Respiratory and other viral illnesses can occur at any time of year. However, in the winter flu season, we see them more frequently and often with more significant symptoms than in the summer.

Illnesses can be caused by bacteria, but more commonly result from a host of viruses. There are the usual suspects of common respiratory viruses and their ongoing mutational strains that have been around essentially forever. These include strains such as rhinovirus and adenovirus. Fancy scientific names aside, these viruses cause the common cold and other respiratory illnesses.

This winter has been a doozy when it comes to viral illnesses, which are often challenging to diagnose. When a patient has tested negative for influenza, Covid, pertussis (whooping cough), or respiratory syncytial virus (RSV), then the presumption is that the causation is one of the countless other routine viruses that love to make their presence known in the winter.

While there are medications that can lessen the severity and duration of influenza or Covid symptoms, there really is no formal treatment for RSV. Therefore, no different than for the host of other viruses that affect millions of people each year, the treatment is mostly “supportive.” The usual boring protocols include fluids, rest, isolation from others (as much as possible in family households), and sometimes the prudent use of symptomatic medications.

Before I go into some of the common medications that might help reduce viral symptoms, remember our discussion in Part 1 of this series. If a pilot is simply too sick to fly, the best decision is to remove themself from flight status temporarily.

We then get to the question of when can that pilot return to work. As always, FAR 61.53 comes into play. The pilot must make a judgment of their condition and whether they have improved enough that any lingering symptoms are so mild that they will not affect their ability to be an effective crewmember.

The pilot must also ensure that they are no longer potentially contagious to other crewmembers. There are plenty of judgment calls for a pilot to make in these situations, and sometimes obtaining advice from an aeromedical consultant is a good idea. However, the final call, per FAR 61.53, is up to the pilot.

If a pilot has required formal prescriptions for medications such as antibiotics, inhalers, and possibly a steroid, then that pilot should certainly stand down for a period of time. But what about a pilot who might not have received a formal diagnosis, was not prescribed any medication, and perhaps simply used some of the over-the-counter (OTC) symptomatic medications that flood the shelves of every grocery store and pharmacy?

In point of fact, some OTC medications provide little benefit, but their marketing is so powerful that billions of dollars are spent on them annually.

Commonly used OTC medications include simple pain relief and anti-inflammatories such as aspirin, ibuprofen (Advil), and acetaminophen (Tylenol). The FAA does not have a big problem with their use as long as the pilot is not having significant side effects or otherwise suffering from symptoms that might compromise the safety of flight. These medications have proven to be reasonably effective for pain and fever, for example.

Next are the commonly used antihistamines. These can be marketed for anything from allergies to sleep to part of the cold and sinus formulations that include more medications than can be addressed in a single blog.

The antihistamines used for these purposes include diphenhydramine (Benadryl) and chlorpheniramine (Chlor-Trimeton), for example. Notice that I mentioned that they can be used in cold and sinus formulations and for sleep. These medications have a sedating effect, which is one of their marketable characteristics.

I recommend that pilots try to stay away from formulations that include OTC cough suppressants. These tend to be ineffective and, in plain fact, do not work all that well. They also have undesirable side effects. If a pilot is coughing so badly that they need a cough suppressant, they should speak with their doctor, obtain a valid prescription, and remain off from flight status until improved.

Many pilots report that, even when not sick, they take one of the many OTC sleep formulations. Common examples include Tylenol PM (acetaminophen and diphenhydramine) and Advil PM (ibuprofen and diphenhydramine). Pilots often report to me that these medications do work well and that they do not experience any residual drowsiness after taking them.

These medications are also often used because they are OTC, do not require a prescription, and because of the understandable reluctance of a pilot to take a prescription medication and then having to report it to the FAA.

Here's the rub with that reasoning; the FAA’s pharmacologic advisors are concerned with residual performance deterioration in pilots who have taken sedating antihistamines. Even if the pilot feels 100% fit to fly, sedating antihistamines are found in an alarming percentage of post-accident toxicology reports. Additional concerns are noted in formal studies on pilot performance.

While some of the prescription sleep aids are commonly permitted by the FAA (with reasonable “wait times” before flying and not taken every night), flight duties are restricted after the use of a sedating antihistamine for, drumroll, 60 hours. To paraphrase humorist Dave Barry, “I am not making this up.”

Without going into all of the details, generally, the FAA restricts flight duties for five half-lives of a sedating medication.

When I give pilots that piece of bad news, they commonly ask me, with understandable frustration in their voices, “How the heck am I supposed to know this? Where is it published?”

In the good old days, this kind of information was not formally published by the FAA. The mysterious and misguided efforts at secrecy by the FAA led pilots (and often AMEs) into no-man’s land when it came to certain medications.

In defense of the FAA, it was considered impossible to publish a list of all medications that included not just what the medication was developed for but also their multiple “off-label” uses.

Many pilot advocacy groups eventually came up with their own lists, which they labor to keep as updated as possible. These lists are quite useful as a place to start, but they are not the final answer. I encourage pilots to use them and then ask their AME or aeromedical advisor any follow-up questions that they may have.

Finally, the FAA began updating its documentation on the use of medications. This was a long-overdue enhancement that has been welcomed by AMEs, advocacy groups, and hopefully pilots too (once the word gets out that this information is available). While, once again, even the FAA’s own list cannot cover all potential uses of medications, it is still a very useful tool. Pilots may not always be happy with the answers that they find (a 60-hour wait period after taking an OTC sleep aid is disconcerting), but having a reasonably thorough document is a useful tool.

This information can be found on the FAA’s Pharmaceuticals (Therapeutics) webpage. There is also a “Do Not Issue—Do Not Fly” section that provides more information on medications that are concerning to the FAA.

Other than for certain medications that would never be approved (either on their own or in regard to a disqualifying medical condition that they may be prescribed for), the FAA makes it clear that, while the published guidance is important, other potential uses of medications may be considered on a case-by-case basis. Even the FAA’s own document is a place to start and not always the definitive answer.

The nuances of question 17a (medications) on a pilot’s periodic MedXpress application are multifaceted. The question's instructions include that a pilot should list medications, both “prescription or non-prescription.” This presents quite the challenge.

While many US Food and Drug Administration (FDA) approved medications have become OTC over the years (allergy, heartburn, anti-inflammatory, etc.) they are still “medications” by definition. Routine supplements such as vitamins are not FDA-approved medications and do not need to be listed.

Disclaimer: the FAA has also begun ruling on certain supplements (for example, sleep aids such as valerian root). These initial inclusions are found in the “Do Not Issue—Do Not Fly” listings.

Not all OTC medications and supplements have any sort of formal FAA ruling, so a pilot must use their judgment and perhaps discuss the specifics with their AME.

There are more considerations to question 17a that likely warrant its own blog in the future. If there are any concerns, before getting themselves into a jam with the FAA, pilots should have a discussion with their AME or aeromedical consultant.

In summary, a pilot’s foremost responsibility medically is to assess their fitness to fly. When ill, therefore, a pilot must determine if they are, in fact, too sick to fly. When recovering, the next decisions involve when that pilot might be able to safely return to work. If the pilot is almost fully recovered but perhaps has a few obligatory days remaining on an antibiotic prescription, then usually it is ethical to return to work (again, a discussion with an aeromedical advisor might be prudent before doing so).

There are responsibilities and restrictions when using symptomatic OTC medications during illnesses (or for other general medical conditions). While the requisite information is not always easy to access, it is the pilot’s responsibility to do so. 

A pilot not only needs to feel symptomatically fit to fly, but they must also meet FAA expectations as referenced in FAR 61.53 and as per FAA protocols published specifically to address medical conditions and the use of medications.

The opinions expressed in this column are those of the author and not necessarily endorsed by AIN Media Group.