Have Medicine, Will Travel

PART TWO: TIMING IS EVERYTHING

Come fly with me.

But bring your medicine.

In this post, I share my strategies for adjusting my carbidopa-levodopa dosing schedule when I travel. I explain why your medication program affects the timing of even local travel for meetings. With me, you will fly against the sun to Madrid and with the sun to California, adjusting your drug regimen to maximize its effectiveness. I suspect you will forever change the way you arrange your travel and dosing timetable based on the details I share. To illustrate my methods, I build on the baseline case** that I shared in Part One.

In Part One of Have Medicine Will Travel, I discussed the miracle Parkinson drug carbidopa-levodopa, the generic name for Sinemet^®. You can read Part One here

In Part Three, I will cover preparing medicine for travel. I take over 20 pills a day. To achieve the greatest benefit from these drugs and supplements, I must take them in a specific order and at precise intervals to function

Let’s start traveling. It is possible to travel with PD, but the challenges are huge. A few years ago, I decided to adjust my medicine and sleep schedules to reduce travel stress. To improve travel experience, tune in to your body and focus on record-keeping as you discover the adaptations that work best for you.

Travel and Medicine

I will examine the following travel scenarios:

Case A: Flying to another city within the same time zone

Case B: Flying against the sun across multiple time zones

Case C: Flying with the sun from New York to California

Case A: You live in New York City and must fly to another city in your time zone, like Boston, Washington DC, or Detroit. As illustrated in the baseline case, you cannot safely leave the house for 1.5 hours following your first dose of medicine. To catch an 8 AM flight, you would need to awaken at 4 AM to start the regimen. However, now your normal 7 AM dosage time shifts to 4 AM, your 10 AM to 7 AM, your 1 PM to 10 AM, and your 4 PM to 1 PM. To be safe, you either take an additional tablet at 4 PM or conclude your business earlier in the day. My advice is to take the extra dose at 4 PM, otherwise the following morning’s dose will be an additional three hours later than the previous day’s last dose. Thus, the day following your flight, you may experience periods when your medicine does not work well. This disruption in your medication schedule could jeopardize your safety (think falls) and hinder your effectiveness (think fuzzy brain) in meetings.

Instead, schedule travel within your time zone around your established drug schedule. The earliest flight you can take and maintain your medicine schedule is 11 AM. You leave the apartment at 8:30 AM, arrive at the airport by 9:30 AM, check your luggage at curbside, arrange for a wheelchair, and are at the gate before boarding at 10:30 AM. If you are a Parkinson’s patient in late Stage 3 or Stage 4, you probably suffer from postural instability. Request a wheelchair at both ends of the flight even if you can walk with a walking stick or cane. The wheelchair removes the danger of another traveler knocking you down in the bustle of the airport and conserves your energy. When I take these “in zone” trips, I usually schedule no meetings on arrival day unless it is dinner with a friend. I am so exhausted, I request in advance an early hotel check-in,

In Case A you adjust your flight, not your medicine schedule. I discovered that the extra energy required to travel to the airport, wrestle with the luggage, secure a wheelchair, clear security, obtain transportation, and check in at my hotel leaves me exhausted. I frequently experience “off” periods, as if my medicine is not working properly. A good night’s sleep usually puts me back on schedule.

By the way, these same considerations apply to local meetings scheduled for the early hours of the business day. To attend an 8 AM meeting across town, you must alter your medication regimen. It is better to modify the meeting time.

Solution: schedule out-of-town business meetings to begin the day after your arrival. Schedule local meetings after 10 AM.

Case B: Tapas anyone? Your home is New York City. Your destination is Madrid, Spain, which is 6 hours ahead of NYC. Your Madrid flight is an overnight flight leaving Newark, NJ at 8:35 PM and you arrive at 9:50 AM, after flying for 7 hours and 15 minutes. How should you schedule your medications?

The considerations are as follows. On the day of departure, you stay on your regular schedule. Upon landing, you must be functional enough to get off the plane, into a wheelchair, through immigration, baggage claim, and customs. I hope for your comfort and safety you have arranged for a car and driver. You find your driver in the arrival hall and head for the hotel. You requested an early check-in, but the hotel manager apologetically explains the cleaning staff is shorthanded. They will try to have a room ready for you at 2 PM, an hour ahead of their standard check-in time. It is currently 10:30 AM local time, and 4:30 AM back home in NYC. You are tired, sleep deprived, and frustrated. You leave your luggage with the bellman and find a comfortable place in the hotel restaurant to kill time.

When should you start taking your medicine?

Solution: For you to safely function, you must start taking your medicine approximately 90 minutes before landing—about 8:20 AM local time or 2:20 AM NYC time. Round the time to 8:30 AM Madrid time. From now on, maintain your usual three-hour dosage interval, taking your next dose at 11:30 AM local time. Due to jet lag, the first few days will be difficult. I set alarms on my smart phone, waking to take my meds on the local time schedule, and I sleep when my body demands it. I take medicine on a schedule based on local time for the remainder of the trip.

Case C: Let’s visit the beautiful City of St. Francis. San Francisco has always been one of my favorite places in the world. To fly from NYC to California is a time zone change of 3 hours. It does not sound like much and, when I was younger and healthy, I enjoyed my frequent trips there.

The flight leaves on Sunday at 11 AM (ET) and arrives in San Francisco at 2:48 PM (PT) or almost 6 PM (ET). While in NYC, you took your medicine on your usual schedule and a tablet just as the plane lifted off. But now what? The best policy is to take your medication on the plane as if you were still in NYC. Why? Because you must function upon arrival. You have taken your last dose one hour before landing so you need to decide. Do you take an extra dose at 5 PM local time? Do the safe thing.  Take the extra dose, placing your regimen on local time.

Trips to California are tricky. By the time, I get checked into the hotel and unpacked it is at least 8 PM (ET). I am hungry, but it is only 5 PM (PT) local time. I typically try to have a light meal in the room and get to sleep by 8 PM local time. This strategy avoids the necessity of a second extra dose of medicine, but a problem arises early the next morning. I am wide awake at 4 AM (PT), hungry for a big breakfast, and unable to move. If I wish to place my medicine schedule on local time without an extra dose, I wait until 7 AM (PT).

Solution: I take my first dose at 4 AM and then every three hours after that, placing my routine on local time, but taking an extra dose. I try to rest in the early afternoon, and by the third day, I am solidly on California time with both my sleep and medicine schedule.

Conclusions

In Case A, we traveled to another city within the same time zone. The energy expended traveling to the airport, going through security, boarding, flying, claiming luggage, locating the car service, and checking in to the hotel is so exhausting that you should not plan any meetings for the day of arrival nor before 10 AM the following day. Schedule car and wheelchair services. Throughout this travel day, take your medicine on schedule. The potential cost of failure is that you find yourself incapacitated and fatigued in another city with slurred, soft speech and in danger of falling.

In Case B, our travel took us on a trip to Madrid, flying against the sun and across six-time zones. Flying across multiple time zones and arriving sleep deprived is the most dangerous situation a PD patient can experience. After many such trips and considerable experimentation, I determined that the safest way to proceed was to place your drug regimen on local time 90 minutes prior to arrival, BUT to let your body sleep whenever it feels like it.

In Case C, we traveled from New York to California. We took a late morning flight so that we were on our home medicine schedule when we fly. An extra dose of medicine permits us to safely check in to our hotel. The challenge comes on the first morning after arrival when we find ourselves wide awake at 4 AM, hungry and unable to move. Our advice, based on years of experience, is to start your medication regimen at 4 AM, placing your medication schedule on local time.  This solution means that you take one extra dose of medicine both on arrival day and the following day.

Additional Considerations

          In the baseline case**, the medicine routine involves taking four pills a day on a precise schedule. I have provided scenarios where you need additional doses when traveling to other time zones to move safely from plane to hotel. Failing to keep this schedule, whether at home or away, means fatigue and increased risk of falling. Along with tiredness, the PD patient increases the probability of mumbled speech, foggy thinking and loss of manual dexterity. These are good reasons to plan to avoid important meetings or decisions on the first day or days of your trip, depending on the number of time zones traveled.

Most PD patients eventually take four or more Sinemet pills and other prescription drugs. Typically, these drugs require an intricate dosage regimen to avoid problems of drug interaction or poor metabolism due to food intake. I currently take seven PD-related prescription drugs and sixteen other pills, both prescriptions and supplements. For the most part, all this medicine must be taken on schedule if it is to be effective.

As a practical matter, this means no critical meetings on arrival day. The formula I found that works well for planning a first meeting is as follows: take the number of time zones from your home starting point and divide by 2 and round-up to the next even number. In the San Francisco example, it would be: (3/2) = 1.5 rounded up = 2. Thus, you could plan a meeting the morning of the second day after arrival. If you arrived on Monday evening, a Wednesday late morning meeting would be safe.

If your trip is to Asia and the time zone difference is 12 hours, it would mean the following: (12/2) = six days. The first “safe” meeting time would be the morning of the sixth day following arrival. A true road warrior would view six days as a long time to wait for meetings, but a PD road warrior gets it.

For the human body’s internal circadian body clock to fully adjust to local time, it can take one calendar day for each hour of time zone change. Flying west, with the sun, is easier for most travelers than flying east, against the sun, where the loss of sleep takes its toll. Frequent travelers will provide you with many tricks to reduce the effects of jet lag. In my days as a road warrior, I found forcing myself to adopt local time was the only method that worked. That meant early morning sun, all meals and sleep on local time. I avoided taking sleeping pills, but I did find that melatonin in the dose of 1 mg per time zone change helped.

In discussions above, when we refer to “meetings,” we are talking about business or diplomatic assignments where a poorly functioning brain can lead to mistakes. Of course, meals with friends and family are possible soon after arrival.

Experienced travelers apply these concepts to time zone travel. How does this apply to Parkinsonian travelers? Most PD patients eventually retire or change their work schedule to eliminate intense business travel. My recommendation is that if you must take a demanding trip, then take the extra time to let your body adjust to local time, food and sleep. Arrive a few days early, and you will have more productive meetings.

 

**Baseline Case: Carbidopa-Levodopa Therapy

7:00 am Patient takes one 25/100 tablet of carbidopa-levodopa. Stays in bed and starts to feel the drug about 7:15 am. Notes extreme tiredness and a desire to go back to sleep. This sensation does not last long, perhaps only 15 or 20 minutes, but, for me, it happens every day.

8:00 am Patient can take a shower and get dressed but must take care in walking; may need a cane or walker; breakfast is necessary and provides a real energy boost.

8:30 am Half-life point of drug dosage. Patient feels good as the drug reaches maximum effectiveness. Patient can leave house.

9:30 am—10:00 am If patient is attuned to his body, the medicine’s diminishing effect is noticeable; fatigue may set in.

10:00 am Patient takes second 25/100 tablet of carbidopa-levodopa.

10:30 am Another feeling of renewed energy.

11:30 am Medicine’s effectiveness peaks; cumulative effect of earlier doses may push time closer to noon.

12:00-12:30 pm Lunch, essential, even if a small soup; little or no protein if patient has discovered that protein taken with medicine reduces its effectiveness. After much testing, I became convinced that protein taken with the carbidopa-levodopa reduces the drug’s effectiveness. I can confuse low blood sugar with diminishing effectiveness of carbidopa-levodopa.

1:00 pm Patient takes third 25/100 tablet of carbidopa-levodopa.

1:00 pm-2:00 pm Medicine can cause sleepiness and require a 30 to 40-minute nap. Avoid driving a car or operating machinery.

2:00 pm-4:00 pm Patient feels pretty good from the cumulative effect of the three doses of medicine.

4:00 pm Patient takes fourth 25/100 tablet. Depending on the person, the stress of the day, activities, and other variables, this fourth dose may last for four hours or more, carrying her through dinner until 8 pm.

8:00 pm + If home, and bedtime is around 9:30 pm to 10 pm, it is possible to get by with no additional medicine PROVIDED great care be taken during nocturnal bathroom trips. A bedside urinal or commode may eventually be necessary to preclude falling during bathroom trips in the middle of the night.

10:00 pm–7:00 am Nine hours of interrupted sleep. Some patients take a time–release dose of carbidopa-levodopa to reduce the risk of falling in the middle of the night. I do not, hoping that by giving my brain an overnight rest, I will extend the drug’s effectiveness by several years.

 

*I shall not discuss the merits or demerits of the Parkinson’s medications on the market beyond my experiences with them. I do not have the education or training to comment on either the drugs or the PD research. I am NOT a medical doctor, and I have no medical training. All my university education has been in accounting, finance, statistics, and economics. My 50-plus years of work experience has been in economic analysis, investment management, and related fields. This blog is based on my personal experience as a Parkinson’s Disease patient searching for answers wherever I can find them. Many of these ideas came from my doctors, other PD patients, books, articles, and my relentless desire to change my life for the better or at least slow down the disease.

I welcome comments, suggestions, and stories.