Keeping Diabetes and Traveling In Sync

Edison So, MD, FPCP, FPCEDM

Tourism was one of the industries heavily affected during the COVID-19 pandemic.  Now that majority of people are vaccinated, global tourism is slowly making its way back.  Travelers with diabetes are challenged by unhealthy dietary options, limited access to medicine and health services, and disruption of usual medicine dosing intervals.  Disruption of routine dosing intervals is most pronounced when travelers cross multiple time zones.  In this article, we will review some of the guidelines and recommendations on management of diabetes during air travel.

Oral Hypoglycemic Agents Use During Air Travel

Based on a systematic literature review by Pavela et al., most publications made recommendations on continuing their oral medications at their usual prescribed doses without specific modifications for travel.  Although, it is important to emphasize to patients not to skip meals especially while taking sulfonylureas¹.  When missing meals, it is recommended to stop sulfonylurea to minimize the risk of hypoglycemia but may continue taking Metformin, DPP4-inhibitors and Thiazolidinediones as these have minimal risk of hypoglycemia².

The timing of oral medications for diabetes is not as crucial as that of insulin.  If the patient is on a twice daily regimen of oral hypoglycemic agent, it might be easier to skip a dose and have slight hyperglycemia rather than take two doses too close together and risk of causing hypoglycemia³.

Insulin Use During Air Travel

According to the systematic literature review by Pavela et al., most publications that made recommendations on adjustment of injectable insulin therapy during travel were based on expert opinion.  Common recommendations are to individualize insulin modification to each traveler, make the modifications simple rather than complex, and consider the use of insulin pens rather than needles and syringes¹.  Some publications made recommendations on the type of insulin travelers should use. These recommendations include switching patients on premixed insulin to a split basal-bolus regimen prior to travel and using rapid-acting insulin analogues rather than regular insulin.  If the patient is not on insulin pump, “Basal-bolus” is the preferred insulin regimen when travelling as it is the most flexible and effective regimen^{3, 6}.

Avoidance of hypoglycemia is the well-accepted primary goal during air travel⁴.  Hypoglycemia reportedly occurs in up to 10% of patients taking insulin while traveling abroad⁵. The goal is to design an insulin regimen that is very simple and avoids hypoglycemia, even if this leads to a short period of suboptimal glycemic control (hyperglycemia)⁴.

Shorter duration trips are typically easy.  According to Pinser et al., when traveling across fewer than 5 time zones or for trips less than 3 days duration, they recommend patients to keep their watches set at their home local time, continue their basal insulin at the usual times and administer bolus doses before meals⁴.

Traveling across 5 time zones and staying in a different time zone longer than 3 days disrupts meal times and medication dosages.  Advise patients to take their insulin according to to their normal home time before departure.  The change in dosing and schedule will depend largely on current glucose control, time of travel, and availability of food and glucose during travel⁷.  As a general rule, traveling east (eg. Philippines to New Zealand) results in a shortened day, requiring a potential reduction in insulin, while traveling west (eg. Philippines to California, USA) results in a longer day, possibly requiring an increase in insulin dose³.  However, this is a guideline/recommendation and may not be applicable to all patients.

Packing for Travel

When packing, it is advisable to include all oral medicines, insulin, syringes, needles, blood testing supplies, and some snacks or glucose tablets to treat low blood glucose.  Keep the medicines and diabetes supplies in a carry-on bag so that they will come in handy.  More importantly, insulin should never be placed in checked baggage. It could be affected by severe changes in pressure and temperature.  Insulin and other injectable therapies must be carried in hand luggage and must be packed in clear, sealable bags. Unused insulins can be stored in a cooler. Used insulin can be stored at room temperature or must be kept in a temperature not over 25 degrees Celsius.  For travelers with insulin pump, it is recommended that they carry injectable insulin in case of pump malfunction or failure, extra amount of pump-related supplies, and should consider bringing a backup pump.^{2, 3, 8}

Going Thru Airport Security

Diabetes-related supplies, equipment and medications in liquid form are allowed through the checkpoint once they have been properly screened by X-ray or hand inspection.  People with diabetes are exempt from the 3.4 oz (100 mL) liquid rule for medicines, fast-acting carbs like juice, and gel packs to keep insulin cool.  Patients on insulin pump or continuous glucose monitoring device must check with the recommendation of the manufacturing companies regarding their use during travel.  Several insulin pump and CGM manufacturing companies allow the passage of their equipment through metal detectors but strictly recommend that their products should not be run through the luggage x-ray machines or body scanners that implement x-ray technology due to potential risk of radiation-induced malfunction.  It may be prudent to ask for a pat-down or hand inspection instead.^{3, 7, 9}

Syringe and Needle Disposal

Insulin syringes, lancets, and pen needles have to be safely disposed.  Although many airports and airplanes have sharps containers for disposal in restrooms, it is prudent to research on the available disposals ahead of time and carrying container for sharps is strongly advised. There are travel sized sharps containers available for purchase. In case these are not available, a container that is puncture proof and with tight fitting lid is a good option. ^{10, 11}

References:

1. Pavela et al. Management of Diabetes During Air Travel: A Systematic literature review of current recommendations and their supporting evidence. Endocrine Practice, 24(2), 205-219.
2. Nassar et al. Diabetes management during travel. Diabetes Manag. 2012;2:205-212.
3. Chandran et al. Have Insulin, Will Fly: Diabetes Management During Air Travel and Time Zone Adjustment Strategies. Clin Diabetes2003;21(2):82–85
4. Pinsker et al. Extensive clinical experience: a simple guide to basal insulin adjustment for long distance travel. J Diabetes Metab Disord 2013; 12: 59.
5. Burnett JC: Long- and short-haul travel by air: issues for people with diabetes on insulin. J Travel Med 2006, 13:255–260
6. Jawad F, Kalra S. Diabetes and travel. JPMA J Pak Med Assoc. 2016;66:1347-1348.
7. Mullin R, Kruger D, Young CF, Shubrook JH. Navigating travel with diabetes. Cleve Clin J Med. 2018 Jul;85(7):537-542.
8. https://www.fda.gov/drugs/emergency-preparedness-drugs/information-regarding-insulin-storage-and-switching-between-products-emergency
9. https://www.diabetes.org/tools-support/know-your-rights/what-can-i-bring-with-me-on-plane
10. https://www.idf.org/our-network/regions-members/europe/publications-and-resources/76-travelling-and-diabetes.html
11. https://www.fda.gov/medical-devices/safely-using-sharps-needles-and-syringes-home-work-and-travel/best-way-get-rid-used-needles-and-other-sharps

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