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insulin preparations have resulted in marked reductions in hypoglycemia incidence and prevalence even among this population.

In addition to the improvements in insulin, newer and far more rapid and sophisticated blood glucose monitoring systems – unavailable at the time of DCCT and UKPDS – facilitate successful patient monitoring of glucose status. New glucose monitoring systems can easily fit in a pocket, utilize miniscule quantities of blood, and provide accurate results in as short as five seconds. At the time of DCCT, blood glucose monitoring required volumes of blood more than ten times greater, took two minutes to obtain a value, and required either visual interpretation of estimated glucose or use of a bulky meter.

Newer developments in blood glucose monitoring include the approval and availability of two separate continuous glucose monitoring devices. The Minimed CGMS provides continuous glucose measurements over a three-day period of time. The Cygnus Glucowatch is worn on the wrist like a watch and provides continuous monitoring for a twelve-hour period. With these systems no interruption of daily activities is required for glucose determinations. These systems also include intrinsic alarms for hypoglycemia but, even more interestingly, will alarm for rapidly falling glucose even before hypoglycemia is reached.

Insulin delivery systems have also improved. During the last five years, technology has advanced to the point where insulin can be delivered without syringes and refrigerated insulin, as previously required. Insulin is now widely available in pens that fit in a shirt pocket, so that the patient can simply set the dosage and push the button to inject the insulin. Not only is this system more convenient, it virtually eliminates the errors that were common with the old system where the patient had to use a syringe to carefully draw out the correct dosage from the refrigerated vial. In addition, many patients are turning to pump therapy as an alternative to traditional injections of insulin. With insulin pump therapy, a

device the size of a beeper continuously delivers a small amount of insulin via a opening just under the skin of the abdomen. Pump therapy is personalized individual’s own needs and adjusts for dietary changes.

small to an

In addition, patient education has improved allowing patients to better understand the warning signs of hypoglycemia and how to take action prior to any impairment. 11 Such training is an integral part of the proposed protocol.

Thus, data taking into account the important medical advances since the time when data was gathered for the DCCT and UKPDS demonstrate the fallacy of using the initial results from these studies to justify continuing a blanket prohibition of commercial drivers who use insulin. Moreover, the subjects of these studies were drawn from the general population of people with diabetes; they did not have to pass the strict assessment, driving, and medical monitoring requirements that would be imposed on commercial drivers under the proposed program.

11

Clement S: Diabetes Self-Management Education. Diabetes Care 18:1204-13 (1995).

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