MacLeod Diabetes & Endocrine Centre Royal Devon & Exeter Hospital

Travelling with insulin-treated diabetes

Having diabetes shouldn’t prevent you from travelling, but you will need to plan ahead. Vaccinations – may need to be ordered in advance Organise any vaccinations you need through your GP well before travelling. Insurance You need travel insurance to cover any possible illness. It’s essential you are covered for claims related to your medical conditions including diabetes, and that you answer all questions about medical conditions completely. Hospital admissions can be extremely expensive, particularly in North America – tens or even hundreds of thousands of dollars. Standard policies may not cover risky or adventurous sports such as skiing, scuba diving, paragliding or even mountain biking. Check! EHIC card A European Health Insurance Card gives access to some health services free or at reduced rate in most European countries. It doesn’t cover all health costs, and is not an alternative to travel insurance. Some insurers insist you have an EHIC card if travelling in Europe. You can apply online, and it’s free. Beware scam websites which charge a fee. Travel letter for airport security From your diabetes clinic or GP surgery. Medical alert jewellery Consider getting a necklace, bracelet or card for your wallet, to show your need for insulin and any other medical treatment, just in case you were in an accident and admitted to a foreign hospital.

Travelling with insulin-treated diabetes

Written March 2016

Take enough insulin – order it in advance Work out your expected insulin requirement for the duration of your trip, and order at least 50% more. You need some spare for unexpected events. If you need an extra prescription, make sure you request this well in advance.

Example. Sue is going away for six weeks. She normally takes Levemir 16 units morning and evening. She has NovoRapid with her meals, about 10, 14 and 16 units on average. Levemir requirements. Her total is 32 units per day. Each cartridge contains 300 units, so lasts 9-10 days. She will be away for 42 days, so will use 4-5 cartridges. NovoRapid requirements. Her total is about 40 units per day. Each cartridge is 300 units, so lasts 7-8 days. She is away for 42 days, so will use about 6 cartridges. Outcome. Sue decides to take two packs of 5 cartridges of Levemir, and the same of NovoRapid. It’s more than she’s likely to need, but it doesn’t take up much space and it’s reassuring to have some spare.

Take enough test strips – order in advance Work out how many blood glucose strips you need for four tests per day, and then at least double it. If you normally test more than four times a day, then take at least double that. Your diabetes may behave differently when away, due to changes in food or activity, and you need to be prepared to check your blood more frequently. In particular, if you get an illness like traveller’s diarrhoea, you may need to check your blood every two hours. If you have type 1 diabetes, take a supply of urine ketone strips, or blood ketone strips if you have a ketone meter. Example. John is going away for three weeks. He normally does a blood test 4-5 times per day. He will be away for 21 days, when he would normally get through 80-100 test strips. John decides to take four boxes of 50 strips – about double what he expects to need.

Travelling with insulin-treated diabetes

Written March 2016

Plan how you will carry and store your insulin Usual advice is that your in-use insulin can be kept at room temperature (11-25°C) for up to four weeks, and insulin that isn’t in use should be in a fridge (2-8ºC). When travelling, your insulin won’t “go bad” out of the fridge for a few days. You do need to make sure it isn’t exposed to high temperatures or direct sunlight. If you are flying, your insulin should be fine in hand luggage for the journey out and back. During the holiday, keep the insulin you aren’t currently using in a fridge. If there isn’t a fridge in your room, check if there is another fridge you can use that is reasonably secure. If you will travel from place to place in a hot climate, plan how to keep your insulin cool. Kitchen freezer blocks (“ice packs”) can help, but need to be recharged in a freezer, and need care to avoid freezing insulin which can be as bad as overheating. Frio wallets are available online. They use water evaporation to keep insulin at 18-26ºC – room temperature. This should be OK for journeys if your insulin goes back in a fridge at each destination. It’s also fine for your in-use insulin for up to four weeks. Long trekking trips could be a challenge. You could carry insulin with you for up to four weeks, if you took great care to ensure it was always cool. You’d need to leave a cache of insulin safely in a fridge somewhere. You’d need to plan how to get back to the insulin cache, or back to a pharmacy, in a hurry if the insulin you had with you stopped working earlier than expected. Plan how you will obtain new insulin in an emergency What would you do if all your insulin was damaged, lost or stolen? Find out a little about medical services in the country you are travelling to. If you are travelling to remote areas, plan where you would go to buy more insulin. Make sure you could pay for new insulin. Consider taking a credit card or cash, for emergency use only, entirely separate from your holiday spending money. The NHS cost of insulins like NovoRapid, Humalog, Lantus and Levemir is around £40 per pack of five cartridges. The cost in other countries could be more or less. In many countries you need a prescription from a local doctor. Take a copy of your UK prescription and a letter from your diabetes clinic if you have one, to confirm you need the insulin.

Travelling with insulin-treated diabetes

Written March 2016

On the journey

Don’t get separated from your insulin It needs to be in your hand luggage. Luggage checked into the hold might not arrive at your destination, or might be damaged by careless baggage handlers, or might be frozen in the aircraft hold. Airport security You are unlikely to have problems. About 1% of the UK population take insulin, so hundreds of insulin-treated passengers pass through a large airport like Heathrow every day. A letter from your GP or diabetes centre is a useful precaution in case you meet an inexperienced member of security staff, or if there are raised security precautions. If necessary, explain that you need your insulin for life-or-death reasons. Travelling across time zones For short-haul – e.g. Europe or the Canaries – the time difference is only an hour or two, so there shouldn’t be a problem. We recommend using local times – if you normally take long-acting insulin at 10pm, take it at 10pm Greek time while holidaying in Greece. Longer flights to Africa also shouldn’t be difficult, as the direction of travel is mainly south and you don’t cross many time zones. Long-haul flights east and west are more tricky. Examples are provided below for the most common long-haul flights, across the Atlantic. For longer journeys, e.g. to Australia, you’ll need an individualised approach depending on stopovers and how long it takes you to adjust to new time zones. If in doubt, discuss with your diabetes specialist team. It’s easiest if you use “basal bolus” insulin – a combination of short-acting insulin with meals, and usually one or two injections of long-acting insulin in the background. If you have another insulin regimen (e.g. two injections per day of long-acting or mixed insulin), you may need to have another type of insulin prescribed for your journey.

Travelling with insulin-treated diabetes

Written March 2016

Flying west When flying west, your day is lengthened. Your plane could land at bedtime in the UK, but the sun is shining and it’s time for a swim!

Example. Bill goes to Florida. The flight leaves at 11.15am, and takes 10hr, arriving at 9.15pm UK time. Due to the 5 hour time difference, local time is 4.15pm. Bill’s normal insulin. NovoRapid 10-14 units with meals, Lantus 40 units at 10pm. On the plane. Bill sticks to UK time. Lunch and an evening meal are served onboard, and he takes his usual NovoRapid with these meals. After landing. Bill changes his watch to Florida time. Now he has an extra five hours, and needs to decide when to go to bed and what to do with his insulin. Option 1 – “fill the gap”. Bill plans to stay up until 10pm, Florida time. That’s 3am in the UK, so it feels late – but he’s on holiday! He’ll take Lantus at 10pm, but the time difference means it’s 29 hours since the previous dose, which will have run out. He needs an extra dose of NovoRapid to ‘fill the gap’ at about 5-6pm, Florida time. The five hour time difference is about a fifth of a full day, so the extra dose is about a fifth of his daily background insulin (Lantus 40 units), or 8 units. Bill has a meal at the same time, and needs 12 units for that, so the total is 20 units NovoRapid. To be cautious, he drops to 18 units and keeps an eye on his blood glucose that evening. Option 2 – change over two days. On the day he arrives, Bill goes to bed and takes his Lantus at 7.30pm Florida time. That’s just after midnight in the UK, so quite late, but manageable. Next day, he goes to bed and takes Lantus at 10pm Florida time. Because each day is only 2½ hours different from the previous day, there’s no need to plan extra insulin doses. Bill may find his blood glucose levels are a little higher before bed, and he can take a little extra NovoRapid if necessary.

Travelling with insulin-treated diabetes

Written March 2016

Flying east When flying east, your day is shortened. Often flights leave in the evening and arrive the following day in the UK, so you have a short night.

Example. Bill’s flight leaves Miami at 8.30pm. He lands the next morning at 9.30am UK time – but as he’s used to Florida time, it feels like 4.30am. Bill’s normal insulin. NovoRapid 10-14 units with meals, Lantus 40 units at 10pm. The problem. If Bill takes Lantus at 10pm Florida time one day, and at 10pm UK time the next day, the two doses will be only 19 hours apart. The doses will overlap for a few hours, and he may be at risk of hypos. Option 1 – reduce the dose. Bill keeps his watch on Florida time on the plane, and takes his Lantus at 10pm Florida time (1-2 hours after departure). He reduces the dose by about a fifth (because the five hour time difference is about a fifth of a full day). So that’s a dose of 32 units. On arrival in the UK, he switches to UK time, and takes his Lantus at 10pm that night. He makes sure his blood glucose isn’t too low when going to bed. Option 2 – change over two days. Bill doesn’t want to go to bed at 10pm on the day he gets home, because it feels like 5pm Florida time and he’s not tired. Instead he goes to bed and takes his Lantus at half past midnight (7.30pm Florida time) which is OK because he didn’t get much sleep on the plane. The following night, he goes to bed and takes his Lantus at 10pm UK time. Because each day is only 2½ hours different from the previous day, there’s less overlap between the Lantus doses. If overnight hypos were a particular concern for Bill, he could reduce the Lantus doses by around 10% (to 36 units) on the day he leaves Florida and on the day he arrives in the UK.

Travelling with insulin-treated diabetes

Written March 2016

While you are away Be prepared to adjust your insulin doses If eating out and having holiday treats, you may need more insulin. But in hotter weather, people often eat less and need less insulin. Lazy holidays may need more insulin. Activity holidays may need less insulin. Be careful with alcohol Some alcoholic drinks are quite sugary, raising your blood glucose levels for a few hours. Overnight, the effect of alcohol tends to be to lower blood glucose levels, so beware hypos overnight or the following morning. It’s not a great idea to be very drunk if you take insulin, as it can be hard to tell the difference between a hypo and the effects of alcohol. So generally, keep a closer eye than usual on your blood glucose levels Test a bit more often, particularly in the first couple of days. Illness If you are unfortunate enough to develop a traveller’s illness, e.g. a stomach upset, watch your blood glucose levels even more closely. Test every two hours if your levels are high, and at least four times per day if they aren’t high but you feel ill. We can’t cover all advice for illness here, so make sure you know what to do. People with type 1 diabetes need to be particularly careful when ill. Remember that if you are off your food, you might need less insulin than usual, but often you will need the same or more insulin than usual. Check your blood glucose frequently and be prepared to take extra insulin every two hours if your readings are high. If you don’t normally use quick-acting insulin, consider taking some on holiday just in case, plus urine ketone strips or a blood ketone meter. If you would normally go to see a doctor in the UK, then go to see a doctor. Don’t allow yourself to get very ill because you were nervous about a foreign health system.

Travelling with insulin-treated diabetes

Written March 2016

Travelling with an insulin pump Most of the preceding advice applies with some obvious modifications. Make sure you order and take enough supplies (cannulae, lines, cartridges) as well as enough insulin and blood test strips. Make sure you know what to do when you are ill. You may not have ready access to a nurse or doctor with insulin pump expertise. Your pump could fail on the first day. Take equipment (insulin pens, plus long-acting insulin, plus needles) to allow you to convert to conventional insulin until you come home. Travelling across time zones is easy with a pump. If you have a simple basal rate profile, you might not need to change anything. Your pump should be insured on your household insurance. Make sure that this, or your travel insurance, will cover for loss or damage while you are away. Do not send your pump through the X-ray machine for carry-on luggage. Walk-through or hand-held metal detectors should not harm your pump. Check the information on your pump manufacturer’s website. There is likely to be information in your pump’s manual, or a separate information card for airports.

Travelling with insulin-treated diabetes

Written March 2016