What particular precautions should be taken during long air journeys when a time difference exists

The problem with time difference concerns primarily individuals who use insulin treatment and is connected mainly with the injections of long acting insulin. In these travels, when the plane flies from east to west, the

24-hour day 'is elongated'. Thus, the first long-acting insulin injection in the destination, if based on the local time, will be later after the previous one (that was injected in the place of departure) than usual. If the difference of time is small (<4 hours), no significant problem usually occurs. If, however, the time difference is larger, a modification in the therapeutic regimen is needed. The modification depends on the type of treatment. Usually, the dose of insulin is given on time (based on the new time) and if a significant time gap exists, it is covered with rapid-acting insulin, depending on the blood sugar levels. The same policy is also usually followed when only one dose of long-acting insulin per day is administered (e.g., insulin Glargine). In any case, during long air-travels, frequent measurements of the blood sugar level (every 2-3 hours) are recommended. In insulin-treated Type 2 diabetics there is usually no need for intermediary administration of rapid-acting insulin, even if the dose is delayed for several hours. Instead, it is recommended that these individuals reduce the intake of carbohydrates at the hours of 'insulin gap'.

When the direction of the air travel is from the west to the east, the 24-hour day is 'shortened'. Thus, the first long-acting insulin injection in the destination will be sooner after the previous one (that was administered in the place of departure) than usual. In these cases, a reduction of the last long-acting insulin dose (before departure) is programmed beforehand (usually by 25-50 percent) and administration of the next injection is given regularly, based on the new time at the destination.

In any case, during such a long journey, a less strict glucose control is preferred: the main objective is to avoid hypoglycaemias, which under these conditions can cause more serious problems.

CASE STUDY 1

A Type 1 diabetic patient is going to travel from Athens, Greece, to Los Angeles, USA. There is a 9-hour time difference and the direction of travel is to the west. The patient is treated with an intensified insulin regimen, with insulin Glargine, 24 units, before bedtime and a very-rapid-acting insulin analogue before each meal. The programme of travel is as follows (Greek time): 08.00: departure from Athens; 17.00 arrival in New York; 18.45: departure from New York; 23.30: arrival in Los Angeles. The local time at arrival is 14.30. What instructions should be given to this patient regarding the administration of insulin?

First of all, the administration of the very-rapid-acting insulin analogue is to be continued as before (i.e., before each meal, depending on the blood glucose levels and the carbohydrates content of the meal). As regards insulin Glargine, two alternative solutions were proposed to the patient:

• Option 1. Administer Glargine regularly (before bedtime and always based on the local time). In this way, there is an insulin gap without coverage with basic insulin of roughly nine hours duration, from the time of arrival in Los Angeles (14.30 local time/23.30 time in Greece -when the patient was supposed to inject his Glargine insulin dose normally, had he not travelled) until the evening of the same day (when the injection will finally be performed). This gap will be covered using very-rapid-acting insulin analogue every three hours, depending on the blood sugar level (Figure 25.1a).

• Option 2. The evening before the departure, split the insulin Glargine dose, aiming at covering the next 33 hours (24 hours of the usual cover + 9 hours of the time difference). Administer half the dose (12 units) at the programmed time (i.e., around 22.00-23.00 hours) and the remainder dose 12 hours later (i.e., 2-3 hours after the departure for New York). The total dose of Glargine can be increased by 25-30 percent because the time period to be covered is increased. Administer the next dose normally, before bedtime, at the day of arrival in the place of destination, based on the local time (Figure 25.1b). In any case, frequently measure blood sugar levels and, if required, correct possible hypergly-caemia with a few units of very-rapid-acting insulin.

CASE STUDY 2

A 61 year old woman with Type 2 DM is treated with a mixture of rapid/ medium action insulin at a proportion of 30/70, with a dose of 38 units in the morning and 18 units in the evening, before breakfast and dinner, respectively. Her glucose control is satisfactory (HbA1c: 7.2 percent). She is to travel from Greece to Thailand. The schedule of her travel is as follows: 06.00: departure from Athens; 15.30: arrival in Ban-gong (local time: 21.30). Before she travels she asked for instructions from her treating physician with regard to the insulin regimen and its adaptation to the time difference.

The time difference causes the following problem: if the second dose of insulin on the day of travel is done at the local time of the country of arrival (i.e., Thailand's time), the injection will be actually performed six hours earlier (due to the time difference between Greece and Thailand). In order to avoid the accumulation of insulin, it was proposed that the

insulin

Glargine (1/2)

Very-rapid acting n

Very-rapid acting (meal)

Glargine (1/2)

22.00

08.00

Glargine (full dose)

Glargine (1/2)

Very-rapid acting

Very-rapid acting (meal)

Glargine (1/2)

Glargine (full dose)

22.00

08.00

17.00 24.00 08.00 (Greek time)

Figure 25.1. Adaptation of insulin regimen in a patient with Type 1 DM who travels to the west by plane: a) Option 1; b) Option 2 (See text).

17.00 24.00 08.00 (Greek time)

Figure 25.1. Adaptation of insulin regimen in a patient with Type 1 DM who travels to the west by plane: a) Option 1; b) Option 2 (See text).

patient reduce the morning dose by 25 percent (i.e., administration of 28 units instead of 38) and administer the second dose regularly, at Thailand local time. A small reduction of the consumed calories (corresponding to the reduction of insulin) was also proposed to her during the journey, so that the blood glucose does not get out of control, as well as intake of a regular dinner after arrival and the injection of the 'evening' insulin dose.

Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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