Answering patients’ travel worries

Our travel health experts provide a guide to answering those tricky questions patients sometimes ask before travelling

1. Will my pacemaker set off the airport security alarm?

Most people with pacemakers can travel without taking any special precautions but it is one of the situations where having a pacemaker identification card can be very useful.

Patients can be reassured that walking at a normal pace through a detector won't affect their pacemaker.1 But – just as with retail and library security systems – it's best not to linger near or lean against these devices.

It's possible the pacemaker's metal case could set off the detector. So when patients approach airport security they are best advised to identify themselves as having a pacemaker and show their card. The security staff can then decide whether they want your patient to walk through the detector or use a hand-held screening device to clear them through.

2. How should I manage my insulin when crossing time zones?

Crossing time zones can cause real alarm for insulin users who are infrequent flyers, but many people with diabetes fly frequently without any serious problem.

It is worth reassuring them that running glucose levels that are a little high for up to 24 hours is unlikely to lead to any real problems. This is especially true for patients with type 2 diabetes who are using insulin on top of oral medication.

If the time zone change is less than four hours, patients will not need to make any major changes to their injections.

But a general rule of thumb for longer flights is ‘westward = more insulin; eastward = less insulin'. When travelling east to west the day is lengthened and patients might want to take an extra meal and cover it with extra insulin. When travelling west to east, the day is shortened and they may eat less and so cut the amount of insulin.

A basal-bolus regime is a generally much more flexible approach that fits well with longer or more complicated journeys. In fact, frequent flyers often opt to switch to this approach.2

Changing to, for example, insulin glargine (Lantus) for basal insulin, with lispro (Humalog) or aspart (NovoRapid) cover before each meal, is a flexible and effective regimen.

But there's a potential problem with this for some patients if their normal sleep cycle is broken, which can mean the medium or long-acting insulin is taken more than once in 24 hours, risking a hypo.

So it is becoming more common for patients to leave out medium or long-acting injections altogether and rely on short-acting insulin before meals until they're safely back on a 24-hour clock at their destination. Many travellers find this very helpful because it allows them the flexibility they need.

But seek the advice of a specialist if your patient's glycaemic control is typically poor or if they have a particularly complex insulin regime.

One final tip: travellers are often advised to change their watches at the start of the journey to the time at their destination. Patients with diabetes should leave their watches unchanged as this will make it easier to judge the timing of their insulin injections and meals.

3. Can I get a letter to confirm you have prescribed my pills?

Many travel insurance companies rather unhelpfully tell customers who are taking prescribed medicines that they need to take a doctor's note with them.

But the best method of confirming medication has been issued by a GP is the repeat prescription form, so advise patients to take that with them. It is printed on NHS paper which – unlike a standard A4 typed letter – cannot easily be changed and includes practice contact details if airport security staff need more information.

An exception is people with diabetes who use insulin. They should be given a letter explaining their need to carry syringes/injection devices and insulin, which they should present to the airline and airport staff. If they encounter any problems they should ask to speak to a manager or senior member of staff.

As a general piece of advice, patients should take as much medication as they need for the flight – plus a few days' extra in case their luggage is delayed – and put the rest in the hold. Insulin though should not be put in the hold as it may freeze. Patients should put all the medications they want to carry in hand luggage in a clear plastic bag or dosette box, along with the repeat prescription order form, and place it in a tray to go through the scanner.

One group of patients had – until recently - a very specific problem when flying to the US. Under the visa waiver scheme travellers from the UK to the US are asked to fill out a green landing card. Up until last year this included a tickbox to confirm they were not infected with HIV- and those with HIV were deemed ineligible for a visitor's visa. Many patients were simply ticking ‘no' on the landing card- but this left a particular problem with carrying HIV medication. Some took the risk of keeping it in their hold luggage while others posted it to their destination in advance. But last year that restriction was finally removed and patients with HIV can now travel to the US with their medication like any other patient.

4. Can you give me a six-month prescription? I'm going to Spain for the winter.

The Department of Health does not specify the period for which prescriptions may be issued as that decision is best made by the patient's GP, taking into account his or her detailed knowledge of the patient's medical history and current medical condition.3

So there is no explicit time limit on prescriptions for patients travelling abroad, but primary care organisations seem to agree that prescriptions for patients leaving the country should not exceed three months.

And it is not considered good clinical practice to prescribe large quantities of drugs to a patient going abroad for an extended period without being able to monitor the patient's progress. Doing so may put you at medico-legal risk.

If a patient asks for additional or longer prescriptions to cover longer stays abroad they could be offered a private prescription (free) for the additional period or be advised to seek advice from a local doctor. It may be helpful to provide a list of current medications and a summary of the patient's relevant medical history.

Pensioners living abroad for extended periods are not entitled to NHS prescriptions for all medications required while out of the country.

5. What's the best treatment for prickly heat?

Prickly heat (miliaria) is caused by the sweat glands becoming blocked, forcing sweat into the skin. It can occur anywhere on the body, but usually appears on the neck and trunk. There are three types: miliaria crystallina, miliaria rubra (the most common) and miliaria profunda.

Miliaria crystallina

• Blockage is in the upper epidermis

• Rash is usually small, clear spots and isn't normally itchy or red.

• Common in babies under two weeks old and adults with fever or have recently entered a tropical climate

Miliaria rubra

• Blockage is deeper in the epidermis.

• Commonly affects one to three week old babies and adults in hot, humid environments.

• Rash contains red spots and skin around the rash is also reddened- can be very itchy and accompanied by prickling sensation

Miliaria profunda

• Blockage in the dermis.

• Spots are large with a flesh-coloured head.

• Usually occurs after repeated bouts of miliaria rubra

• Rare outside tropical countries.

Some medicines have reportedly caused prickly heat, including neostigmine, bethanechol, clonidine and isotretinoin.

In most cases the rash will clear within days without any treatment, but severe cases can last for several weeks.

If the rash is particularly itchy or uncomfortable, patients could try using cooling creams containing menthol or calamine. Lanolin-based creams have shown some benefit in miliaria profunda.

Complications are uncommon. Occasionally, a staphylococcal infection can develop, but most will not require antibiotics. In miliaria rubra or profunda, there is a risk that the lack of sweating may lead to heat stroke.

The key to management is to stop sweating. Patients should avoid hot, humid environments and if they can't they should try to become acclimatised to the heat slowly, stick to cool, air-conditioned places as much as possible and wear loose, lightweight clothing.

6. How can you help me with my fear of flying?

People with a debilitating phobia of flying can benefit from formal psychological therapies such as systematic desensitisation and cognitive behavioural therapy. And a benzodiazepine is clinically justified for patients who fly infrequently, but are extremely anxious when they do.

If your patient flies frequently with work they should ask their employer to fund a course of therapy – and a letter from you might help.

But there are simple, helpful tips you can give nervous flyers:

• Leaving plenty of time to get to the airport and check-in will help reduce stress before you get on the flight.

• Turbulence is normal but unsettling.

• Ask for a seat at the front – turbulence is usually much worse in the back of the aircraft.

• Don't be afraid to tell the cabin crew about your fears – they are trained to help and will keep an eye on you during the flight.

• Use a variety of distractions – music, magazines, books, puzzles – whatever occupies your attention. Working may help but avoid anything that's stressful.

• Talking to the person next to you can help take your mind off the flight.

• Avoid sugary snacks and caffeine-fuelled drinks that will overstimulate you.

• A small amount of alcohol can take the edge off your nerves, but don't drink excessively and drink plenty of water.

• Try to identify anything that happened on a previous flight that triggered your fear – it could help ease your anxiety.

7. Does melatonin work for jet lag?

A number of studies of airline crews have shown melatonin has the potential to reduce long-haul jet lag and a Cochrane review concluded it seems effective and short-term use is safe.4

Melatonin is not a regulated drug – either in Europe or the US – so recommendations on its use in general and its dose in particular need to be given very carefully. It's probably not a good idea to suggest it without prompting from the patient. But those who do ask should know of the evidence to date.

The research seems to suggest the following strategy can be effective:

• Eastbound travellers should take melatonin 3-5mg for three nights before departure at 2am or 3am destination time, then at bedtime for four days after arrival. So, for instance, if travelling to Bangkok you would take melatonin at around 9pm for three nights before travelling.

• Westbound travellers need not take melatonin before departure, only after arrival at bedtime for four nights.

Patients will ask you to recommend a dose and the Cochrane review suggested no benefit over 5mg, so it is probably safer to advise patients to try a 3mg dose.

Those who would prefer not to use melatonin can try using light cues to try and restore normal body rhythm. Again- there's not a hugely reliable evidence-base but there is emerging data that suggests it can help5. And it's a more appropriate recommendation than use of a unlicensed medication

• West-to-east travellers who cross six or less time zones should increase their exposure to morning daylight for the first few days after arrival, if possible to at least as many hours of light as the number of time zones crossed .

• Those crossing seven or more time zones should stay indoors early in the morning and get their sunlight later in the day.

• Those travelling west should do the opposite.

• Indoor light does not have the same effect.

Even if one cannot adhere to the specific recommendations, the greater exposure to the outdoors on arrival appears to be helpful in adjustment.

Our expert travel health panel included:

Dr Margaret Williams, a dermatology GPSI in Glasgow

Dr Ali Ansari, a GP in Birmingham and medical director of TravelWell Clinic

Dr Helen Fraser, a clinical psychologist for the South Wales Psychotherapy and Counselling Society