Key Points:

Pre-departure planning is very important for people with diabetes, especially those on insulin.
Crossing more than five time zones may require adjustments in dosages of medications.
When an insulin- dependent diabetic traveler has unpredictable food intake or eating habits, insulin lispro (Humalog) and insulin aspart (Novolog) offer flexibility in that these ultra–short-acting insulins can be timed with meals.
Long-acting insulin glargine, combined with ultra–short-acting insulin lispro or insulin aspart, may provide the best, most convenient control of blood sugar on long-haul flights.
Frequent blood glucose monitoring is the key to good diabetes control.

The thought of traveling with diabetes can discourage the most confident of travelers. Diabetes may not be the ideal travel companion, but with adequate preparation and common sense, the two are very compatible. Anticipating and avoiding common health problems in both tropical and temperate climates, and being able to manage them on your own, will ensure a more pleasurable, healthier journey. Being cavalier and leaving home without the necessary preparation can be fraught with danger, whereas excess caution might lead you to avoid adventurous travel altogether; the appropriate balance is somewhere in between.

Pre-departure Consultation In addition to contacting your primary care provider, it may be advisable to visit a travel medicine specialist 6 to 8 weeks before departure. You may need itinerary-specific advice, and one or more immunizations. Also obtain a summary of your medical history, including allergies. Ask for a signed and dated letter on your physician’s letterhead outlining your diabetes care and the need for you to carry medications and injection supplies. This letter will help avoid problems from overly zealous or suspicious customs and security officials. FAA guidelines allow you to board aircraft with insulin pens/needles/syringes if these items are identified with their original pharmaceutical company labels; it is recommended also to bring the packaging with the affixed pharmacy label.

Time Zone Changes If you will be crossing more than five time zones, you may need to modify your insulin or oral medication dosing. Your doctor or diabetes educator can help you plan the dose and timing of the injections. Eastward travel means a shorter day, and less insulin may be needed. Westward travel means a longer day, and more insulin may be needed.

Medications Review Chapter 2 to see which medications are recommended for such illnesses as travelers’ diarrhea. Put all medications and glucose-monitoring equipment in your carry-on luggage. Checked bags may be exposed to extremes of temperature, and, most importantly, your luggage may get lost. Although insulin can be stored for 30 days at room temperature, in warm climates you may wish to request a room with a refrigerator or air conditioning. Before using insulin, check vials for signs of damage (crystals, clumps, discoloration, etc.) and discard frozen or damaged vials. Insulin travels well, except above 86° F and below 32° F, so never keep insulin in direct sunlight or on ice. Where temperatures might be an issue, consider carrying an insulated medication kit. These are available from B & A Products: 918-696-5998 and www.baproducts.com. Bring snacks and bottled water in your carry-on luggage in the event of unanticipated delays or a sudden change in plans.

Medical Care Abroad Identification cards and useful phrases in foreign languages (such as “sugar, please”) are available from the American Diabetes Association (www.diabetes.com). Information on health-care providers abroad can be obtained from the International Diabetes Federation (www.idf.org) and from the following commercial organizations, which charge a fee or request a donation: The International Association for the Medical Assistance of Travelers (IAMAT: 417 Center Street, Lewiston, NY 14092; 716-754-4883), the International SOS (www.internationalsos.com), and Medex Assistance Corporation (www.medexassist.com).

Travel Checklist

The supplies below are in addition to those basic supplies listed in Chapter 2. Note: a small first-aid kit is essential. Be sure to bring blister pads. An infected blister could put your health at risk and possibly spoil some planned activities.

Oral diabetes medication
Other prescription medications
Copies of prescriptions with both brand and generic names
Bottles of each kind of insulin
Syringes
Insulin pen and cartridges
Lancing device or lancets
Blood glucose testing strips
Urine ketone testing strips
Blood glucose meter
Insulin pump supplies
Extra batteries for each device
Alcohol wipes, tissues, cotton balls
Glucagon for injection
Carbohydrate sources (e.g., snacks, glucose gel, Glutose)
Diabetes medical identification/wrist bracelet
Doctor’s/clinic telephone number and e-mail address
Pharmacy telephone number
Diabetes travel letter signed by your physician or health-care provider

Further trip preparation checklist guidelines can be found on the website of the American Diabetes Association: www.diabetes.org/pre-diabetes/travel/when-you-travel.jsp

Going Through Airport Security

Notify the screener that you have diabetes and are carrying your supplies with you. The following diabetes-related supplies and equipment are allowed through the checkpoint once they have been screened:

Insulin and insulin-loaded dispensing products (vials or box of individual vials, jet injectors, pens, infusers, and preloaded syringes) that are clearly identified and labeled
Unlimited number of unused syringes when accompanied by insulin or other injectable medication
Lancets, blood glucose meters, blood glucose meter test strips, alcohol swabs, meter-testing solutions
Insulin pump and insulin pump supplies (cleaning agents, batteries, plastic tubing, infusion kit, catheter, and needle)
Glucagon emergency kit clearly identified and labeled
Urine ketone test strips
Unlimited number of used syringes when transported in sharps disposal container or other similar hard-surface container

Pump Wearers Although insulin pump manufacturers indicate that pumps can safely go through airport security systems, pump wearers may request a visual inspection rather than walking through the metal detector or being hand wanded. Note that this may subject you to closer scrutiny or a “pat-down.”

Advise the screener that the insulin pump cannot be removed because it is connected to a catheter inserted under your skin.
Insulin pumps and supplies must be accompanied by insulin with a label clearly identifying the medication.

During the Flight

Keep your carry-on bags within easy reach. Show your travel companion, or tour group leader, where your glucose meter and medications for the treatment of hypoglycemia are located. When traveling at altitudes above 8,000 feet, pressure in insulin vials needs to be equalized; be sure to re-equalize the pressures once you are back at sea level. Insert the syringe without the plunger into the vial. Then, withdraw the syringe, replace the plunger, and withdraw insulin as usual. It is not necessary to inject air into the vial at high altitude.

Two health tips to consider during a flight: (1) drink fluids liberally, and (2) exercise frequently to improve lower limb circulation and glucose control. Take a walk around the cabin for at least 10 minutes every two hours, and do isometric exercises such as pressing your toes against the seat in front of you to tighten calf muscles.

Meal Options During Flight Diabetic diets on air flights are quite low in carbohydrates and are designed more for type 2 diabetics. These diets may predispose to hypoglycemia. It is better to order a regular meal and make up for it with insulin rather than run the risk of hypoglycemia from a too-low carbohydrate meal.

Adjusting Insulin Dose and Meal Times Across Time Zones*

One of the more challenging aspects of diabetes management is the problem of travel across many time zones. No alteration in your dose is needed if you are crossing fewer than five times zones, nor does north-south travel require insulin-dosing adjustment.

The goal of control during travel is to avoid extremes—tight control is not the objective. Better to let your glucose level run a bit higher than usual than to suffer a bout of hypoglycemia in a strange land with strange people speaking a strange language. At the risk of being redundant, “monitor, monitor, monitor your blood glucose level!” Even if you don’t test frequently at home, you should test your blood every 4 to 6 hours while traveling. This is the only way to determine how travel is affecting you and what adjustments you need to make in diet or insulin dosing. Be aware that glucose meters may be affected by high altitude. Check the manual or contact the customer service toll-free hotline before departure, and be sure to carry an extra battery.

Ultra–short-acting insulin lispro (Humalog) and insulin aspart (Novolog) and long-acting insulin glargine (Lantus) add flexibility to diabetic management. You administer Lantus (insulin glargine) once daily at bedtime, to get a 24-hour basal insulin activity; then, simply administer an ultra–short-acting insulin (either Humalog or Novolog) within 15 minutes before each major meal, or immediately afterward. Figure 13.1 illustrates the more rapid activity of insulin lispro (Humalog) compared with regular insulin.

Complex tables have been published advising diabetics how to administer insulin during a trip, but insulin pumps and the recent availability of ultra–long-acting insulin glargine (Lantus) and the ultra–short-acting insulins—Humalog and Novolog—have simplified matters. You get long-acting baseline control with Lantus and on-the-spot mealtime control with one of the others. Here’s how it can work on an eastbound flight lasting about 11 hours. For example, if you fly from San Francisco to Paris (9-hour time difference), departing in the evening, you would

Take your full 24-hour dose of insulin glargine (Lantus) at 10.00 p.m. (while on the plane).
The next day, cover your meals with a short-acting insulin, the amount depending on meal size and carbohydrate content.
Twenty-four hours later (it is now 7.00 , take one half of the insulin glargine dose, and the other one half that evening at 10.00 p.m., thus keeping the 24-hour insulin glargine dose the same.
The next evening at 10:00 p.m. (the third night), take the full insulin glargine dose.

Figure 13.1 Serum Humalog and Insulin Levels After Injection of Human Regular Insulin or Humalog Immediately Before a High-Carbohydrate Meal in a Patient with Type 1 Diabetes

Note: It is best to keep your watch on home time during travel to determine when your meal/insulin doses should be taken. Set your watch on local time the morning after arrival to get in step with meal activities of the destination country. During the flight, administer ultra–short-acting insulin with meals.

An example of a westward-bound flight would be from New Jersey to Honolulu, Hawaii. The flight departs New Jersey at 11:40 a.m., which is 6:40 a.m. in Honolulu (5-hour time difference). It arrives in Honolulu at 10:40 p.m. New Jersey time, which is 5:40 p.m. Honolulu time. Total flight time is 11 hours.

Take your daily dose of long-acting insulin glargine (Lantus) at 10.00 p.m. the night before departure.
Adjust for meals with rapid-acting insulin.
Twenty-four hours later, just before landing in Honolulu at 10.40 p.m. New Jersey time, take one half of your usual dose of insulin glargine
That night at 10.00 p.m. Honolulu time, take the remaining one half dose of insulin glargine.

Pre-meal coverage with rapid-acting insulin would remain the same, unless you consume extra food during the flight, the amount based on the carbohydrate content of the food and your blood glucose levels.

TRAVELERS USING INSULIN PUMPS*

Patients using insulin pumps can continue with their normal routine of basal and bolus doses, and they can change the time setting on their pump once reaching the destination. It may be safer to allow blood glucose levels to run slightly higher than normal for the first day or so rather than to risk hypoglycemia.

Patients on pumps should carry supplies of long-acting insulin (ultralente or glargine) and regular insulin or rapid-acting insulin analog (lispro or aspart), along with syringes and extra batteries to use in case of pump malfunction or battery failure. In such cases, patients should be instructed to administer a once daily dose of glargine equivalent to the total 24-hour basal dose. If the patient has ultralente, the total dose (which is again equivalent to the total basal rate) should be split between the morning and evening. All doses of short- or rapid-acting insulin should remain the same and should be given before each meal as usual.

Oral Medications for Type 2 Diabetes The timing of oral medications for diabetes is not as crucial as that for insulin. If you are on twice-daily metformin (Glucophage), a thiazolidinedione (Actos, Avandia), or a sulfonylurea (e.g., glipizide, Glucotrol) it might be easier to skip a dose if you are on twice-daily dosing; if you are in once-a-day dosing, reduce the dose by one half. It is better to have slight hyperglycemia for 1 to 2 days than to risk low blood sugar. Patients on carbohydrate absorption inhibitors or one of the newer nonsulfonylurea drugs, such as Prandin or Starlix, can continue these drugs as usual.

If you take both insulin and oral diabetes medications, discuss your medications with your health-care provider. Remember that hypoglycemia is what you want to avoid, and that frequent monitoring of blood sugar is key. Hypoglycemia can occur if you do not eat enough or you take too much medication.

After Arrival

Your blood glucose meter is your best travel guide to continued good health, and it is a must because your eating pattern and activity level are likely to be different during travel. You must test your blood glucose level more often to make appropriate adjustments after arrival.

Insulin Abroad Insulin produced in other countries may have reduced purity, and hence reduced activity. Outside of North America, insulin is often dispensed as U80 or U40 concentration, instead of the standard U100. Syringes corresponding to these concentrations may be the only ones available. Read labels carefully to avoid dosing disasters. It is not recommended to use a U100 syringe to draw up U40 or U80 insulin because a very serious dosing error could occur. Also, cartridges and/or pen needles may not be available worldwide. The best safeguard is to bring extra medication and supplies from home.

When going on an outing, always take vital supplies with you regardless of the proposed duration and type of outing. Don’t forget bottled water. Try to eat as close to your usual meal plan as possible. Counting carbohydrates and the plate method of meal planning can be especially useful.

Travelers’ Diarrhea Although the standard food rules for the prevention of travelers’ diarrhea are often impractical, make an effort to avoid the following: raw, undercooked foods (e.g., salads); roadside stands; unpurified water and ice cubes; buffets; and unpasteurized milk products. Every traveler with diabetes should carry an antibiotic (preferably a quinolone) for self treatment of travelers’ diarrhea.

Sun Exposure Travel to hot climates brings the risk of sunburn, a particular concern for those with diabetes, because healing is slower and secondary infection is more likely to occur. Wear light colored, cotton clothing and a hat, and use sunscreen (minimum 15 SPF); postpone strenuous activity soon after arrival and drink enough sugar-free fluids to promote urination, whether or not you are thirsty; moderate intake of alcohol and caffeine is acceptable.

Altitude Sickness At high altitudes, hypothermia may be mistaken for hypoglycemia, and vice versa. At about 16,000 feet, retinal hemorrhages may occur, a particular concern for those with preexisting diabetic retinopathy. Altitude sickness, characterized by headache and fatigue, can usually be prevented by slow ascent and dosing with acetazolamide (Diamox).

Foot Care Foot problems can ruin your trip. Never travel with a new pair of shoes that has not been broken in. Take one or more pairs of worn-in walking shoes, slippers for your hotel room, and beach shoes. Avoid pressure points by changing socks and shoes frequently. Inspect feet daily for blisters, redness, and skin breakdown. Never delay treatment of injuries. Never walk barefoot, even on a beach.

Don’t forget to review the potential risks of travel medications with your pharmacist or health-care provider: glyburide and doxycycline increase sun sensitivity; chloroquine, quinine, and Pepto-Bismol may increase hypoglycemia; acetazolamide (Diamox) may aggravate hyperglycemia; and antibiotics predispose to vaginal yeast infections. Keep in mind that not taking medication, such as antimalarial medication, may increase your risk of illness, which in turn can cause loss of blood sugar control. In this regard, protection with DEET repellents, permethrin fabric spray, a mosquito bed net, and protective clothing is crucial to the prevention of malaria (transmitted by night-biting mosquitoes) and dengue fever (transmitted by day-biting mosquitoes).

Accidents It is worthwhile to keep in mind that the major cause of preventable death during travel is not an infectious disease such as malaria, cholera, or Ebola virus. A motor vehicle accident is a much more likely cause. Your risk of an accident is increased overseas (especially in less developed countries) because of poor road conditions, poorly maintained vehicles (often without seat belts), inexperienced and/or reckless drivers, and a general disregard for rules of the road. Here are three important safety tips to remember: don’t ride on motorcycles; don’t travel in overcrowded public vehicles; and never travel by road at night in rural areas.

The vast majority of diabetic travelers return safe and sound from their trips. Remember that healthy, comfortable travel is enhanced by adherence to common sense precautions with respect to food, water, insect bites, safe sex, and road travel, as well as close attention to diabetic control.