Travelling with medicines

The overseas traveller needs to plan ahead to ensure medicines are available and used properly. This planning needs to take account of relevant legal, customs and Pharmaceutical Benefits Scheme restrictions. Medicines should be transported in their original packaging whenever possible and refrigeration during flight is seldom necessary. The timing of the use of drugs, like insulin, can be difficult when crossing time zones. A health summary including any allergies and a medication list, which includes generic names, is of great assistance to the traveller. Advice should be given about any new medicines that are prescribed or advised specifically for the trip such as drugs for malaria prophylaxis. The traveller may also seek advice about which drugs to carry in a medical kit.

In 2004, Australian residents made 4.4 million short-term overseas departures¹ and the number of Australians travelling continues to grow. These travellers include many people with chronic illnesses taking long-term treatment, so the need to travel with drugs is common. This raises questions about supply, packing and storage, documentation and the timing of medicines. There are also issues concerning drugs taken specifically for the trip such as prophylaxis for malaria.

People need to ensure that they have sufficient quantities of their regular drugs prescribed and dispensed before travelling. The patient should check the expiry date to make sure the drugs will not expire during the trip.

Drugs subsidised by the Pharmaceutical Benefits Scheme (PBS) can only be taken or sent out of Australia for the personal use of the traveller or someone they are accompanying such as a child. There are other legal restrictions on the quantity of PBS drugs that a traveller can take or send overseas. The formula for calculating the designated amount is in the providers section of the Medicare Australia website.^* Information for the general public about taking PBS medicines overseas is also available from the Medicare Australia website.^† The designated amount can be as much as 360 days' supply for some items. Patients should only take with them a quantity that is appropriate for the duration of travel and allows for any unexpected delays in returning to Australia. In some instances patients need to contact the embassy of the countries they are visiting to ensure their medication is legal there. Medicines most often affected by legal restrictions are narcotic analgesics and amphetamines. However, some medicines that may not be scheduled as addictive in Australia can be illegal in other countries. For example, taking medications containing codeine into some countries, such as United Arab Emirates, is illegal.

Problems can arise if travellers need more medicines after the PBS-designated quantity is used. Drugs can be prescribed on a private prescription, supplied by a pharmacist in Australia and sent overseas. However, the Australian Customs Service should be contacted to ensure it is legal to export the medicines concerned and the embassy of the country of destination should also be asked if that importation is legal.

Travellers should be advised to transport their drugs in their original containers wherever possible. This ensures the drugs are clearly labelled and also reduces the risk of difficulty with customs officials on arrival overseas. To help ensure that the drugs are available when needed the supply should be either carried in hand luggage or divided between hand luggage and checked luggage. It is a good idea to suggest that there is enough medicine in the hand luggage to cover the duration of travel and several days afterwards in case checked bags are delayed.

Some drugs can be adversely affected by temperature and this creates potential problems during travel, especially if refrigeration is required. As a general rule airlines are not willing to take the responsibility of storing passengers' medicines in aircraft refrigerators. As well as the reluctance of the airlines, there is also the risk that doing so could result in the drugs being lost.

Storage away from heat is necessary for some formulations. These include pessaries and suppositories that are designed to melt at body temperature.

The product information and consumer medicine information for thyroxine were changed in 2004 to state that thyroxine should be stored in a refrigerator between 2 and 8^oC. This recommendation has been controversial because of concerns that condensation forming when a refrigerated glass bottle is opened may damage the tablets and affect potency.² However, the product information and consumer medicine information note that thyroxine can be stored at room temperature (below 25^oC) for a maximum of four weeks if refrigeration is not possible, for example during travel. If travel is for longer than four weeks, the patient could take a second unopened bottle of thyroxine and refrigerate this after arrival at their destination.

Insulin remains stable at room temperature for several months³ so refrigeration during travel is not necessary. Packing double the quantity of insulin needed and dividing this between hand luggage and checked luggage has been suggested.⁴ Insulin should be transported in its original packaging and travellers should take a doctor's letter with a health summary, medication list and a statement about the injecting and testing equipment they are carrying. A Medic-Alert bracelet is a worthwhile extra precaution, especially if travelling alone.

A health summary including any drug allergies and an up-to-date medication list are very helpful for all travellers with chronic medical problems. As brand names vary from country to country the generic names of the medicines should be included. Medical software programs that allow printing of a patient summary make summaries easier to provide and more legible. If they do not have a doctor's letter, patients can complete a Medicine export declaration form.^†

The traveller should be advised to take adequate supplies for all chronic conditions including those that may not have been a recent problem, but which could recur. A good example of this is asthma where exposure to triggers in other countries can lead to a recurrence in someone who has been free of attacks for some time.

Diabetes

The timing of drugs for diabetes during travel is a common medicines management problem. Patients on oral hypoglycaemic drugs should take them as prescribed according to the local time. Those taking insulin should seek advice from their specialist on adjusting the doses if time zone changes are involved. A detailed itinerary of the trip is helpful with departure and arrival times, duration of flights, stopovers and approximate meal and snack times. The patient should carry a supply of rapidly acting carbohydrate such as jelly beans as a precaution against hypoglycaemia.^‡

Trips with a change of time zones of less than four hours do not usually require an adjustment of insulin dosage. East or west trips with greater time zone changes may require adjustment. One simple regimen which is suggested for people who are familiar with managing their diabetes is to monitor the pre-meal glucometer reading and give an appropriate dose of short-acting insulin. Longer-acting insulin can be added before sleep on the plane on long flights. The traveller then returns to their usual dose the morning after arrival.

Contraception

Travel across time zones can cause confusion about timing of the oral contraceptive pill. Regular dosing is especially important for the progesterone-only pill. The risk of decreased effectiveness arises with flying west where the time between doses is prolonged if based on local time. Travellers taking the oral contraceptive pill can take a second watch and leave this set to the time at home. When adapting to local time on arrival the traveller should err on the side of a shorter dosage interval rather than extending the dosage interval.

The extent to which the risk of travel-related deep vein thrombosis is increased by the combined contraceptive pill is not yet known. In the absence of other risk factors women can be advised to use the standard precautions which include exercises and maintaining hydration. Below-knee compression stockings are an additional precaution. Aspirin has not been shown to be effective at preventing deep vein thrombosis. It is associated with an increased risk of gastrointestinal bleeding so aspirin cannot be currently advised for prophylaxis.

Purchasing drugs overseas

Buying medicines overseas can be problematic due to confusion over variations in brand names and in some countries due to counterfeit drugs. In parts of Asia, Africa and South America 10-50% of prescription drugs may be counterfeit.⁵ This causes problems with efficacy and occasionally with toxicity. If travellers have to purchase medicines overseas they need to check the generic name of the item and if possible get advice from a pharmacist. Buy from a reputable source, not a street market.

Travellers often ask what medicines and first aid supplies should be included in a medical kit for travel in addition to their regular drugs. These kits can be quite extensive depending on the nature of travel and include first aid items such as antiseptic and dressings, illness care items such as analgesics, antidiarrhoeals and rehydration salts, and preventive care items such as insect repellent, antimalarial drugs, sunscreen and condoms. In a study of British travellers the most frequently used items in travel to developing countries were analgesics, treatments for diarrhoea, antiseptics and sticking plasters. Under-use of insect repellents was noted, and 16% of the travellers in the study used antibiotics during their trip, most commonly for travellers' diarrhoea.⁶

A new prescription may be needed for the prevention or treatment of illnesses associated with travel. The most common examples are drugs for malaria prophylaxis and self-treatment courses of antibiotics for travellers' diarrhoea. Consideration needs to be given to indications, contraindications, possible adverse effects and interactions. Poor compliance with drugs for malaria prophylaxis is common, especially with more complex regimens. Advice is therefore needed to improve compliance and on how else to reduce the risk of infection.

^*http://www.medicareaustralia.gov.au/providers/programs_services/pbs/overseas_drug_diversion/about_oddp.htm#legal

^†http://www.medicareaustralia.gov.au/yourhealth/going_overseas/travelling_overseas/taking_pbs_medicine_os.htm
(or phone 'Travelling with PBS medicine' enquiry line 1800 500 147)

^‡Travel and diabetes. Diabetes Australia: http://www.diabetesaustralia.com.au. Go to Resources/fact sheets.

Conflict of interest: none declared

The following statements are either true or false.

1. When a patient with insulin-dependent diabetes travels by air, their insulin must be kept in the aircraft's refrigerator.

2. There are no limits on the quantity of Pharmaceutical Benefits Scheme drugs that can be taken out of Australia for personal use.

Answers to self-test questions

1. False

2. False