PRACTICAL POINTERS

Have , Will Fly: Management During Air Travel and Time Zone Adjustment Strategies

Manju Chandran, MD, and Steven V. Edelman, MD

he world definitely has become a diabetes management and prevention of during travel. Patients with dietary smaller place. Traveling across acute complications, to offer information restrictions should contact their airline in Tmultiple time zones within the on preventing and managing common advance about special meal options. span of a few hours or days is now com- travel-related problems, and to deter- “Diabetic meals” on airplanes are usual- monplace. mine the need for any immunizations. ly very low in and Overseas travel poses special prob- Any changes in medication regimen designed more for patients with type 2 lems for people with diabetes, especially should be made well in advance of diabetes than for those with type 1 dia- those on insulin. However, the fear of departure so that there is enough time to betes. It is also helpful to find out dealing with medications and acute com- incorporate them into daily routines. beforehand what time(s) meals are plications should not prevent people with It is important for patients to obtain a served during the flight. diabetes from traveling, whether for travel itinerary showing departure and work or recreation. Advanced planning arrival times, durations of flights, and Before Boarding can help to prevent or minimize emer- time differences between the points of Patients should have enough, or, if possi- gencies that may occur away from home. embarkation and disembarkation. With ble, more than enough, of all medica- One problem insulin-treated people this information, providers will be able tions and diabetes supplies to last the with diabetes face when flying across to “guesstimate” necessary adjustments entire trip (Table 1). This should include time zones is confusion about how to adjust their insulin times and dosage Table 1. What to Pack amounts to avoid being “out of sync” with local time on arrival. Very little ¥ Two monitoring devices, with extra batteries, packed in separate information is available regarding time bags zone insulin adjustment strategies. A ¥ Enough insulin, syringes, lancets, and test strips to last the entire trip British study in 1993 clearly demonstrat- ¥ For pump users, enough pump supplies for the entire trip, extra batteries, and ed that most physicians, including dia- supplies of long-acting insulin (ultralente or glargine) and regular or rapid-acting betologists, are uncertain about how to (lispro or aspart) and syringes for use in case of pump malfunction adjust insulin doses for patients who or battery failure travel across several time zones. ¥ Prescription medicines (including a glucagon emergency kit), for diabetes and This article provides some recom- other medical conditions mendations on managing diabetes during ¥ Simple sources, such as glucose tablets, gels, candy, and nondiet- air travel. It is important to remember, etic soft drinks to relieve symptoms of however, that these are general guide- ¥ Complex carbohydrate sources, such as breakfast bars, cheese crackers, granola lines and that management should be bars, and trail mix to serve as snacks when meals are missed or delayed individualized for each patient. ¥ Regular insulin or short-acting insulin analogs for treating high blood glucose and for sick-day management even if these are not part of the patient’s regular Planning Ahead regimen Ideally, patients who are planning over- ¥ Identification (diabetes identification card, Medic Alert necklace or bracelet) seas travel should schedule an office ¥ Insurance papers (Confirm before travel what medical coverage is available from visit with their health care provider at the insurer in the event of a medical problem abroad.) least 4Ð6 weeks before departure. This ¥ Medications for vomiting and diarrhea gives providers an opportunity to assess ¥ A first aid kit, including analgesics, and antifungal creams, bandages, their patients’ current level of diabetes sterile gauze, and adhesive tape control, to give specific advice regarding

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two devices insulin pumps. If there is any concern, short of pump therapy, this is the ideal (packed in separate bags) with extra bat- passengers can request that their carry- system to cope with all time zone travel teries; insulin lancets, test strips, and on bags be hand-checked. situations. Changing to insulin glargine syringes; and, for users, (Lantus) for basal insulin, with lispro pump supplies, extra batteries, and inulin On Board (Humalog) or aspart (Novolog) coverage and syringes in case of pump failure. before each meal, would probably be the All medications and supplies should Adjusting insulin injections and most flexible and effective regimen. be packed in carry-on luggage rather mealtimes while crossing time zones In general, patients should be than in checked baggage. This is not Frequent blood glucose monitoring is advised to leave their wristwatches unad- only to prevent loss from bags being essential for safety during flight. Even justed during flight so that they continue misplaced, but also because baggage individuals who do not test frequently at to correspond to the time at their point of stored in cargo holds can be subject to home should test at least every 4Ð6 embarkation. This will make it easier for extreme temperature changes that may hours while traveling. Patients should be patients to judge the timing of their alter the potency of insulin. cautioned to keep themselves well insulin injections and meals. The American Diabetes Association hydrated with nonalcoholic, caffeine- has published new air travel guidelines free beverages throughout their flight. Advice for traveling east across five or from the Federal Aviation Association Diabetes management is usually more time zones (FAA). These guidelines, which cover based on a normal 24-hour medication An example of an eastward-bound flight U.S. travel only, are available online at schedule. When traveling north or south, would be one from Los Angeles, Calif., http://www.diabetes.org/main/type2/ no adjustments in the 24-hour schedule to London, U.K., as shown in Table 2. living/travel/default.jsp. According to the are needed. However, east or west travel The flight departs Los Angeles at 8:45 updated FAA guidelines, boarding air- across time zones abbreviates or extends p.m., which is 4:45 a.m. London time. It craft with syringes or insulin delivery the day depending on the direction of arrives in London at 7:15 a.m. Los systems is acceptable only if the insulin travel. Angeles time, which is 3:15 p.m. vials/pens/cartridges have a professional, In general, adjustments to insulin London time. Total flight time is 10.5 preprinted pharmaceutical company doses are unnecessary if patients are hours. label clearly identifying the medication. crossing fewer than five time zones. Scenario 1. Assume that the patient The FAA recommends that passengers Traveling east will shorten one’s day, taking this flight normally takes insulin bring the original insulin box, which and, in general, may necessitate a reduc- (basal and rapid-acting) on a twice-daily usually displays label and pharmacy tion in insulin (especially for shorter schedule as follows: NPH plus regular instructions. Boarding with lancets for flights) because insulin doses would be insulin, 16 units and 10 units, respective- blood glucose monitoring is acceptable administered closer than normal and thus ly, before breakfast, and 10 units and 10 as long as the lancets are capped and could cause hypoglycemia. In contrast, units, respectively, before dinner. brought aboard with a that westward travel means a longer day, and Assuming that he will be served two has the manufacturer’s name printed on so insulin doses may need to be meals and a snack (dinner shortly after it (i.e., “One Touch”). The FAA further increased. However, this seemingly sim- takeoff, a mid-flight snack, and breakfast recommends that passengers traveling ple and workable rule of “westward = before landing), the following course can with glucagon kits keep them intact in more insulin; eastward = less insulin” be recommended: their original containers that bear pre- may not always hold true. Differing times Before departure, he should take his printed pharmaceutical company labels. of departure and prolonged flights may usual evening dose of 10 units NPH plus Although written prescriptions and let- require a more complicated approach. 10 units regular. Keeping his wristwatch ters from health care providers may be Patients who are not insulin pump synchronized to Los Angeles time while helpful once travelers reach their desti- users should be transferred to a “ basal- in flight, about 11Ð12 hours later, he nations, the FAA, because of forgery bolus” insulin regimen before traveling should take half of his usual morning concerns, no longer accepts them as ade- if they are not on one already, because, dose of NPH (8 units) plus the full com- quate proof of insulin necessity. Insulin is stable under normal condi- Table 2. Time Differences Between Departure and Destination Points on an tions at airport terminals and passenger Eastward-Bound Flight From Los Angeles, Calif., to London, U.K. security check points and when passing through X-ray machines that scan carry- Los Angeles time London time on baggage. X-ray machines also should Departure 8:45 p.m. 4:45 a.m. have no effect on currently available Arrival 7:15 a.m. 3:15 p.m. blood glucose monitoring devices and

CLINICAL DIABETES • Volume 21, Number 2, 2003 83 PRACTICAL POINTERS

plement of regular insulin (10 units), fol- taken at around 10:00 p.m., would have (10 units lispro before each meal). The lowed by a meal (which, in this case, is to be taken at around 6:00 a.m. while in alternative would be to take his usual likely to be breakfast). Because of the London. dose of glargine (24 units) the night long duration of the flight, however, before his departure. Twenty-four hours extra short-acting insulin may be neces- Advice for traveling west across five later, which in this case would be just sary for meals or snacks consumed at or more time zones before landing in Honolulu, he can take times that are not similar to the patient’s An example of a westward-bound flight half of his usual dose (12 units). That normal routine (e.g., the dinner and the would be from New Jersey to Honolulu, night at bedtime (Honolulu time), he can mid-flight snack). That evening in Lon- Hawaii, as shown in Table 3. The flight take the remaining half of his usual bed- don, just before dinner (London time), departs New Jersey at 11:40 a.m., which time dose of glargine (12 units). Again, the remaining half of the usual morning is 6:40 a.m. in Honolulu. It arrives in the 24-hour glargine requirement would dose of NPH insulin (8 units) plus the Honolulu at 10:40 p.m. New Jersey remain the same, but the dose would be full complement of regular insulin (10 time, which is 5:40 p.m. Honolulu time. split to help him adjust to the change in units) is taken. Total flight time is 11 hours. time zone. Premeal coverage with a Thus, the patient’s total NPH insulin Scenario 1. If this is the same patient rapid-acting insulin analog would also dose has not been altered, but rather has as in scenario 1 for eastward travel remain the same or, if more than the usu- been split to help him adjust to the above, i.e., someone who normally takes al amount of food or number of meals change in time zone. The next morning insulin on a twice-daily schedule of 16 are consumed, extra lispro could be giv- in London, on local time, the patient’s units NPH plus 10 units regular in the en during the flight, based on carbohy- pre-travel regimen can be resumed. morning and 10 units NPH plus 10 units drate content of the food to be consumed Scenario 2. Assume that the patient regular in the evening, the following and blood glucose values. taking this flight is instead on a regimen course can be recommended: of once-daily glargine (24 units at bed- He should take his usual morning Advice for those who use insulin time) with a premeal rapid-acting insulin dose (16 units NPH plus 10 units regu- pumps analog (10 units lispro before each lar) in the morning before departure. Patients using insulin pumps can contin- meal). An alternative would be to take Again, keeping his wristwatch synchro- ue with their normal routine of basal and the usual dose of glargine at the usual nized to New Jersey time, about the time bolus doses, and they can change the time, say 10:00 p.m. Los Angeles time of his usual evening meal (i.e., about 10 time setting on their pump once reach- (this would be on the flight). Twenty- hours after the morning dose of insulin), ing the destination. It may be safer to four hours later (i.e., again around 10:00 he should take half of his usual evening allow blood glucose levels to run slight- p.m. Los Angeles time, which would be NPH plus the full complement of short- ly higher than normal for the first day or around 6:00 a.m. London time on the acting insulin (i.e., 5 units NPH plus 10 so rather than to risk hypoglycemia. morning of the day after arrival), he can units regular), followed by a meal or Patients on pumps should carry sup- take half his usual glargine dose (12 snack. That evening at dinner (Honolulu plies of long-acting insulin (ultralente or units). That night at bedtime (London time), he should take the remaining half glargine) and regular insulin or rapid- time) he can take the remaining half of of the intermediate-acting insulin along acting insulin analog (lispro or aspart), his usual glargine dose (12 units), thus with his full dose of short-acting insulin along with syringes and extra batteries to keeping the total 24-hour glargine dose (i.e., 5 units NPH plus 10 units regular). use in case of pump malfunction or bat- the same. Premeal coverage using short- The next morning (local time), his usual tery failure. In such cases, patients acting insulin would remain the same or insulin doses can be resumed. should be instructed to administer a be increased if he will be eating more Scenario 2. Assume, as in scenario 2 once-daily dose of glargine equivalent to than his usual amount or if there are for eastward travel above, that the patient the total 24-hour basal dose. If the more meals than usual. The pre-travel taking this flight is on a once-daily regi- patient has ultralente, the total dose regimen of 24 units of glargine at bed- men of glargine (24 units at bedtime) (which is again equivalent to the total time can be resumed on the third night with premeal rapid-acting insulin analog basal rate) should be split between the (second night in London). For shorter stays, especially if Table 3. Time Differences Between Departure and Destination Points on a patients are on glargine, it might be easi- Westward-Bound Flight From New Jersey to Honolulu, Hawaii er just to continue taking the insulin according to the usual time in Los Ange- New Jersey time Honolulu time les, recognizing that this might involve Departure 11:40 a.m. 6:40 a.m. some inconvenience. For example, the Arrival 10:40 p.m. 5:40 p.m. “bedtime dose” of glargine, normally

84 Volume 21, Number 2, 2003 • CLINICAL DIABETES PRACTICAL POINTERS

morning and evening. All doses of short- or in thermal insulated bags or contain- ical schools for a list of English-speak- or rapid-acting insulin should remain the ers. If refrigerated, the insulin should be ing doctors. same and should be given before each inspected before use for crystals, since meal as usual. crystallization can alter its potency. Summary Extreme temperatures and humidi- Planning ahead for travel is especially Advice for those on oral agents for ty can also affect glucose meters and important for people with diabetes. Pre- diabetes test strips. Meters generally perform travel office visits give diabetes care The timing of oral medications for dia- best within temperatures of 15Ð35C providers an opportunity to review dia- betes is not as crucial as that of insulin. (59Ð95F). When a meter is to be used betes management with their traveling If the patient is on a twice-daily regimen in extreme temperatures, most manu- patients and to provide valuable infor- of (Glucophage), a thiazo- facturers recommend performing fre- mation for blood glucose control during lidinedione, or a sulfonylurea, for quent quality-control checks using glu- long flights. Such advice needs to be instance, it might be easier to skip a cose solutions to ensure that the meter simple and individualized. Variations of dose and have slight for is maintaining its accuracy. the “westward = more insulin; eastward 6Ð8 hours rather than to take two doses People with diabetes who travel also = less insulin” rule can be employed for too close together and risk becoming need to know that while “U-100” insulin adjusting insulin doses when patients are hypoglycemic. Patients on carbohydrate and syringes are standard in the United traveling across multiple time zones. absorption inhibitors (i.e., acarbose States, many other countries still use “U- With some simple precautions, people [Precose]) or one of the newer nonsul- 40” and “U-80” insulin and syringes. A with diabetes and wanderlust can safely fonylurea secretgogues such as repaglin- U-100 syringe used to draw up U-40 or go wherever their hearts lead them. ide (Prandin) or nateglinide (Starlix) can U-80 insulin will provide a smaller dose continue their usual regimen of taking it than is needed, whereas a U-40 or U-80 Manju Chandran, MD, is a senior fellow before meals. syringe used with U-100 insulin will in the Division of Diabetes, Endocrinol- provide a larger dose than is needed. ogy, and Metabolism at the University of Throughout the Trip Patients who must switch to a U-40 California, San Diego School of Medi- Travel usually involves a drastic depar- insulin preparation while abroad should cine and a research fellow at the Special ture from daily routine. Meals may be know that they must also use U-40 Diagnostic and Treatment Unit in the delayed or unavailable, and physical syringes, because the syringes are cali- Division of Diabetes at San Diego VA activity is often greatly increased. These brated to match the insulin preparation, Health Care Systems. Steven V. Edelman, factors can greatly increase the risk of or they should adjust the drawn up MD, is a professor of medicine in the hypoglycemia. amount accordingly. For example if the Division of Diabetes, , Carrying suitable snacks, such as patient is on 20 units of NPH, and if the and Metabolism at the University of Cal- crackers, dried fruits, or nuts, to eat if only insulin available is U-40, he can use ifornia, San Diego School of Medicine meals are delayed or to supplement his U-100 syringe but should draw up and the Division of Endocrinology and meals when necessary is especially 0.5 cc rather than 0.2 cc. Metabolism at San Diego VA Health important while traveling. Glucose Care Systems. He is the founder of the tablets or gels should also be available in Obtaining Medical Assistance Abroad nonprofit organization Taking Control of case of hypoglycemia, which may occur The names of English-speaking physi- Your Diabetes. at unusual times. People with diabetes cians practicing in foreign countries can should advise their traveling companions be obtained from the International Note of disclosure: Dr. Edelman has about the signs of hypoglycemia and Association for Medical Assistance to received honoraria for speaking engage- teach them how to use a glucagon kit. Travellers at www.iamat.org. If people ments from Eli Lilly and Co., Aventis, Open insulin vials retain their poten- with diabetes experience a medical and Novo Nordisk Pharmaceuticals. cy at room temperature for at least 1 emergency while traveling and do not These companies manufacture insulin month, but in warm climates, insulin have that list, they can contact the near- and other products for the treatment of should be stored either in a refrigerator est United States Embassy or local med- diabetes.

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