SUMMARY

Planning ahead is key for travelling with medicines to ensure sufficient supplies, compliance with legal restrictions and adequate documentation.

In general, the Pharmaceutical Benefits Scheme allows up to a six-month supply of subsidised drugs to be taken overseas for personal use.

Medicines should be transported in their original packaging whenever possible. Refrigeration during flight is seldom necessary.

Some medicines, such as insulin, will require adjustment of dosing with a change of time zones.

Travellers should avoid purchasing medicines in low-income countries if possible. Substandard and counterfeit medicines are common.

Introduction

In 2016, Australian residents made 9.9 million short-term overseas departures.1 As greater numbers of older people and those with chronic conditions are travelling, health professionals (in particular GPs and pharmacists) will be providing more advice on travelling with medicines. Carrying medicines while travelling is common. A US survey of over 13 000 travellers found 58% were taking daily medication.2

A review of medicines before travel may reduce the risk of medicine-related problems. Caution is needed if introducing potentially toxic medicines or those that require monitoring. Be cautious when prescribing hypnotics to assist with jet lag, especially in the elderly, as the drugs are associated with confusion and an increased risk of falls.

Before travel, advise patients on the medicines required specifically for travel such as antimalarials and vaccines. The US Centers for Disease Control and Prevention website and ‘Yellow Book’ publication provide information on travel risks and preventive advice.3 Advise also on the risks of purchasing drugs overseas given the increasing problem of substandard and counterfeit medicines.

Supply of medicines for travel

Travellers need to take adequate supplies of their regular drugs and check that the medicines will not expire during the trip. However, there are legal restrictions on taking medicines subsidised by the Pharmaceutics Benefits Scheme (PBS) overseas. Only a reasonable quantity can be taken overseas for the personal use of the traveller or someone they are accompanying such as a child. Information for travellers is available on the Medicare Australia website or by phone.4 In general, a supply for up to six months is not questioned, but up to 12 months may be permitted for some drugs such as antihypertensives. For authority items only six months is allowed. Prescriptions can be annotated with PBS Regulation 24 to allow the pharmacist to dispense the original and repeat supplies of pharmaceutical benefits at the same time.

The Office of Drug Control5 recommends that Australians going overseas carry either a prescription or a doctor’s letter stating that the traveller is under their treatment and that the drugs have been prescribed for the traveller’s personal use. The doctor’s letter must specify the name and dose of the drugs. Generic drug names are preferable as brand names vary from country to country.

Packing medicines for travel

Travellers should take their prescribed drugs in their original containers. To ensure that they are available when needed, carry medicines in hand luggage or divided between hand luggage and checked luggage. Some medicines are affected by temperature and this creates potential problems during travel, especially if refrigeration is required. In general, airlines are not prepared to take responsibility for storing medicines in aircraft refrigerators and, even if they are, there is a risk of the drugs getting lost. Insulin remains stable for several months at room temperature, so refrigeration during air travel is not necessary. The consumer medicine information for thyroxine recommends storage in a refrigerator at 2–8°C, but this is definitely not needed for short periods such as air travel.

Diabetes

Planning ahead is particularly important for travellers with diabetes.8 Permission may be needed from the airline to take diabetes equipment (e.g. pen needles, insulin pump consumables, fingerprick devices and lancets) on board the aircraft. In general, all the documentation required by the airline is a doctor’s letter.

The timing of doses is an issue when flying across multiple time zones. Patients can be advised to take their glucometer to monitor blood sugar and a supply of glucagon or a rapidly acting carbohydrate as a precaution against hypoglycaemia. People on oral hypoglycaemic drugs should take them as prescribed according to local time. Adjustment of insulin dosing is not usually needed for trips with a change of time zone of less than four hours. East or west trips with greater time zone changes may require adjustment and detailed advice from the GP or specialist depending on the person’s insulin regimen. If this advice is difficult to access, the website Diabetes Travel provides a guide.9 In flight, bolus or mealtime insulin should only be injected once the meal has been served as turbulence can delay food service.

Contraception

Travel across time zones can cause confusion about when to take the oral contraceptive pill. Regular dosing is especially important for the progestogen-only pill. The risk of decreased effectiveness arises with flying west as the time between doses is prolonged if based on the time at the destination. 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. Other forms of hormonal contraception such as implants and the vaginal ring are not affected by time zone changes.

The extent to which the risk of travel-related deep vein thrombosis is increased by the combined contraceptive pill is uncertain. In the absence of other risk factors, women can be advised to use the standard precautions which include exercises and maintaining hydration. 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.

Travellers’ diarrhoea

Travellers’ diarrhoea may interfere with absorption of the oral contraceptive pill. The general advice is to continue taking the oral contraceptive pill but use additional contraception for the duration of the illness and a further seven days. The absorption of other medicines such as lithium and digoxin may be affected by travellers’ diarrhoea. People with renal disease and with diabetes should be particularly careful to maintain hydration during episodes of travellers’ diarrhoea.10

Purchasing medicines overseas

Travellers need to be aware that drugs have different names in different countries and that some medicines may not be available. Buying medicines overseas, particularly in the developing world and via the internet,11 is a risk given the prevalence of substandard and counterfeit medicines. In a review of studies from 25 different countries (predominantly low-income or lower middle-income countries) the median prevalence of substandard or counterfeit medicines was 28.5% (range 11–48%). Antimicrobials were the most frequently substandard group and Asia and Africa were the continents most affected by the problem. Fake or substandard antimalarials are a major problem.12 The World Health Organization (WHO) has estimated that falsified drugs represent up to 50% of drugs sold in some African countries. The WHO also estimates that drugs purchased over the internet from websites that conceal their physical address are counterfeit in over 50% of cases.

Clearly, travellers need to be advised to purchase their drugs, including antimalarials if needed, before leaving Australia. In the event that they do have to purchase antimalarial or other drugs overseas, they should try to buy from a reputable source and carefully examine the packaging. The traveller could telephone their travel insurance hotline for advice on services. The International Society of Travel Medicine has an online list of travel medicine clinics and contacting one of these would be another option for local advice about medicines.13 If travellers do choose to buy medicines over the internet they can look for the Verified Internet Pharmacy Practice Sites (VIPPS) Seal of the National Association of Boards of Pharmacy.14

Medical kits for travel

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 hand sanitiser, insect repellent, sunscreen and condoms. Commercially available kits have the advantage of having a list of contents and instructions as well as a document explaining that the items are being carried for personal use.

Conclusion

Planning and preparation are the key elements of travelling safely with medicines.

Conflict of interest: none declared

If you prescribe subscribe

Australian Prescriber welcomes Feedback

References

  1. Australian Bureau of Statistics. 3401.0 - Overseas arrivals and departures, Australia, Dec 2016. 2017 Feb 13. [cited 2018 Jul 1]
  2. LaRocque RC, Rao SR, Lee J, Ansdell V, Yates JA, Schwartz BS, et al. Global TravEpiNet: a national consortium of clinics providing care to international travelers--analysis of demographic characteristics, travel destinations, and pretravel healthcare of high-risk US international travelers, 2009-2011. Clin Infect Dis 2012;54:455-62.
  3. Centers for Disease Control and Prevention. Travelers’ health. wwwnc.cdc.gov/travel [cited 2018 Jul 1]
  4. Department of Human Services. Travelling overseas with PBS medicine. 2018 May 12. [cited 2018 Jul 1]
  5. Department of Health. The Office of Drug Control. [cited 2018 Jul 1]
  6. United Nations Office on Drugs and Crime, International Narcotics Control Board, World Health Organization. Guidelines for national regulations concerning travellers under treatment with internationally controlled drugs. Vienna: UNODC; 2012. [cited 2018 Jul 1]
  7. Mutie M, Cooper G, Naunton M, Kyle, G, Zwar N. Travelling with medications and medical equipment across international borders. Travel Med Infect Dis 2014;12:505–10.
  8. Zwar N. Guide to travelling for people with diabetes: be prepared. Endocrinol Today 2016;5:6-9.
  9. Kerr D, Martinez J. Diabetes Travel. Time zones. [cited 2018 Jul 1]
  10. Lea-Henry T, Baird-Gunning J, Pretzel E, Roberts D. Medication management on sick days. Aust Prescr 2017;40:186-73.
  11. Kelly B. Online pharmacies: buyer beware. Aust Prescr 2015;38:186-7.
  12. Almuzaini T, Choonara I, Sammons H. Substandard and counterfeit medicines: a systematic review of the literature. BMJ Open 2013;3:e002923.
  13. International Society of Travel Medicine. Global travel clinic directory. [cited 2018 Jul 1]
  14. National Association of Boards of Pharmacy. VIPPS. 2018. [cited 2018 Jul 1]
Creative Commons License