Endocrine Abstracts

JOINT906

Case History: We present a case of a 46-year-old female, who has past medical history of Graves disease, treated with radioiodine in 2020 and rendered hypothyroid, on a stable dose of levothyroxine 100 mg daily. She works as a commercial airline pilot holding Class 1 licence. Four years later, she presented with lethargy, dizziness and reduced exercise tolerance. Mentstrual periods were regular. She had postural hypotension and investigations revealed low 9 am cortisol of 67 nmol/l, elevated ACTH of 124 ng/l (normal <50), Renin level of 88 mU/l (normal 5.4-30) and positive adrenal antibodies. Synacthen test confirmed adrenal insufficiency. Remaining of pituitary profile was normal. She was diagnosed with primary adrenal insufficiency (Addisons disease) and her symptoms resolved after initiation of hydrocortisone and fludrocortisone. She is aware of sick day rules and has been issued an emergency steroid pack. She is deemed unfit to fly by the Civil Aviation Authority (CAA) and is currently awaiting an appointment with Occupational health and the Aviation Medical Examiner to discuss next steps.

Discussion: Both the UK Civil Aviation Authority and the European Aviation Safety Agency regard commercial pilots with Addisons disease by default as unfit to fly. A licence may be issued, valid only in multipilot operations, and provided pilots carry with them the necessary cortisone replacement and are trained to use it. The Federal Aviation Administration does not set out any specific rules and decides on a case-by-case scenario. It is also worth noting the challenges pilots with Addisons face. They need to carry their emergency hydrocortisone injection kit and an adequate supply of their medications during their working days, in case of flight delays or cancellations. Furthermore, they may need additional doses of hydrocortisone replacement when travelling across time zones. Finally, pilots will have less access to urgent medical treatment should they develop an adrenal crisis, and their co-workers will need appropriate education. For all those reasons, a careful occupational health assessment needs to be undertaken. This case highlights the impact a diagnosis of adrenal insufficiency can have on various aspects of a person’s life. Its professional implications are often less well recognised and addressed, especially when compared to other endocrinology disorders such as diabetes.