Minimizing Turbulence when Flying with Diabetes
Written by: Lourdes Cross, PharmD, BCACP, CDE, Sullivan University College of Pharmacy/University of Louisville Hospital, Louisville, KY
Patients with diabetes can encounter multiple challenges while traveling, especially with long-haul travel across time zones. In one study of 493 patients with diabetes, 15% of those traveling in the past year reported that insulin use affected travel plans due to perceived health risks such as traveling long distances. Approximately one-third of patients reported that guidance would help diminish fears about travel.1 However, there are limited public resources that offer travel support, and some only provide generalized advice on packing and transportation of suppies.2–4 Ultimately, education from health care professionals can minimize the incidence of health-related problems and improve the overall traveling experience.
Before Boarding:
Schedule an appointment
Patients who are planning to travel, especially overseas, should schedule a medical appointment at least one month prior to departure.5 At this visit, health care professionals should assess and discuss the following:
- current level of glucose control
- prevention of acute complications
- management of travel-related problem
- need for immunizations
- review the patient’s itinerary including departure and arrival times, travel duration, and time-zone differences to provide guidance on medication adjustments
Pack appropriate supplies
Table 1 lists important items that patients with diabetes should pack for travel. Medications and supplies should be packed in carry-on luggage to allow for easier access while traveling and prevent loss if bags are misplaced. In addition, extreme temperature changes are more likely to occur in the luggage storage area of the plane rather than in the cabin areas, which could affect insulin.6
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Table 1. Packing List
Consider packing most of this in carry-on luggage!
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o Physician letter and emergency number: describes health condition, medication regimen, and medical necessity to carry supplies
o Medical identification: wear to alert others of health condition(s) in event of emergency
o Medical alert card: print from ADA website to provide first responders with critical information
o Health insurance cards
o Medications that are clearly labeled
o Medication-related and testing supplies (eg, syringes, needles, cold pack, lancets, test strips, sharps container): pack double what is needed
o Glucometer: possibly an extra if one fails
o Treatment for hypoglycemia (eg, glucose gel, tablets, glucagon pen)
o Healthy snacks
o Ketone strips
o First-aid supplies (eg, bandages, antibiotic ointment)
o Extra batteries
o Comfortable shoes
Insulin pump users should also carry:
o Extra pump (many manufacturers will provide a loaner for international travel) and supplies
o Alternative basal and bolus insulin and syringes or pen needles
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Travel Day:
Expect security screening
Guidelines for traveling with diabetes medications and supplies can change at any time, so it is always important to check with the Transportation Security Administration for current recommendations.7 At the airport, travelers should:
- Separate diabetes-related items from other belongings before screening
- Be aware of manufacturer recommendations for insulin pumps or continuous glucose monitors: potential for radiation-induced malfunction if passed through luggage x-ray machines6
- Understand that medications in excess of 3.4 ounces (100 milliliters) may be packed in a carry-on bag and are not required to be placed in a plastic zip-top bag
Prevent hypoglycemia
Hypoglycemia occurs in up to 10% of patients taking insulin during travel or in the first 24 hours after arrival.1 Changes in dietary patterns, physical activity, insulin dose, and timing of insulin administration can contribute to this risk.8 In addition to glucose tablets, gels, or a glucagon kit, patients should be reminded to include snacks with simple and complex carbohydrates in their carry-on luggage in the event that they become hypoglycemic.
Anticipate changes in airplane pressure
Changes in airplane pressure during a flight may affect insulin administration for patients who use vials, pens, or pumps. Patients may encounter resistance when using a syringe to draw up insulin from a vial. In addition, insulin pens may leak when a pen needle is connected to the device.6 For insulin pump users, data suggests the possibility of unintended insulin delivery during ascent due to bubbles displacing insulin in a pump. During descent, the bubbles dissolve again as the air pressure increases, which may decrease insulin delivery. However, the clinical significance of these effects is unknown and more data is needed before insulin pump recommendations during flight should be made.9
Consider adjusting medications
There is limited information and little scientific evidence on adjusting insulin for travel across time-zones. The day shortens when traveling from west to east and lengthens when traveling from east to west. This can increase the risk of hypoglycemia or hyperglycemia if a patient does not monitor glucose closely and make appropriate insulin adjustments. If fewer than 5 time zones are crossed, insulin adjustments are generally not necessary. For trips of less than 3 days duration, patients may consider keeping their watch set to the departure time zone and continue taking medications as previously scheduled. However, medication administration should be adjusted to the destination time zone for trips longer than 3 days.6 One example of a simplified insulin adjustment protocol was published by providers from the Tripler Army Medical Center in Honolulu, HI and is presented in Table 2.8 According to the protocol, if a patient is traveling east, a single dose reduction should be given based on the departure time zone. Then, the patient may resume normal basal insulin dosing based on the arrival time zone, which may occur during the flight or after landing.
The timing of oral medications is not as critical as that of insulin. If a patient is on a sulfonylurea, it may be better to skip a dose and have slight hyperglycemia rather than take two doses close together and increase hypoglycemia risk.5 It is important to note that most recommendations, including the ones in this review, are from expert opinion based on clinical experience and insulin pharmacokinetics.
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Table 2. Example of Basal Insulin Adjustment
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Eastbound Travel
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Westbound Travel
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Note: Patients can develop hypoglycemia because the day “shortens,” which can lead to stacking of insulin doses. The goal of this adjustment is to reduce the amount of basal insulin by approximately 10-20% depending on length of travel.
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Note: Patients can develop hyperglycemia because the day “lengthens,” which can lead to gaps in medication dosing. However, the goal of this adjustment is to prevent hypoglycemia and adjust insulin in a simplified manner.
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· Continue to use bolus insulin as needed for meals.
· During travel, start with the departure time zone and give the travel dose at the usual time.
o Travel dose =
(Normal basal dose) x (0.9 - [# time zones crossed ¸ hours between basal insulin doses])
· After basal insulin is given, adjust watch to the arrival time zone.
· Resume normal basal insulin dosing in the arrival time zone (may be while still traveling or after).
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· Continue to use bolus insulin as needed for meals.
· During travel, start with the departure time zone and give 50% of the normal basal insulin dose at the usual time.
· After basal insulin is given, adjust watch to the arrival time zone.
· Then, give 50% of the normal basal insulin dose at the usual time (using arrival time zone).
· Thereafter, resume normal basal insulin dosing in the arrival time zone.
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After Arriving:
Throughout the trip, patients should monitor blood glucose more often due to the compounding effects that stress, dietary changes, increased physical activity, and adjusted medication regimens can have on glucose control. An individual may perform more walking than usual while traveling, which may increase glucose utilization. This could require a decrease in insulin requirements or necessitate eating more carbohydrates to keep glucose levels steady. In addition, comfortable and appropriately fitting footwear is important to prevent the formation of blisters or abrasions which could lead to an infection.
Conclusion
Patients with diabetes report fears associated with travel-related health complications. Health care professional can provide education to discuss self-management skills and adequate preparation for travel. Advice may help reduce fluctuations in glucose control and minimize other health risks. In addition, it can alleviate patient stress and increase confidence in planning for future trips, whether for work or recreation.
References
- Burnett JCD. Long- and short-haul travel by air: Issues for people with diabetes on insulin. J Travel Med. 2006;13(5):255-260.
- Bettes TN, McKenas DK. Medical advice for commercial air travelers. Am Fam Physician. 1999;60(3):801-810.
- Lumber T, Strainic P. Have insulin, will travel: planning ahead will make traveling with insulin smooth sailing. Diabetes Forecast. 2005;58(8):50-54.
- Boerner H. Tips to trip by: the art and science of traveling with diabetes. Diabetes Forecast. 2008;61:42-45.
- Chandran M, Edelman S V. Have insulin, will fly: diabetes management during air travel and time zone adjustment strategies. Clin Diabetes. 2003;21(2):82-85.
- Nassar AA, Cook CB, Edelman S. Diabetes management during travel. Diabetes Manag. 2012;2(3):205-212.
- Transportation Security Agency. Disabilities and Medical Conditions. https://www.tsa.gov/travel/special-procedures. Accessed April 16, 2018.
- Pinsker JE, Becker E, Mahnke CB, Ching M, Larson NS, Roy D. Extensive clinical experience: A simple guide to basal insulin adjustments for long-distance travel. J Diabetes Metab Disord. 2013;12(1).
- King BR, Goss PW, Paterson MA, Crock PA, Anderson DG. Changes in altitude cause unintended insulin delivery from insulin pumps: Mechanisms and implications. Diabetes Care. 2011;34(9):1932-1933.