With the rising use of Glucagon-like Peptide-1 (GLP-1) receptor agonists in patients with Type 2 Diabetes Mellitus (T2DM) and obesity, certified medical examiners (CMEs) are increasingly likely to encounter commercial motor vehicle (CMV) drivers prescribed these medications. This blog explores the therapeutic role of GLP-1s, their potential side effects, and the implications for driver safety and medical certification.

Clinical Role of GLP-1 Receptor Agonists

GLP-1s are antidiabetic agents used to:

• Improve glycemic control in T2DM as an adjunct to diet and exercise.

• Support weight loss in patients with obesity, including those with obstructive sleep apnea (OSA).

• Reduce cardiovascular risk (e.g., myocardial infarction, stroke, cardiovascular death) in adults with T2DM and established cardiovascular disease.

• Slow the decline in estimated glomerular filtration rate (eGFR) in patients with T2DM and chronic kidney disease (CKD), potentially delaying progression to end-stage renal disease.

Common GLP-1 Agents

Zepbound, in particular, may benefit drivers with moderate-to-severe OSA and obesity, as weight loss can improve sleep apnea symptoms and metabolic rate.

Adverse Effects and Safety Concerns

GLP-1s are generally well tolerated, but potential side effects include:
• Gastrointestinal issues: nausea, vomiting, diarrhea, abdominal pain, dyspepsia
• Gallstones (cholelithiasis), sometimes requiring cholecystectomy
• Muscle wasting, weight loss, hair loss
• Post-marketing reports: acute pancreatitis, necrotizing pancreatitis, acute kidney injury, dizziness, and rare fatalities.
• Dehydration and Hypotension
• Severe hypoglycemia—especially when combined with other antidiabetic agents

Black Box Warning

GLP-1s carry a warning for potential thyroid C-cell tumors, including medullary thyroid carcinoma (MTC). They are contraindicated in individuals with a personal or family history of MTC or multiple endocrine neoplasia syndrome type 2. In January 2024, the FDA also reviewed reports of suicidal ideation and behavior associated with these agents.

Certified Medical Examiner (CME) Guidance

When evaluating a CMV driver prescribed GLP-1s, CMEs can consider the following:

• Obtain a thorough medical history: Confirm the diagnosis (T2DM, obesity, OSA), medication regimen, and any side effects that may impair safe driving.

• Conduct a comprehensive physical exam: Assess for comorbidities such as cardiovascular disease, retinopathy, renal disease, or neuropathy that may disqualify the driver.

• Request medical clearance: The treating provider should confirm the diagnosis, dosage, and safety of treatment, and understand the physical and mental demands of CMV operation.

• Use FMCSA Form MCSA-5895 (optional): This form can help document provider clearance for medications of concern.

• Educate the driver: Emphasize hydration to reduce the risk of acute kidney injury and monitor for rapid weight loss, which may cause hypoglycemia or hypotension.

• Review labs if needed: While not required, CMEs may request metabolic panels and HbA1c levels to assess stability and safety.

As the use of GLP-1 receptor agonists continues to expand, certified medical examiners must remain vigilant, informed, and compassionate in their evaluations. These medications offer powerful benefits for managing chronic conditions, but they also carry risks that can directly impact a driver’s ability to operate a CMV safely.

By combining thorough clinical assessment with thoughtful collaboration between examiners and treating providers, we can uphold both public safety and patient dignity assuring that every driver is evaluated with care, respect, and evidence-based insight.

References: https://emedicine.medscape.com/article/123702-overview

NRII Implementation Deadline

The Federal Motor Carrier Safety Administration (FMCSA) has set June 23, 2025, as the official compliance date for the National Registry Integration Initiative (NRII). However, states may implement NRII earlier if they are prepared. Once a state integrates NRII, medical certification information for Commercial Learner's Permit (CLP) applicants and Commercial Driver’s License (CDL) holders will be electronically transmitted from the National Registry to the State Driver Licensing Agency (SDLA). In such states, the paper Medical Examiner’s Certificate (MCSA-5876) may no longer serve as valid proof of medical certification.

Key Changes Effective June 23, 2025

Several important modifications will take place:

• FMCSA will electronically transmit medical examination results (qualified, unqualified, and voided) for CLP applicants and CDL holders to the SDLAs.
• FMCSA will transmit medical variance information (medical exemptions and Skill Performance Evaluation (SPE) certificates) electronically to the SDLAs.
• SDLAs will update CDL Information System (CDLIS) driver Motor Vehicle Records (MVR) with examination results and restrictions.
• Medical examiners will no longer issue paper certificates (MCSA-5876) to CLP applicants or CDL holders.
• CLP applicants and CDL holders will no longer need to submit paper certificates to their SDLAs.
• Motor carriers must verify medical certification electronically through the CDLIS driver MVR instead of using paper Medical Examiner’s Certificates.

Medical Variances

If a medical examiner determines that a driver requires a medical variance, such as an SPE Certificate or medical exemption, the driver’s examination results will not be transmitted to the SDLA until FMCSA issues the variance. Once obtained, the National Registry system will link the variance with the original examination results and transmit them to the SDLA. Despite electronic transmission, drivers must still carry proof of medical variances while operating.

Ensuring Your Medical Certification is Posted to Your Record

Since drivers do not have direct access to the National Registry or SDLA systems, errors in transmission may occur. If a driver receives a CDL downgrade letter despite having completed a physical qualification exam, their medical certification was not received by the SDLA. Follow these steps to resolve the issue:

1. Contact the medical examiner who conducted your exam and ask them to verify if an error message was received regarding your certification.
2. Contact your SDLA to confirm whether the corrected medical certification was posted.
3. If the issue persists, reach out to FMCSA’s National Registry Technical Support Helpdesk at This email address is being protected from spambots. You need JavaScript enabled to view it. or (617) 494-3003.
If stopped by law enforcement and informed that you are not medically certified, follow the same steps immediately to correct the issue.

Non-CDL Holders

If you do not hold a CDL, NRII does not apply to you. Medical examiners will continue to issue the paper Medical Examiner’s Certificate (MCSA-5876) as proof of medical certification, and you must carry it while operating a commercial motor vehicle. However, if you later obtain a CDL, the SDLA can retrieve your existing certification information from the National Registry and post it to your CDLIS driver MVR.

On November 18, 2024, FMCSA published the attached technical amendment final rule that amends 49 CFR 391.49(d)(3)(i)(B) and (d)(3)(ii)(C) to clarify the meaning and effect of the current requirement that individuals with upper limb loss or impairment must be capable of demonstrating precision prehension and power grasp prehension to be eligible for a skill performance evaluation (SPE) certificate issued by FMCSA. The amendments clarify that a functioning hand is necessary to demonstrate precision prehension and power grasp prehension and that a prosthesis is required if the applicant does not have a hand. The amendments also clarify when an applicant has upper limb impairment that a prosthesis or orthotic device is required if the applicant is not capable of demonstrating precision prehension and power grasp prehension with each hand separately without a prosthesis or orthotic device.

Specifically, paragraphs (B) (for limb loss) and (C) (for limb impairment) relating to the statements made by the physiatrists and orthopedic surgeons in the medical evaluation summary have been amended to read as follows:

(B) A statement by the examiner that the applicant is capable of demonstrating precision prehension (e.g., grasping and manipulating knobs and switches using the fingers/thumb) and power grasp prehension (e.g., grasping, holding, and maneuvering the steering wheel using a hand) with each hand separately. Prior to applying for an SPE certificate, an applicant with loss of a hand or arm must be fitted and proficient with a proper prosthesis that enables the applicant to demonstrate precision prehension and power grasp prehension with each hand separately. This requirement does not apply to an individual who was granted a waiver, absent a prosthetic device, prior to January 6, 1986, the effective date of the requirement.

(C) A statement by the examiner that the applicant is capable of demonstrating precision prehension (e.g., grasping and manipulating knobs and switches using the fingers/thumb) and power grasp prehension (e.g., grasping, holding, and maneuvering the steering wheel using a hand) with each hand separately. Prior to applying for an SPE certificate, an applicant with upper limb impairment must be fitted and proficient with a proper prosthesis or orthotic device, if the applicant is not capable of demonstrating precision prehension and power grasp prehension with each hand separately without a prosthesis or orthotic device. This requirement does not apply to an individual who was granted a waiver, absent an orthotic device, prior to January 6, 1986, the effective date of the requirement.

In addition to the attached technical amendment final rule, FMCSA has also attached information outlining prevalent issues present when MEs are documenting evaluation outcomes of limb loss and impairment under 49 CFR 391.41(b)(1) and (2) during the physical qualification examination. These errors require FMCSA to void the examinations and require the drivers to obtain a new examination. FMCSA requests that all MEs review this information closely to ensure that examinations are recorded in accordance with the Federal Motor Carrier Safety Regulations.

Alternative Physical Qualification Standards for the Loss or Impairment of Limbs

Skill Performance Evaluation (SPE) Certificate Issues

Certified medical examiners (MEs) should understand the rights and options of commercial motor vehicle (CMV) drivers for obtaining a Department of Transportation (DOT) physical examination after disqualification. This is crucial for fair treatment, health and safety, legal compliance, driver retention, and advocacy. It promotes health, fairness, and safety on our roads and workplaces. If a medical examiner deems a driver unqualified to operate a CMV should the ME examiner be concerned that the driver will obtain a medical certificate from another ME?

The answer is No! Here’s Why

If a certified medical examiner (ME) deems a commercial motor vehicle (CMV) driver unqualified to operate a CMV, there could be a risk that the driver might seek a medical certificate from another ME. This is why it is crucial for MEs to not only understand the rights and options of CMV drivers but also to uphold the standards and regulations set by the Department of Transportation (DOT).

If a certified Medical Examiner (ME) determines that a driver is not physically qualified according to 49 CFR 391.41(b) (physical qualifications standards for drivers), they must inform the driver of this determination and explain why they are not qualified. This information is reported to the Federal Motor Carrier Safety Administration (FMCSA).

MEs play a vital role in ensuring the health and safety of our roads and workplaces. They must remain vigilant and committed to their responsibility, ensuring that only those who meet the health requirements are certified. This includes being aware of the potential for “doctor shopping” by disqualified drivers and taking appropriate steps to prevent such practices.

Furthermore: The National Registry of Certified Medical Examiners (NRCME)

Since May 21, 2014, the FMCSA requires that all healthcare professionals performing qualification examinations on CMV drivers and issuing medical certificates be certified and listed on the NRCME.

Certified MEs upload their results to the national registry within one business day. The physical qualification exam results of CMV drivers are submitted to the FMCSA via the National Registry. Consequently, if two different MEs upload conflicting exam results for the same driver, it would raise a significant concern, or a “Red Flag.” This situation underscores the importance of consistent and accurate evaluations by MEs to ensure road safety and regulatory compliance.

Interstate CMV drivers (drivers operating across state lines) must obtain their physical qualification examination from an ME listed on the National Registry and must comply with the physical qualification standards (49 CFR 391.41) outlined by the FMCSA.

-Drivers need to obtain a Medical Examiner’s Certificate (Form MCSA-5876) before operating a CMV (initial examination) and prior to the expiration of their current certificate (recertification examination).

-If there is a change in their physical or mental health status, they must obtain an updated certificate.

-Drivers must provide a photo ID during the physical qualification examination and disclose their health history accurately.

The original paper Medical Examiner’s Certificate (Form MCSA-5876) serves as proof of medical certification.

CLP/CDL applicants and holders must provide form MCSA-5876 to their State Driver’s Licensing Agency (SDLA) before their current certificate expires.

Drivers Pursuing an Additional DOT Physical Examination or a Second Opinion

Just like any patient seeking a second medical opinion, CMV drivers have the right to seek another DOT exam from a different medical provider if deemed unqualified to operate a CMV.

Remember, drivers are required to disclose an accurate and complete health history on the Medical Examination Report Form, MCSA-5875, and in discussions with the certified ME during any physical qualification examination.

When a CMV driver disagrees with the certified medical examiner’s decision, they can obtain another DOT physical from a different certified medical examiner, however, transparency is crucial during this process. The driver should disclose all relevant information about their prior exam, including health history and any previous test results.

Resolution of Conflict

Question: Does the Federal Motor Carrier Safety Administration (FMCSA) provide official medical verdicts regarding the physical fitness of individual drivers?

Answer: No, the FMCSA does not typically issue such decisions. However, they may intervene to resolve discrepancies in medical evaluations upon request.

The FMCSA Resolution of Medical Conflict stipulates that if there is a disagreement between two Medical Examiners (MEs) regarding a driver’s medical certification, a provision is in place for drivers and motor carriers to request FMCSA’s intervention to resolve the conflicting medical evaluations. This is applicable when either party does not accept the decision of a medical specialist.

As per the requirements outlined in 49 CFR 391.47, the applicant, who can be either the driver or the motor carrier, must submit a report. This report should include the results of all medical tests and the opinion of an impartial medical specialist in the field where the medical conflict originated. The applicant has the option to submit this information via fax or email.

Website: https://www.fmcsa.dot.gov/contact-us

FMCSA uses the collected information, including medical data, to determine the driver’s qualification. Without this provision and its associated requirements for collecting driver medical information, there is a risk that unqualified individuals may be allowed to drive, and conversely, qualified individuals may unjustly be prohibited from driving.

“Status of driver. Once an application is submitted to FMCSA, the driver shall be deemed disqualified until such time as FMCSA decides, or until FMCSA orders otherwise.”

Remember, transparency, accurate disclosure, and adherence to the NRCME regulations are essential for CMV drivers seeking a second opinion or obtaining a new certificate!

In January 2024, FMCSA will be enhancing its comprehensive medical examiner (ME) performance monitoring and auditing program. Part of this program will include an increase in the Agency’s monitoring of MEs for compliance with the Federal Motor Carrier Safety Regulations (FMCSRs). There are 11 regulatory requirements that MEs must comply with as part of their certification with the National Registry. Failure to comply with the following regulatory requirements outlined in the FMCSRs may result in the removal of an ME from the National Registry:

1. Have a valid unexpired medical license listed in the ME’s National Registry account
2. Provide records within 48 hours of request from FMCSA
3. Submit examination results by midnight (local time) of the next calendar day following the examination
4. Report when no examinations are performed during a given month
5. Complete 5-year periodic training no sooner than 4 years and no later than 5 years after the ME’s certification credential was issued
6. Complete 10-year periodic training no sooner than 9 years and no later than 10 years after the ME’s certification credential was issued
7. Pass the 10-year certification test no sooner than 9 years and no later than 10 years after the ME’s certification credential was issued
8. Update information in the ME’s National Registry profile within 30 days of a change
9. Complete assigned training by the date provided by FMCSA
10. Complete training resulting from an audit by the date provided by FMCSA
11. Correct errors received for CLP/CDL applicants/holders (NRII)

In 2024, FMCSA plans to begin taking action to remove MEs for noncompliance with all of these requirements but will start in January 2024 with MEs who have failed to complete the required 10-year periodic training and/or pass the 10-year certification test as the first certified MEs were due to complete these requirements by December 31, 2023.

For MEs who are required but have failed to complete the required 10-year periodic training and/or pass the 10-year certification test by December 31, 2023, a formal Notice of Proposed Removal (NOPR) from the National Registry of Certified Medical Examiners (National Registry) will be issued to them via the professional contact email address provided in their National Registry account. The NOPR will outline the reason for removal and provide specific details of correction action(s) that the ME must take to avoid removal from the National Registry. FMCSA stresses the importance of thoroughly reading and completing ALL required corrective actions to avoid removal.

After an NOPR has been issued, the ME will see a notification in their National Registry account that prompts them to take the following actions:

1. Acknowledge, through the ME’s National Registry account, that they will take the corrective action(s) outlined in the NOPR or that they disagree with the NOPR. If the ME believes FMCSA has relied on an erroneous reason, in whole or in part, in proposing their removal from the National Registry, the ME can select the option to disagree with the NOPR but must explain the basis for their belief that FMCSA relied on an erroneous reason in proposing their removal for FMCSA to review and respond.

PLEASE NOTE that if the ME has not acknowledged that they will take corrective action(s) in their National Registry account as instructed in the NOPR, the ME will be removed 30 days from the date the NOPR was issued. If the ME acknowledges that they will take the corrective action(s) through the ME’s National Registry account, the ME will have 60 days from the date the NOPR was issued to take corrective action(s) as specified in the NOPR. An example of what the acknowledgement notification in the ME’s National Registry account may look like is provided below.

2. Once the ME acknowledges that they will take the corrective action(s) outlined in the NOPR, they must complete all corrective actions (e.g., completing, entering details, and uploading proof of completion of the 10-year training into the ME’s National Registry account and/or passing the 10-year certification test).

3. Once all corrective actions have been completed, the ME must log into their National Registry account where they will see a notification that they must respond to indicating that all corrective actions have been completed. An example of what the notification may look like is provided below.

PLEASE NOTE that this confirmation is a regulatory requirement and is outlined in the NOPR. MEs who fail to indicate completion of all corrective actions in their National Registry account as indicated in this step, will be removed from the National Registry and will no longer be authorized to perform physical qualification examinations of interstate commercial motor vehicle drivers at the end of the 60 days.

If you receive an NOPR for failure to complete the required 10-year periodic training and/or pass the 10-year certification test by December 31, 2023, you should immediately take the steps outlined in this email and provided in the NOPR, to correct the issue(s) and avoid removal from the National Registry.

To assist MEs in understanding the 11 regulatory requirements listed above that must be met for continued listing on the National Registry, FMCSA will be posting an informational training webinar on the National Registry website in the coming months. MEs will be notified by email when it is available.