1. Sleep and Safety Emphasis on DOT guidelines Christopher M Nolte, MD, MS Comprehensive Sleep Wellness Center Knoxville, TN

2. Upcoming Change May 21, 2014 Federal Motor Carrier Safety Administration (FMCSA) requirement all DOT exams must be performed by providers certified and listed on National Registry of Certified Medical Examiners http://nrcme.fmcsa.dot.gov/documents/National_Registry_FAQ.pdf

3. FMCSA ‘Best Practices’ Medical Examiner should: – ask the driver about sleep disorders – ask about such symptoms as daytime sleepiness, loud snoring, or pauses in breathing while asleep http://nrcme.fmcsa.dot.gov/mehandbook/respiratory4_dis_secondary_sleep_ep.aspx

4. FMCSA ‘Best Practices’ If the patient uses CPAP or oral appliance Waiting period Minimum — 1 month after starting CPAP No mention of oral appliance Recommend to certify if: Continuous successful nonsurgical therapy for 1 month Resolution of apneas confirmed by repeated sleep study during treatment Multiple sleep latency testing values within the normal range Compliance with therapy http://nrcme.fmcsa.dot.gov/mehandbook/respiratory4_dis_secondary_sleep _ep.aspx

5. FMCSA ‘Best Practices’ Patients undergoing sleep apnea surgery Waiting period Minimum — 3 months symptom free after surgery Recommend to certify if: Resolution of symptoms following completion of post-surgical waiting period. http://nrcme.fmcsa.dot.gov/mehandbook/respiratory4_dis_secondary_sleep _ep.aspx

6. FMCSA ‘Best Practices’ The driver who is being treated for sleep apnea should remain symptom free and agree to: Continue uninterrupted therapy Undergo yearly objective testing (e.g., multiple sleep latency test or maintenance of wakefulness test) http://nrcme.fmcsa.dot.gov/mehandbook/respiratory4_dis_secondary_slee p_ep.aspx

7. DOT Medication Policy modafinil/armodafinil (Provigil, Nuvigil) driver is disqualified until completion of: Waiting period Minimum – 6 weeks of close monitoring Treating physician and the Medical Examiner should agree that the medication is effective in preventing daytime somnolence and document that no untoward side effects are present. www.gpo.gov/fdsys/pkg/CFR-2011-title21-vol9/pdf/CFR-2011-title21-vol9-sec1308-11.pdf

8. DOT Medication Policy amphetamine, narcotics, or sodium oxybate (Xyrem) The driver is medically unqualified unless: the prescribing doctor can write that the driver is safe to be a commercial driver while taking the medication. www.gpo.gov/fdsys/pkg/CFR-2011-title21-vol9/pdf/CFR-2011-title21-vol9-sec1308-11.pdf

9. Narcolepsy and DOT “Narcolepsy and sleep apnea account for about 70% of EDS. “ The examiner should consider general certification criteria at the initial and follow-up examinations: Severity and frequency of EDS Presence or absence of warning of attacks Possibility of sleep during driving Degree of symptomatic relief with treatment Compliance with treatment http://nrcme.fmcsa.dot.gov/mehandbook/respiratory4_dis_secondary_sleep_ep.aspx

10. Other transportation modes Rail - http://sleepapnea.org/assets/files/2011%20Conference/Wednesday/BJ%20Arsene au.pdf Air - http://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/ guide/special_iss/all_classes/sleep_apnea/ Sea – http://www.uscg.mil/hq/cg5/nvic/pdf/2008/NVIC%2004- 08%20CH%201%20with%20Enclosures%2020130607.pdf