Many people with diabetes in the U.S. will seek or currently hold a license to drive. For many, a driver’s license is essential for everyday life. Considerable discussion has focused on whether, and the extent to which, diabetes may be a relevant factor in determining driver ability and eligibility for a license. This statement addresses such issues in relation to current scientific and medical evidence. A diagnosis of diabetes on its own is not sufficient to make judgments about an individual driver’s ability or safety. This statement provides an overview of existing licensing rules for people with diabetes in the U.S., addresses the factors that affect driving ability, identifies general guidelines for assessing driver fitness and determining appropriately tailored licensing restrictions, and provides practical guidance for health care professionals regarding clinical interventions and education for people with diabetes.
Introduction
Of the nearly 30 million people in the U.S. diagnosed with diabetes (1), many will seek or currently hold a license to drive. For these individuals, possessing a license is critical for employment; managing family responsibilities; accessing both public and private amenities, services, and institutions; socializing; receiving education; and fulfilling numerous other daily activities. In various communities and regions across the U.S., motor vehicles represent the sole, or most practical and economical, mode of transportation available.
How diabetes can, or should, be considered when assessing driving capabilities and the criteria for obtaining a license remains a matter of debate. This statement addresses such issues in relation to current scientific and medical evidence.
Historically, some entities with a particular interest in road safety, such as motor vehicle divisions and employers, associate diabetes with unsafe driving when, in fact, most drivers with diabetes safely operate motor vehicles without creating any meaningful risk of injury to themselves or others (2,3).
When concerns arise regarding the suitability of a person with diabetes to drive, it is essential to conduct an individualized evaluation. This assessment should focus crucially on 1) hypoglycemia that impairs the ability to drive, 2) neuropathy that reduces the capacity to feel or operate foot pedals, and 3) retinopathy or related vision issues that may affect the ability to safely operate a motor vehicle. Having a diabetes diagnosis is, by itself, inadequate for determining a person’s driving capabilities or safety.
This statement provides an overview of existing licensing rules for people with diabetes, addresses the factors that affect driving ability for this population, identifies general guidelines for assessing driver fitness and determining appropriate licensing restrictions, and provides key points and principles for health care professionals to consider regarding clinical interventions and education for people with diabetes. This is an update of the 2013 American Diabetes Association (ADA) diabetes and driving statement (4). Although some similarities exist between the documents, the present work includes critical information such as updates in federal regulations, diabetes technology, and new studies. This statement applies exclusively to on-road motor vehicles.
Licensing Requirements
People with diabetes are currently subject to a variety of licensing requirements and restrictions. These licensing decisions involve different levels and types of review depending on the type of license. Some state and local jurisdictions impose no special requirements for people with diabetes. Other jurisdictions question drivers with diabetes about their condition, including their management plan and whether they have experienced any diabetes-related medical issues that would affect their ability to safely operate a motor vehicle. Answers to these questions may result in restrictions being placed on a person’s license, including restrictions on the type of vehicle they may operate and/or where they may operate that vehicle (5).
Commercial motor vehicle and licensing regulations, including those limiting the transportation of passengers or hazardous materials, vary and can be particularly burdensome for individuals with diabetes, especially for those who require insulin therapy (6).
Aside from commercial interstate driving, which adheres to established federal regulations (7), the rules for both private and commercial driving are set by individual states. Regulations differ from state to state because each state adopts its own method to assess medical fitness to drive and its own process for issuing licenses. The criteria for identifying diabetes, the process for medical evaluations, and the imposition of restrictions on people with diabetes to receive state-issued licenses thus vary by state. Interested parties should contact the local motor vehicle administration for specific guidance on regulations in a particular state.
Approximately half of the states require drivers to disclose directly if they have diabetes or mandate self-identification of the condition (8–10). Other states inquire if drivers have any medical conditions that could lead to altered perception or loss of consciousness while driving (11,12). In most states, an affirmative response to either question initiates an investigation into the prospective driver’s health status.
Types of Medical Evaluations of People With Diabetes Seeking a Driver’s License
In most states, drivers whose medical conditions can lead to significantly impaired consciousness are evaluated for their fitness to drive. For people with diabetes, such an issue may exist when a person has experienced significant hypoglycemia (13,14) behind the wheel, even if this did not result in a motor vehicle accident. Other states evaluate all people with diabetes, even if hypoglycemia has not occurred while driving. A fitness evaluation may also occur when a person has experienced severe hypoglycemia when not driving and a clinician reports the episode to the licensing authority. Such reporting by clinicians is mandatory in some states. In most other states, clinicians are given discretion to determine when such reports are necessary. Some states specify that clinicians may voluntarily report people who pose an imminent threat to public safety because they are driving against medical advice. The American College of Emergency Physicians (ACEP) recommends that reporting of potentially impaired drivers “should be individualized to the patient’s clinical condition and the objective risk posed to the patient and public by continued driving” (15). Importantly, the ACEP “opposes mandatory reporting of entire classes of patients or diagnoses . . . unless compelling evidence exists for a public health benefit for such reporting” (15). This statement agrees with this recommendation.
In some jurisdictions, licensing authorities will refer a driver for a medical evaluation if they learn that a driver experienced an episode of hypoglycemia that potentially affected the ability to drive. In some cases, driving privileges can be suspended temporarily. A suspension period can vary but typically lasts from 3 to 6 months.
Medical evaluation processes for commercial driver’s licenses generally occur at set intervals. The Federal Motor Carrier Safety Administration (FMCSA) implemented important regulatory changes in 2018 applicable to interstate truck drivers with insulin-treated diabetes (16). For this group, certification is required every 12 months (17). The FMCSA has no diabetes-specific restrictions for individuals who manage their disease without insulin therapy (16).
The FMCSA approval process includes a two-step certification. First, the treating clinician completes an evaluation and FMCSA assessment form, which must confirm a stable insulin plan and maintenance of adequate glucose management. Second, a certified medical examiner reviews the information provided by the health care professional and determines whether the individual meets FMCSA’s physical qualification standards for driving a commercial motor vehicle in interstate commerce. Consistent with the ADA’s recommendations, the FMCSA approval process does not use an HbA1c cutoff (13).
Understanding Diabetes-Related Risk Among Drivers
Operating a motorized vehicle carries inherent responsibilities and risks. While incidents related to diabetes do happen and deserve attention, it is crucial to note that they are relatively rare. The main medical concerns associated with diabetes that could affect driving safety are 1) hypoglycemia that impairs the ability to drive, 2) neuropathy that reduces the capacity to feel or operate foot pedals, and 3) retinopathy, cataracts, and/or glaucoma that impair the vision required for driving (18). However, the presence of these conditions in some individuals with diabetes does not justify imposing blanket restrictions on the driving privileges of everyone with diabetes.
Weighing Diabetes-Related Risks Among Drivers
Numerous medical conditions can affect driving safety, including unstable coronary heart disease, obstructive sleep apnea, narcolepsy, seizure disorders, Parkinson disease, attention deficit/hyperactivity disorder, and disorders related to alcohol and substance use (19). Similarly, individuals with diabetes, especially those experiencing significant vision and neurological complications and those experiencing episodes of severe hypoglycemia or occasionally severe hyperglycemia, may pose a higher risk when driving (20). In the absence of such high-risk factors, individuals with diabetes ought to have the opportunity to obtain and maintain a driver’s license. Moreover, those identified with high-risk conditions should collaborate with their health care team to adopt strategies that mitigate their driving risks.
The overall risk of drivers with diabetes having a motor vehicle accident is very similar to that of the general population. A meta-analysis of 15 studies suggested that the relative risk of having a motor vehicle accident for people with diabetes as a whole, that is, without differentiating those with a significant risk from those with little or no risk, compared with the general population is about 1.2–2% higher; however, this finding was not statistically significant (21). There is evidence that drivers with type 1 diabetes may have a slightly higher risk (22).
Severe Hypoglycemia and Driving
A particular diabetes-related concern is sudden incapacitation from hypoglycemia, or low glucose levels, with no warning symptoms. There are three levels of hypoglycemia (Table 1). Several international bodies have adopted the definition of hypoglycemia proposed by the International Hypoglycaemia Study Group (23), for which there is international consensus and validation in several clinical trials (14).
Levels of hypoglycemia
| . | Glycemic criteria and description . |
|---|---|
| Level 1 | Glucose <70 mg/dL (<3.9 mmol/L) and ≥54 mg/dL (≥3.0 mmol/L); hypoglycemia alert level |
| Level 2 | Glucose <54 mg/dL (<3.0 mmol/L); significant hypoglycemia |
| Level 3 | A severe event characterized by altered cognitive impairment and requiring assistance for treatment of hypoglycemia, irrespective of glucose level |
| . | Glycemic criteria and description . |
|---|---|
| Level 1 | Glucose <70 mg/dL (<3.9 mmol/L) and ≥54 mg/dL (≥3.0 mmol/L); hypoglycemia alert level |
| Level 2 | Glucose <54 mg/dL (<3.0 mmol/L); significant hypoglycemia |
| Level 3 | A severe event characterized by altered cognitive impairment and requiring assistance for treatment of hypoglycemia, irrespective of glucose level |
Level 2 and level 3 hypoglycemia (significant and severe, respectively) carry a substantial risk to driving safety. Cognitive functions necessary for safe driving (such as attention, information processing speed, reaction times, and hand-eye coordination) are impaired during episodes of level 2 and level 3 hypoglycemia (24,25). Changes in visual information processing can occur during hypoglycemia that can negatively affect driving performance (26).
The yearly occurrence of severe hypoglycemia among individuals with type 1 diabetes ranges between 30% and 40%. However, this incidence is unevenly distributed, with a small number of individuals experiencing multiple episodes, while many never encounter any severe events. Furthermore, various factors, including age and the length of time since diabetes diagnosis, contribute to the increased incidence of hypoglycemia. Adults with type 2 diabetes requiring insulin treatment encounter hypoglycemic episodes less frequently than adults with type 1 diabetes. However, the occurrence of severe hypoglycemic events tends to increase progressively with extended duration of insulin therapy (27).
The overall incidence of severe (level 3) hypoglycemia is considered to be low (28). Although significant (level 2) hypoglycemia does not require the assistance of another individual, it is associated with varying degrees of cognitive impairment that may adversely affect driving performance (29). Multiple studies describe the effect of level 2 hypoglycemia on driving, demonstrating that driving performance (25,30) and judgment (31,32) are impaired, as is the ability to decide whether to drive or self-treat (33,34) under such metabolic conditions (25,31–34).
Given the risks of severe hypoglycemia, individuals with diabetes requiring insulin often face stricter driving regulations and restrictions. However, when accounting for the type of diabetes, insulin therapy itself has not been linked to a higher risk of driving incidents (35). Instead, a significant risk factor for driving collisions among those with diabetes seems to be a recent history of severe hypoglycemia independent of diabetes type or treatment method (29,36,37).
Individuals with type 2 diabetes who are prescribed medications that stimulate insulin secretion, such as sulfonylureas, could face an increased risk of hypoglycemia episodes significant enough to affect driving safety (38). For these individuals, education by health care professionals with expertise in diabetes is particularly crucial.
Continuous glucose monitoring (CGM) may help people detect a trend toward hypoglycemia before glucose levels fall to a level that will affect safe driving (39–41). CGM effectively reduces the incidence of severe hypoglycemia (42,43). Using a collaborative person-centered approach, these systems should be considered and their benefits discussed with all individuals with diabetes who are at heightened risk of hypoglycemia. However, the effect of CGMs and CGM alarms on driver cognitive workload, distractedness, and actual driving collisions and near misses is unknown, and more research is needed in this area. Real-time CGM, as opposed to intermittently scanned CGM, has the added benefit of predictive low-glucose alerts and can further reduce rates of clinically significant and severe hypoglycemia (44). Importantly, drivers who use CGM should be encouraged to maintain access to capillary blood glucose monitoring if symptoms do not match the CGM reading, to measure recovery from hypoglycemia, and in the event of technology failure.
Other Diabetes-Related Conditions and Their Effects on Driving Ability
Certain long-term medical complications related to diabetes can also negatively affect driving ability. Unlike hypoglycemia, which is infrequent, these conditions are chronic, potentially affecting driving performance continually. Lower-limb peripheral neuropathy and amputation may reduce a driver’s ability to feel and operate foot pedals and can negatively affect safety. In some cases, adaptation of the vehicle so that the driver can use hand-operated controls may circumvent this issue. Vision loss from diabetes, caused by retinopathy, glaucoma, or cataract formation, also requires assessment in the context of driver safety, as is the case with other causes and forms of vision impairment.
Differentiating Diabetes-Related Risks Based on Individual Assessments
Given the diverse risk profiles for severe hypoglycemia and long-term medical complications among individuals with diabetes, conducting individualized assessments is essential to identify any diabetes-related driving risk factors. A one-size-fits-all approach is not suitable in this context.
Studies have found that previous instances of severe hypoglycemia while driving, hypoglycemia-related driving mishaps, or hypoglycemia-related collisions were associated with a higher risk of driving mishaps in the future (29). Thus, a recent pattern of severe hypoglycemic events and driving mishaps can indicate an increased risk of future incidents for drivers who manage their diabetes with insulin. In these scenarios, implementing further education, screening, and management strategies could prove beneficial. It is important to note that these situations are relevant to a relatively small percentage of individuals with diabetes.
Studies comparing drivers with type 1 diabetes who had no hypoglycemia-related driving mishaps in the past year with those who had two or more mishaps in the past year found that the latter group 1) drove significantly worse during mild hypoglycemia but drove equally well when blood glucose was normal, 2) had a lower epinephrine response while driving during hypoglycemia, 3) were more insulin sensitive, and 4) demonstrated greater difficulties with working memory and information processing speed (29,45,46).
Many drivers with diabetes fear that disclosing hypoglycemic episodes could endanger their ability to obtain or renew their driving license. This concern was highlighted in a Danish study that showed a significant decrease in the self-reported occurrence of severe hypoglycemia among adults with type 1 diabetes after the introduction of European Union legislation whereby drivers could lose their license if they experienced recurrent episodes within a year (47). A study from the Czech Republic also showed that drivers with insulin-treated diabetes concealed previous episodes of severe hypoglycemia (48). Thus, it is important to combine appropriate and individualized assessments of diabetes-related driving risk factors with constructive interventions, including diabetes education.
Education to Address Diabetes-Related Driving Risks
Drivers with diabetes should receive guidance on safe driving practices, including the importance of checking their glucose level and treating a low glucose level before driving (49). Surveys have found that a significant number of drivers with type 1 diabetes have driven a motor vehicle while experiencing some level of hypoglycemia (50,51), and 25% incorrectly believed it was safe to drive when blood glucose was below 70 mg/dL (3.9 mmol/L) (51).
Three studies have demonstrated that a procedure called blood glucose awareness training reduces the occurrence of collisions and moving vehicle violations while improving judgment about whether to drive while hypoglycemic (52,53). Blood glucose awareness training is an 8-week psychoeducational training program designed to assist individuals with type 1 diabetes to better anticipate, prevent, recognize, and treat extreme blood glucose events. Health care professionals can also provide direct educational interventions to their patients to improve awareness and develop strategies regarding preventing and managing hypoglycemia, including in the context of driving safety, through diabetes self-management education and support (DSMES) and diabetes self-management training education programs.
Key Points
Identifying and Addressing Driver Risk for Diabetes-Related Driving Mishaps
Given the wide variability of driving risk among individuals with diabetes, identification and evaluation methods must be tailored, personalized, and grounded not merely in a diabetes diagnosis but on tangible evidence of actual risk. Laws should not mandate universal medical evaluations for all individuals with diabetes (or those specifically requiring insulin) as a precondition for licensing. Such broad measures improperly categorize all people with diabetes as a singular high-risk group without discerning which drivers genuinely pose a heightened risk due to challenges in managing hypoglycemia or due to serious neurological or vision-related complications. Moreover, registering and assessing millions of drivers with diabetes would place a significant administrative and financial strain on licensing authorities.
In individual cases where there are indicators of an elevated driving risk, a concise questionnaire developed and used by the licensing agency could serve as an effective tool to identify drivers who can benefit from further evaluation by the treating clinician or another diabetes specialist. That clinician can review recent diabetes treatment history and provide to the licensing agency a recommendation about whether the driver’s specific diabetes management or complications impair their ability to safely operate a motor vehicle. The questionnaire may ask whether the driver has, within the past 12 months, lost consciousness due to hypoglycemia, experienced hypoglycemia that required intervention from another person to treat, experienced hypoglycemia that interfered with driving, or experienced hypoglycemia that developed without warning. It may also inquire about loss of visual acuity or peripheral vision and loss of sensation in the feet. Any positive answer should initiate an evaluation to determine whether restrictions on the license or mechanical modifications to the vehicle (e.g., hand controls for people with insensate feet) are necessary to ensure public safety. The evaluation should be performed by the treating clinician or another health care professional who is knowledgeable about diabetes and driving. Using a driver's HbA1c levels to assess risk is not appropriate. HbA1c provides an average of blood glucose levels over a prolonged period and is not a predictor of risk.
When evaluating a driver with a history of severe hypoglycemia, impaired hypoglycemia awareness, or a history of a diabetes-related motor vehicle accident(s), it is necessary to investigate the reasons for the hypoglycemia and to determine whether it is a function of the driver’s treatment plan, the driver’s lifestyle, the driver’s psychological reaction to the management of their diabetes, or other factors.
Licensing Decisions Following Evaluation
Drivers with diabetes should have a license suspended or restricted only if doing so is the sole practical way to address an established safety risk. Licensing decisions should reflect deference to the professional judgment of the evaluating clinician with regard to diabetes while also considering the licensing agency’s need to keep the roads and the public safe.
A history of hypoglycemia does not mean an individual is not, or cannot be, a safe driver. When there is evidence of a history of severe hypoglycemia, an appropriate evaluation should be conducted to determine the cause of the low glucose, the circumstances of the episode, whether it was an isolated incident, whether adjustment to the diabetes management plan can mitigate the risk, and the likelihood of such an episode recurring. It is important that licensing decisions take into consideration contributory factors that may mitigate a potential risk and that licensing agencies do not adopt a “one strike” approach to licensing restrictions for people with diabetes. The mere fact that a person’s diabetes has come to the attention of the licensing agency should not by itself predetermine the licensing decision.
Where the circumstances of severe and/or recurring episodes of severe hypoglycemia that suggest a high risk to driver safety cannot be effectively addressed, appropriate licensing restrictions may be considered in the interest of public road safety.
States with licensing rules leading to a suspension of a driver’s license following a hypoglycemic episode should allow for an exception where the hypoglycemia can be explained and/or addressed by the treating clinician and the person with diabetes such that it is not likely to recur. For example, suspension or denial of a license may not be warranted in a case where past hypoglycemia episodes were the result of a change in medication or during or concurrent with illness or pregnancy, or where a health care professional confirms that the person with diabetes has addressed any identified safety risk related to hypoglycemia (including through patient education or diabetes management strategies such as routine use of CGM technology) (Table 2).
Considerations for health care professionals in assessing an individual’s diabetes-related driving risk
| Diabetes-related driving risk factors . | Health care professional considerations for all risk factors . |
|---|---|
| • Ability to detect and appropriately treat hypoglycemia • Presence of impaired hypoglycemia awareness • Recent and/or recurrent severe hypoglycemia • Previous hypoglycemia while driving • Hypoglycemia-related driving mishaps • Loss of or diminished vision or visual acuity • Loss of sensation in the feet | • Underlying circumstances • Likelihood of persistence and/or recurrence • Whether and how high-risk factors can be addressed through patient education, modifications to diabetes management plan, or other interventions |
| Diabetes-related driving risk factors . | Health care professional considerations for all risk factors . |
|---|---|
| • Ability to detect and appropriately treat hypoglycemia • Presence of impaired hypoglycemia awareness • Recent and/or recurrent severe hypoglycemia • Previous hypoglycemia while driving • Hypoglycemia-related driving mishaps • Loss of or diminished vision or visual acuity • Loss of sensation in the feet | • Underlying circumstances • Likelihood of persistence and/or recurrence • Whether and how high-risk factors can be addressed through patient education, modifications to diabetes management plan, or other interventions |
Drivers with a license suspended because of factors related to diabetes should be eligible to have their driver’s license reinstated following a sufficient period that is no longer than necessary (generally no more than 6 months) and upon advice from the treating clinician that the driver has made appropriate adjustments to address the risk that warranted license suspension. Following reinstatement of driving privileges, periodic follow-up evaluation may be warranted to ensure the person can continue to safely operate a motor vehicle. People who experience progressive impairment of their awareness of hypoglycemia should consult a health care professional to determine whether it is safe to continue driving with proper measures to avoid disruptive hypoglycemia (Table 2).
Clinician Reporting of Diabetes-Related Driving Risks
There is no evidence that broad mandatory clinician reporting requirements regarding diabetes-related driving risk factors reduces the accident rate or improves public safety (54). Clinician reporting laws have the unintended consequence of discouraging people with diabetes from discussing their condition honestly with a clinician when there is a problem that needs correction because they fear losing their license (47,48). People who are not candid with their clinicians are likely to receive inferior treatment and therefore may experience complications that worsen health outcomes and even increase driving risk.
Clinicians should be permitted to exercise professional judgment in deciding whether and when to report a person with diabetes to the licensing agency for review of driving privileges. States that allow clinicians to make such reports should focus on whether the driver’s mental or physical condition impairs the person’s ability to exercise safe control over a motor vehicle. Reports that are based solely on a diagnosis of diabetes, that are tied to a characterization that the driver has a condition associated with lapses of consciousness, or that are based solely on an elevated HbA1c value are too broad and do not adequately measure individual risk (13). Clinicians should use professional and individualized judgment about whether a person poses a safety risk while driving.
Education and Clinical Interventions for People With Diabetes
Health care professionals play an important role in educating people with diabetes about driving-related risk reduction and how to address it. Health care professionals should provide education about driving with diabetes, including potential risk management strategies. This education could be incorporated into DSMES and diabetes self-management training educational programs. Diabetes management plans should include instruction on avoiding and immediately responding to hypoglycemia as well as when it is, and is not, safe for someone with diabetes to drive (Table 2).
For example, while the risks of driving under the influence of alcohol are well known, people with diabetes are often unaware of the delayed hypoglycemic effects of alcohol consumption or that alcohol exacerbates the cognitive impairment associated with hypoglycemia (55). Given that hypoglycemia can mimic signs of intoxication and both conditions elevate the risk of motor vehicle accidents, it is important for drivers with diabetes to be advised to monitor their glucose levels more frequently for several hours following any consumption of alcohol. Additionally, when a person reports experiencing diabetes-related complications that could affect driving, such as impaired hypoglycemia awareness, neuropathy in the lower extremities, or vision impairment, it is crucial for the clinician to address with the person how these issues might influence their ability to drive safely (56). Adaptive equipment such as hand controls may be available for individuals with significant lower-extremity neuropathy (57). The choice of treatment strategies for diabetic retinopathy should take into consideration functional impact on vision, including driving ability (58,59) (Table 2).
Health care professionals who treat people with diabetes play an important role in education about the risk of driving when glucose is low. Studies have found that most people with insulin-requiring diabetes had not had a discussion regarding diabetes and driving with their health care team (50,60). Other studies have demonstrated low rates of blood glucose testing before driving and during long journeys, waiting to begin driving until blood glucose is at a safe level, or pulling over and treating hypoglycemia when it is detected (49,61–63). Drivers with diabetes report a lack of health care guidance as a key reason for why they do not participate in these safety practices (63).
Clinical interventions in response to hypoglycemia may include strategies for the frequency and timing of glucose monitoring, use of CGM, changes in medication dosage, and adjusting glycemic goals for someone with a history of severe hypoglycemia. Advances in automated closed-loop insulin delivery systems, in which an insulin pump interacts directly with a CGM sensor and adjusts insulin delivery automatically based upon glucose values and trends, may be useful for people at higher risk of hypoglycemia.
Key Points for Health Care Professionals, Licensing Agencies, and Drivers
1. Health care professionals should:
Discuss driving safely with diabetes as part of standard DSMES curricula
Educate people with diabetes on the physiological changes associated with hypoglycemia, loss of sensation in the feet, and impaired vision or cognitive function that can affect driving
Discuss driving-related risks regularly with people with diabetes, not just at initial diagnosis or after an incident
Evaluate people with diabetes for driving risk when circumstances warrant
Recommend safe driving practices (see below)
2. Licensing agencies should:
Understand that diabetes per se is not associated with driving mishaps
Use a concise questionnaire for further evaluation of high-risk drivers with diabetes (not all drivers with diabetes) based on individualized factors
Defer to treating clinician’s individualized evaluation and reasonable, individualized recommendations based on their evaluation
Suspend or revoke the driver's license of a person with diabetes only if doing so is the sole practical way to address a clearly identified safety risk
Avoid license suspensions where severe hypoglycemia incidents can be explained and addressed by the treating clinician and the individual such that it is not likely to recur
Maintain medical review boards whose membership includes a diabetes specialist to help inform agency policy
3. Drivers should:
Always carry a blood glucose meter, a quick-acting source of glucose, and snacks with complex carbohydrate, fat, and protein in their vehicle
Measure blood glucose before and periodically during longer drives
Raise blood glucose if the level is <90 mg/dL before driving to prevent mild symptoms of hypoglycemia
Safely stop the vehicle as soon as symptoms of low blood glucose are experienced and measure and treat the blood glucose level as needed
Be ready to self-treat low blood glucose with fast-acting glucose, even in mild hypoglycemia ranges
Not resume driving until blood glucose and cognition have recovered
Work with a diabetes health care professional to consider and implement new diabetes management technologies (CGM, closed-loop insulin delivery system, etc.) where clinically indicated
Use in-vehicle hand controls if experiencing loss of feeling in the foot
Main Principles
The main principles articulated in the statement are reiterated here.
1. The diagnosis of diabetes alone is not sufficient to justify limiting a person’s ability to operate a motor vehicle. Risk assessment of a driver should be individualized, regardless of health condition. A diagnosis of diabetes or out-of-range HbA1c level, without further individualized assessment, is an insufficient basis to limit a person’s ability to drive.
2. State laws and licensing forms can include a concise questionnaire to determine risk; however, they should not lead to blanket bans on people seeking a license absent further individualized assessment.
3. Federal law permits people with diabetes, including those who use insulin, to obtain commercial driver’s licenses.
4. Licensing decisions following evaluation should be individualized. Because preventing and managing risk of hypoglycemia is an individualized process, licensing decisions involving consideration of a person’s ability to drive should be individualized. Licensing agencies should not have policies that include blanket revocation or limitation of driving licenses without assessment of individual risk and interventions.
5. Mandatory clinician reporting should not be required by states, as it does not reduce accidents or increase safety. If health care professionals are given the option to report, licensing agencies should defer to the professional judgement of clinicians as to when to report.
6. Health care professionals should educate people with diabetes on the risks associated with hypoglycemia, alcohol intake, impaired vision, neuropathy, and retinopathy when it comes to driving. These educational interventions should happen regularly.
7. Health care professionals should identify and recommend actions to enhance driving safety. Interventions will necessarily be individualized and can include CGM use, checking blood glucose before driving, checking blood glucose intermittently during long drives, etc.
8. Drivers with diabetes should work constructively with their health care professionals to implement strategies to stay safe while driving.
Conclusions
Operating a motor vehicle carries inherent risk. Medical conditions such as diabetes can increase that risk in ways that warrant intervention by health care providers and, in some cases, preventative action by licensing agencies. This statement has reviewed the published evidence on identification and mitigation of diabetes-related driver safety risks. It is important that laws and regulations on licensing reflect the reality that, in most cases, diabetes-related risks can be mitigated and addressed through appropriate individual evaluation, patient education, and other interventions.
This ADA Statement was reviewed and approved by the American Diabetes Association Professional Practice Committee in May 2024.
This article is featured in a podcast available at diabetesjournals.org/care/pages/diabetes_care_on_air.
Article Information
Duality of Interest. A.F. is a consultant for ADA’s legal advocacy program. The law firm of J.G. provides legal services to ADA regarding estate litigation. B.F. is an advisory board member for Zucara Therapeutics and the U.K. Civil Aviation Authority Diabetes Panel. No other potential conflicts of interest relevant to this article were reported.
Handling Editors. The journal editor responsible for overseeing the review of the manuscript was Steven E. Kahn.
