Endocrinology Metabolism

Travel and Diabetes

Traveling and Diabetes: What You need to know

Pretrip Preparations

The best way to enjoy travel is to be prepared before traveling. Patients should be advised to start by asking questions. They can go online and look at the area they plan to visit. Questions should include not only what activities there will be to participate in or what sites they will visit, but also what amenities are available at the place where they will stay, as well as what health care is available in the area. It will be important to be ready for the unexpected such as flight cancellations, lost luggage, unavailable food, and potential illness. Understanding what can go wrong and being prepared will make traveling more enjoyable, with a positive outcome.

I recommend that 4 to 6 weeks before travel, patients schedule an appointment to discuss their travel plans and review their diabetes program. It is also a good time to review sick day care, foot care, and provide travel letters and prescriptions as needed. Use this time to be sure patients have written down their insulin doses, a list of all their medications, or pump settings. Many patients assume they can call their health care providers at any hour to get this information if needed. Remind patients that it is their responsibility to keep this information with them at all times, even when not traveling.

Although sick day plans may have been discussed, if the sick day plans have not been used, patients may no longer recall what they are. Use this time to review sick day care for any illness that may occur while traveling. If patients are on an insulin pump and their pump breaks down, be sure they have a backup plan and long-acting insulin with them as a backup. This is where they will also need to know or have written down what their pump settings are as they may need to convert to injections.

Provide travel letters even if they are not flying. These letters should include what medications they are taking, insulin dose, diabetes supplies they may be traveling with, and any other information they may need, not only to get through security at an airport, but also that can be presented in an emergency room if needed. Provide prescriptions for their medications in case any medications are lost. Patients may not be able to get insurance coverage if the prescriptions have just been filled, but the patients can pay cash for what they need in the interim. Having all prescriptions on file with a national pharmacy is also helpful. If the pharmacy is available, in most cities across the country they can walk in and get their prescriptions filled in an emergency.

The letter and prescriptions should be photocopied. Place the letter in several places, such as purse, brief case, and suitcase. Provide a copy to a traveling companion.. If luggage is lost or stolen, extra copies will be available. One copy should always be kept physically on the patient.

Prescriptions should always be written with generic names, especially if the patient is traveling outside the United States. (Medications may have different names in other countries). This will make the medications easier to find if needed.

Prior to traveling, remind the patient to check out health care facilities in the area. Visitor bureaus in each city are helpful in providing this information. Visitor bureaus can be located online before travel occurs. Determining where a pharmacy and emergency room are located ahead of time may be helpful in an emergency.

In an emergency, patients should be aware that a prescription may not be required to purchase some medications and supplies, but prescriptions are needed to get coverage by insurance companies. Oral medications require prescriptions. Rapid-acting insulins (Humalog®, NovoLog®, Apidra®) require a prescription. All other insulin may be purchased over-the-counter without a prescription. Blood glucose testing supplies may also be purchased in a pharmacy without a prescription.

Advise patients to contact their insurance company before they travel to determine what health care coverage they have once they leave their home state. Some insurance companies require obtaining approval if patients are seen in an emergency room out of state, or may require patients to go to a specific health care system. If patients are admitted, they may only have a certain number of days in the hospital before they must be transferred home. Determining this information before traveling is helpful.

If traveling out of the country, patients may need new vaccines or boosters for vaccines they have already received. Patients often do not realize that vaccines may need to be taken months ahead of the trip to be effective or may need to be given in a series over several weeks.

Being sure that the patient's tetanus booster is up-to-date before traveling is a good idea. Patients may go to www.cdc.gov to check the list of vaccines they might need based on where they will be traveling. They can also call a local hospital and speak with their department of health travel or infectious diseases, or the public health department to learn what shots are needed. The public health department can usually provide them. Remind patients to provide a list of these vaccines and boosters to be put in their medical record and to take a copy with them when traveling.

All patients with diabetes should wear a medical alert and carry a medical alert card in their wallet. However, if they have not yet done so, this is a good time to start wearing one and placing a medical alert card in their wallet. If patients are found unconscious or have symptoms of low blood glucose, they will receive the correct care.

Packing for Travel

Packing will depend on where the patient will be traveling, the climate, the travel schedule, whether traveling for work or pleasure. In addition to clothes and the correct shoes, diabetes supplies, snacks, and items for an emergency should be packed. Encourage patients to make a list of the activities they will participate in, how many days they will be gone, and their schedule. They can then match up clothes needed for each activity or event and enough supplies and medication for the days they will be gone. Checklists of all diabetes supplies and medications, and needed clothes is often helpful.

Patients should be advised to pack twice as much medication and supplies as they will need. The extra amount is always good to have in case the patient gets ill, or some medicines get lost or damaged. Medications and supplies should never be packed in checked luggage. They should be put in carry-on bags.

Put all medications with original prescription labels in zip-lock bags. If the patient will go through security at an airport, these can be pulled out of the carry-on bag to go through x-ray. Although they should be taken out so that the security agent can see them, they do not count as part of the 3-ounce liquids that must also be in a zip-lock bag. It is best not to try and get juice through security to treat low blood glucose. Carry glucose tablets or life savers to treat low blood glucose. Once through security, cans of juice can be purchased.

Supplies to treat low blood glucose, as well as snack foods, can be packed in the checked luggage. Food may be difficult to get when traveling, might be expensive, and may not be healthy. Having items to treat low blood glucose in both carry-on and checked bags allows the patient to always be prepared.

If available, pack a second blood glucose meter to have as a backup in case a meter stops working or is lost. Also, pack extra blood glucose monitoring strips and lancets.

Traveling can be dehydrating. Carrying a water bottle that can be easily be filled once through security or anywhere on the road will help prevent dehydration. Lip balm and hand cream are also helpful. If traveling to an area with sun, sun tan lotion, a hat, and sun glasses are important.

Take comfortable shoes and socks if the trip will include any walking. Buying new shoes before travel may not be in the patient's best interest. Purchase shoes at least 2 to 3 weeks before the trip. This will allow the shoes to become broken in and to ensure they are comfortable for walking. Shoes that are broken in and comfortable will prevent blisters from developing.

Whether the patient has neuropathy or not, foot care should be reviewed before travel. Any signs of blisters or ulcers should be taken seriously. Advise patients to travel with more than one pair of shoes. Alternating shoes that are comfortable will decrease the risk of irritations, blisters, calluses, or other potential problems.

Insulin on the Road

Once opened, Insulin is good for about 1 month at room temperature, depending on the type of insulin. It should not be allowed to get warmer than 86° F or colder than 40° F. If the patient will be traveling to areas where the temperature will be outside these limits, to be sure that the insulin is not exposed to extremes in temperature, keeping it in a cool pack is helpful.

There are several cool packs commercially available. Frio cooling products have an outer wallet size for use with either vials or a pen device. The wallet comes with a reusable gel pack that, when run under cold water for 5 to 7 minutes, activates the gel pack. The gel pack will keep the insulin or other medications cool for 3 to 5 days. The gel pack is reusable indefinitely (www.wisechoicefrio.com). If the patient is unsure of the temperature, using a cool pack will keep insulin at a safe temperature.

Remind the patient not to put syringes, pen needles, lancets, or insulin pump supplies in the trash while traveling. These supplies can be placed in a personal size safety box, or a small disposable plastic box. They should be placed in their suit case or carry-on bag and disposed of at home according to local regulations.

Insulin Names, Concentration, and Insulin Syringes

Insulin may have different names outside the United States. For instance, 70/30 insulin is called 30/70 insulin in Europe. If the patient needs to replace insulin when traveling, it will be important to be sure the patient knows what it is called in the country being visited. Each of the insulin companies has an 800 number (on box of insulin) and a website. Determining the name of the insulin in the country the patient will be visiting is helpful.

In the United States, the concentration of insulin is u-100. This means that there are 100 units of insulin in 1 ml of fluid. In Europe and other countries, the concentration of insulin is usually u-40. This means that the patient will get 40 units of insulin in 1 ml of fluid. If u-40 insulin is used, then it is important to use u-40 insulin syringes to be sure the correct dose is taken. Assuming the patient has a u-40 syringe to use with the u-40 insulin, the dose will not change. If the dose is 20 units of u-100 insulin with a u-100 syringe, then the dose will be 20 units of u-40 using a u-40 insulin syringe. The patient will just get more fluid with the u-40 insulin and syringe.

If the patient uses a u-100 syringe with u-40 insulin, the patient will get less than half of the usual dose of insulin. If a u-40 syringe is not available for u-40 insulin, then multiply the usual u-100 dose by 2½. Take the new dose using u-40 insulin in a u-100 syringe.

Example: Usual dose of u-100 insulin is 20 units.

Available insulin is u-40

Available syringes are u-100

20 units x 2.5 = 50 units of insulin

Insulin pens have been used in Europe long before they were used in the United States. Finding them should not be difficult.

Adjusting Insulin for Time Zones

It is best to adjust to the new time zone as soon as possible. If the time zone change is less than 3 hours, adjusting to the new time zone is relatively easy. Be sure that the patient understands the need to adjust insulin in both directions when traveling.

If the time change is 1 or 2 hours on the day of travel, have the patient take the insulin on his or her home time. Upon arrival at the destination, he or she can begin administering insulin using the local time.

When the patient is traveling east with a time change of 3 or more hours, the day will be shortened. On the day of travel, insulin should be taken at the usual time with the usual dose. If there is a concern about hypoglycemia, the dose may be decreased by 10% to 29%. On the first full day at the destination, the patient should awaken at the local time schedule and should take the usual dose of insulin. While in that time zone, the patient should take insulin based on the new time zone.

Traveling west with a time change of 3 or more hours, the day will be longer. On the day of travel, the patient should take insulin at home as usual. If the patient takes a long-acting insulin, the length of the day should not matter. However, if taking only an intermediate-acting insulin (NPH) once daily, the patient may find blood glucose levels higher in the evening. On the day of travel, a second injection of intermediate-acting insulin may be needed at dinner with the regular or rapid-acting insulin. The dose for this second injection of NPH should be about one third of the morning injection. The patient might also compensate by adjusting the dinner regular or rapid-acting insulin.

If the patient takes a mixed insulin (70/30, 75/25, 50/50) once daily, he or she may also need to take a second injection on the day of travel only. The dose for the second injection would be one third of what is typically taken at breakfast.

Patients should always be instructed when they rise on the first full day of travel to start their insulin dosing based on the local time, not their home time. It is not unusual for travel days to cause their blood glucose to be elevated from inactivity or eating food on the go. Patients can be instructed in how to adjust regular or rapid-acting insulin to cover these rises in their blood glucose, but they should be aware that this can occur.

Insulin Pump Travel

The insulin pump clock should be set to the new time zone during travel. Patients should consider using a constant daytime basal rate while traveling. When they arrive at their destination, the pump can be reset with their usual basal rates. Bolus insulin should be taken as usual based on the timing of meals and snacks.

Remind patients to pack extra pump supplies and insulin. All pump settings should be written down in several places in case there is a mechanical problem with the pump. Long-acting insulin should be packed as a backup as well. If the insulin pump fails, patients should call the 800 number on the back of their pump. In most instances, a loaner pump can be shipped to them directly by the pump company within 48 hours.

If patients need to be switched to insulin injections for any reason, they should have a written plan before they travel. Advise patients to tally all of their daily basal rates. The total is then divided by two; 50% of the total is given as long-acting insulin at breakfast and 50% of the total is given as long-acting insulin between 9 and 10 p.m. The patient should then use the usual insulin pump bolus doses before meals using either an insulin syringe and vial or insulin pen.

The patient should continue to use the backup program until their loaner pump arrives. The patient needs to be aware that the loaner pump will need to be programmed with their pump settings. If needing assistance, the patient can call the 800 number on the pump for customer service. On the day the pump arrives, the patient should not take the long-acting insulin in the morning.

Taking Off The Insulin Pump

Based on activity, the patient may choose to be off the pump for several hours at a time. If very active, the patient may not need to replace the basal insulin not received while the pump was off. However, if blood glucose levels are elevated, then the insulin should be replaced when the pump is resumed or for long periods of time by syringe or insulin pen.

To replace the insulin, patients need to know what the basal rates were for their time off the pump. Multiply the rates by the hours off the pump. For example, if their basal rate was 1.0 per hour while they were off the pump and they were off the pump for 3 hours, they would need to take 3 units of insulin. They might prefer to use a correction factor of 1 unit to lower the blood glucose every 50 mg/dl over 150 mg/dl or whatever their usual correction is.

Changing Routines

Anytime a routine is changed, it is easy to forget something. Patients who are on oral medication should be advised to set up their daily pills in a pill box. If the pills are gone, they know they have taken them for that day. All medications and supplies should be kept with the patient in a small carry-on bag.

Physical activity may change while traveling. The patient should be able to adjust medication for both hyperglycemia and hypoglycemia. Being prepared is the best way to enjoy travel.

What's the Evidence?/References

Kruger, DF. "The Diabetes Travel Guide: How to Travel with Diabetes Anywhere in the World".

(This book provides the reader with all the information needed to travel anywhere in the world with diabetes safely.)

Chandrin, M, Edelman, S. "Have insulin, will fly: Diabetes management during air travel and time zone adjustmet strategies". Clinical Diabetes. vol. 21. 2003. pp. 82-5.

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