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FAA updates AME Guide with new disposition tables, imaging rules and medication guidance
Summary
The FAA’s Office of Aerospace Medicine on its April Grand Rounds released AME Guide updates introducing new disposition tables (including eosinophilic esophagitis and female hormone-replacement therapy), changed carotid-stenosis imaging requirements, added several biologic and HIV PrEP medications, and shortened some post-dose observation windows for weight-loss and prediabetes drugs.
The Federal Aviation Administration’s Office of Aerospace Medicine presented a package of updates to the Aviation Medical Examiner (AME) Guide during Session 2 of April Grand Rounds, detailing new disposition tables, imaging requirements, medication lists and observation-period changes for AMEs who evaluate airmen.
Dr. Samantha King, a medical officer with the FAA Office of Aerospace Medicine, summarized the new disposition table for eosinophilic esophagitis and told AMEs that “the biggest concern for individuals with eosinophilic esophagitis is the risk for food impaction, which … could be suddenly incapacitating” during flight. The table and a related “khaki” status outline criteria under which an applicant may be considered for issuance, including histologic remission on recent endoscopy and no evidence of fibrostenotic disease; applicants with a history of food impaction within the last 12 months or who remain symptomatic should be deferred.
The guide’s CACI worksheet now requires documentation from the treating physician that the airman is clinically stable and compliant and that a recommended recent endoscopy shows histologic remission and no rings, strictures or narrow-caliber esophagus before considering issuance.
The updates also include medication- and observation-related guidance. Acceptable treatments noted for eosinophilic esophagitis include proton pump inhibitors, topical or oral steroids not exceeding a prednisone-equivalent dose of 20 mg per day, and dupilumab (Dupixent); dupilumab carries a 4-hour post-dose observation requirement. For weight-loss and qualifying prediabetes medications, the post–dose or post–formulation-change observation period was shortened from 72 hours to 48 hours, though a two-week initial observation after starting a new medication remains required. The weight-loss worksheet no longer requires an A1c unless an applicant has a prior A1c of 6.5 or greater, in which case the diabetes pathways apply; an A1c of 5.7–6.4 should be handled under prediabetes guidance with a current A1c within 90 days when required.
Cardiac and vascular clarifications were included. For typical atrial flutter treated with ablation within the past two years (or for applicants on antiarrhythmic therapy), the guide requires a 24-hour cardiac monitor performed at least 90 days after an ablation; that monitor does not have to be within 90 days of the AME exam so long as it occurred at least 90 days after the procedure. For carotid stenosis cases at the highest risk (stenosis ≥80 percent, on anticoagulation or with surgery recommended), the guide removes a routine ultrasound requirement and instead asks for CTA, MRI or angiography of the head and neck performed within 90 days of the AME exam plus a current brain MRI; those cases remain deferred for FAA special-issuance consideration.
The guide expands acceptable medications in several areas. Tamoxifen was added to the low-testosterone (low-T) khaki guidance. For colitis, the monoclonal antibodies guselkumab (Tremfya) and risankizumab (SKYRIZI) were added as potentially acceptable medications for CACI qualification depending on the underlying condition. The HIV pre-exposure prophylaxis (PrEP) list was amended to include lenacapavir. FAA staff clarified that many biologic medications are listed as conditionally acceptable and that issuance decisions depend on the underlying diagnosis and whether the biologic is used in monotherapy; some cases will still require FAA review and deferral.
New pharmacy pages were released for osteoporosis and for smoking cessation. The osteoporosis page lists acceptable and unacceptable medications and notes observation periods that vary by drug class (for example, romosozumab carries a two-week initial observation and a 4-hour post-dose observation; oral bisphosphonates require no observation). The smoking-cessation page lists nicotine-replacement options and varenicline (Chantix) as acceptable; bupropion and nortriptyline are listed as unacceptable for smoking cessation. Staff noted that an applicant who received bupropion for smoking cessation must not be issued during active treatment but may be considered after a 7-day no-fly interval following the last dose; applicants on extended bupropion regimens (>6 months) should follow the anxiety and depression table.
Moderator Christy reminded attendees that the session was recorded for posting on the FAA YouTube channel and that AMEs may send suggestions to AMEguide@FAA.gov. Dr. Brett Wyrick, deputy federal air surgeon, closed by thanking AMEs for their work. The session provided guidance and examples but took no formal votes or regulatory actions during the presentation.
The FAA said AMEs should submit relevant documentation (endoscopy reports, imaging, cardiac monitoring, medication lists and treating-physician statements) as indicated by the updated disposition tables when referring cases to the AMU for special-issuance review.
