-treated diabetes driving cars or motorcycles?

There is no requirement for people with insulin-treated diabetes who hold a group 1 vehicle driving licence to drive cars or motorcycles to monitor their blood glucose with a meter with a memory function, as for group 2 drivers. However, there is a requirement that there must be appropriate blood glucose monitoring.

No definition of appropriate monitoring is given by the DVLA, but in the letter (DIABINF: A guide to insulin treated diabetes and driving, see below) sent by the DVLA to all insulin-treated diabetic drivers (whether they have a group 1 or group 2 vehicle driving licence), drivers with insulin-treated diabetes are advised to take several precautions, including the following:

You must always carry your glucose meter and blood glucose strips with you. You must check your blood glucose before driving and every two hours whilst you are driving.
In each case if your blood glucose is 5.0mmol/l or less, take a snack. If it is less than 4.0mmol/l or you feel hypoglycaemic, do not drive.

In the draft minutes from Secretary of State for Transport’s Honorary Medical Advisory Panel Meeting from October 2011, the following additional information was given:

The Panel clarified the advice given to a driver with insulin-treated diabetes regarding the frequency of blood glucose monitoring in relation to driving. If driving multiple short journeys, such as a delivery driver, it would be appropriate to measure blood glucose before the first journey and then every two hours. It is not necessary to test before each individual journey.

NICE guidance advises that SMBG should be available to patients with type 2 diabetes who are treated with insulin, and should be available to ensure safety during activities, including driving.

Group 1 drivers with diabetes who are receiving temporary insulin treatment, e.g. for gestational diabetes, post-myocardial infarction or participants in oral/inhaled insulin trials, need not notify the DVLA provided they are under medical supervision and have not been advised by their doctor that they are at risk of disabling hypoglycaemia. However, if these people are experiencing disabling hypoglycaemia, the DVLA should be notified. The DVLA should also be notified if treatment continues for more than three months or for more than three months after delivery for gestational diabetes. In correspondence, the DVLA have stated that there is also a requirement for group 1 drivers with diabetes who are receiving temporary insulin treatment to carry out appropriate blood glucose monitoring.

What are the DVLA blood glucose monitoring requirements for people with non-insulin treated diabetes driving buses or lorries?

For group 2 drivers with diabetes who are managed by tablets which carry a risk of inducing hypoglycaemia i.e. sulfonylureas and glinides, there is a requirement that they regularly monitor their blood glucose at least twice daily and at times relevant to driving. The DVLA state that evidence will be required to demonstrate adequate control of the condition by regular blood glucose monitoring (at least twice daily and at times relevant to driving). There is no requirement to use a glucose meter with a memory function to measure and record blood glucose levels, as there is for insulin-treated group 2 drivers, although the DVLA have stated in correspondence that this would be advised. The evidence of adequate control would normally take the form of a report from the driver’s doctor.

For group 2 drivers with diabetes who are managed by other tablets (e.g. metformin or gliptins) or by non-insulin injectables (exenatide or liraglutide), there is no requirement to monitor blood glucose. However, there is advice from the DVLA to monitor blood glucose regularly and at times relevant to driving.

NICE guidance advises that SMBG should be available to those on oral glucose-lowering medications to provide information on hypoglycaemia, and should be available to ensure safety during activities, including driving. The NHS diabetes document, SMBG in non-insulin treated diabetes, recommends that SMBG with appropriate structured education should be available to people receiving sulfonylurea treatment to identify hypoglycaemic episodes. They also state that SMBG can provide clinically useful information on driving for people treated with sulfonylureas.

What are the DVLA blood glucose monitoring requirements for people with non-insulin treated diabetes driving cars or motorcycles?

For group 1 drivers with diabetes who are managed by tablets which carry a risk of inducing hypoglycaemia i.e. sulfonylureas and glinides, the DVLA have stated in correspondence that there is a requirement for appropriate blood glucose monitoring. For example, if the driver is advised by their doctor to monitor blood glucose, this would be a requirement. The DVLA state in the ‘At a glance guide’, that it may be appropriate to monitor blood glucose regularly and at times relevant to driving to enable the detection of hypoglycaemia.

In the draft minutes from Secretary of State for Transport’s Honorary Medical Advisory Panel Meeting from October 2011, the following additional information was given:

The Panel considered a letter from a NHS prescribing advisor regarding Group 1 drivers on sulfonylureas and glinides and the requirement for blood glucose monitoring. The Panel noted that hypoglycaemia is most commonly observed soon after commencing treatment with sulfonylureas when, although at low dosage, the sensitivity to these drugs is high. In addition, the annual prevalence of severe hypoglycaemia in patients taking sulfonylureas who had good glycaemic control was 7% in the report from the UK Hypoglycaemia Study Group.The Panel advised that the frequency of blood glucose testing should depend on the clinical context.

For group 1 drivers with diabetes who are managed by other tablets (e.g. metformin or gliptins) or by non-insulin injectables (exenatide or liraglutide), there is no requirement or advice to monitor blood glucose from the DVLA, although the DVLA have stated in correspondence that drivers should take advice from their doctor in this regard.

What are the DVLA requirements around episodes of hypoglycaemia?

For group 2 drivers with diabetes who are managed by insulin or tablets which carry a risk of inducing hypoglycaemia i.e. sulfonylureas and glinides, no episode of hypoglycaemia requiring the assistance of another person must have occurred in the preceding 12 months.

For group 1 drivers with diabetes who are managed by insulin or tablets which carry a risk of inducing hypoglycaemia i.e. sulfonylureas and glinides, not more than one episode of hypoglycaemia requiring the assistance of another person must have occurred within the preceding12 months.

In the draft minutes from Secretary of State for Transport’s Honorary Medical Advisory Panel Meetings from October 2011, the following additional information was given:

The Panel accepted that the new annex does not distinguish between episodes of severe hypoglycaemia occurring either when awake or asleep and noted the media interest in this issue.
The Panel emphasised that severe hypoglycaemia is defined in the EU Annex as: “the assistance of another person is needed”. This means that if help was proffered (for example by a relative or associate) but had not actually been essential to treat an episode of hypoglycaemia, it would not be classified as “severe”.

What do the DVLA say about police, ambulance and health service vehicle drivers?**

Responsibility for determining the standards, including medical requirements, to be applied to police, ambulance and health service vehicle drivers, over and above the driver licensing requirements, rests with the individual Police Force, with the NHS Trust, Primary Care Trust or Health Service body in each area. The Secretary of State’s Honorary Medical Advisory Panel on Diabetes and Driving has recommended that drivers with insulin treated diabetes should not drive emergency vehicles. This takes account of the difficulties for an individual, regardless of whether they may appear to have exemplary glycaemic control, in adhering to the monitoring processes required when responding to an emergency situation.

What do the DVLA say about taxi drivers?**

The House of Commons Transport Select Committee on Taxis and Private Hire Vehicles recommended in February 1995 that taxi licence applicants should pass a medical examination before such a licence could be granted.

Responsibility for determining the standards, including medical requirements, to be applied to taxi drivers, over and above the driver licensing requirements, rests with the Transport for London in the Metropolitan area and the Local Authority in all others areas. Current best practice advice is contained in the booklet ‘Fitness to Drive’: A Guide for Health Professionals published on behalf of the Department by The Royal Society of Medicine Press Limited in 2006. This recommended that the Group 2 medical standards applied by DVLA in relation to bus and lorry drivers, should also be applied by local authorities to taxi drivers.

**Caveat: The advice of the Panels on the interpretation of EC and UK legislation, and its appropriate application, is made within the context of driver licensing and the DVLA process. It is for others to decide whether or how those recommendations should be interpreted for their own areas of interest, in the knowledge of their specific circumstances.

Further information about SMBG can be found on NHS Evidence and in the type 2 diabetes e-learning section of the NPC website

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