Monthly Archives: August 2014

International traveling with medications?

It’s something that most don’t think about. Many readers of this blog are lucky enough to not have chronic medical problems, but not all are. Still, most of us regularly interact with an increasing number of patients with chronic conditions. And more and more of those patients are traveling internationally, potentially due to the treatments they are now able to receive. But what are the rules for people travelling with their medications and medical devices?

These authors set out to figure out how hard it is to find the requirements for travellers who may need to bring medications or medical devices with them. They determined 25 popular destination countries for Australian tourists, and then searched their embassy websites for 5 categories of information pertaining to medications, required documentation, and customs information. They also sent an email to each embassy requesting information about the same topics. They then rated the embassy websites using the RATER scale, which is a modified Service Quality tool (SERVQUAL).

In 2 weeks, they got responses back from 11 of the 25 embassies they had emailed. This lack of service was mirrored by the impressively low scores the embassy websites received on their RATER scales. And even though the title and attempt of the study was to include medical equipment, neither the email responses nor the websites gave any guidance on medical equipment.

More concerning is the fact that no country followed the recommendations of the International Narcotics Control Board, which is an independent body that exists to help carry out the UN Drug Control Conventions.  All of them had more restrictive policies, some so severe as to require the patient to go to a local physician to certify that the medication is needed. Now, we mostly talking about narcotic and psychotropic medications, and generally supplies of less than 30 days. Anabolic steroids will also raise eyebrows in many countries.

Basically, the recommendations boil down to these.

  • Only possess your own medications
  • Carry the prescription or other documentation for those medications
  • Check with competent authorities in your destination countries well before travelling

For travelers planning on spending more than 30 days? Not much guidance, as you probably will have difficulty bringing it through customs initially, and you may have trouble getting prescriptions filled once there. And for those with medical devices (think neurostimulators), make sure to carry backup batteries and plenty of documentation for them.

Unfortunately, while the thought behind their study was valiant, the poor response rate combined with apparently terrible embassy websites means that each person travelling with controlled medications has their homework cut out for them. Still, without much else out there, it gives everyone a place to start.

Note that this doesn’t apply to medical providers carrying medications for expedition or humanitarian purposes. There is an entirely different set of rules for that.

Travelling with medications and medical equipment across international borders
http://www.travelmedicinejournal.com/article/S1477-8939(14)00133-1/abstract

Stroke after crotalidae antivenom

When it first came out, crotalidae polyvalent immune Fab (CroFab), was seen as a godsend by many. It didn’t cause anaphylaxis or serum sickness to nearly the same degree as the old product. There was plenty of safety data, so it started to be used in less severe cases that before, antivenom would be withheld because the risks outweigh the benefits. And now there are case reports like this.

Sean Bush, who just happens to have been on the tv show “Venom ER”, collected these two cases of acute ischemic stroke after treatment of snake bites with CroFab. Both were probably Southern Pacific rattlesnakes (one definitively identified, one presumptive).


Crotalus viridis Southern Pacific Rattlesnake Juvenile” by Matthew Robinson from Santa Monica, USA – baby rattle. Licensed under CC BY 2.0 via Wikimedia Commons.

The first case was a 50 yr old, bitten on the leg, with pain, swelling, shortness of breath, and parasthesias. He got the initial dose of 6 vials, then had his compartment pressures checked. That got him another 12 vials. Later that evening, he showed classic signs of CVA with slurred speech, right-sided weakness, and right facial droop. Labs remained normal, CT was negative, and tPA was withheld due to risk of hemorrhage. However, he got 6 more vials of antivenom because of neurologic symptoms. MRI showed devastating bilateral lesions, and the patient expired. Autopsy showed emboli in the lungs, heart, and multifocal infarcts of the CNS.

Case 2 was a little different. He was 17, bitten on the finger, and had pain, swelling, and parasthesias of that extremity. He got 6 vials initially, then got 20 more over the next 3 days. On that third day, he showed classic cva symptoms with left-sided facial droop, and total left-sided body weakness. His CT was negative, but again no tPA was given (for good reason). MRI showed multiple infarcts as well, but not as globally as the first.

Both patients were tested for hypercoagulability and were negative. So what gives? Why did two patients in the middle of a classic crotalidae envenomation develop ischemic CVAs after treatment? Fibrinogen and platelet levels were normal in both patients, indicating that they weren’t coagulopathic when given the CroFab. INR isn’t mentioned in the paper, presumably it was normal. The key aspect in this case series is the species of snake itself. One southern pacific rattler (Crotalus oreganus helleri) was discovered to have procoagulant activity in its venom, and among crotalidae, they have some of the most varied venom studied to this point. And it has been demonstrated that CroFab doesn’t have activity against rare, or small proteins that aren’t immunogenic.

Because it is unlikely that CroFab includes fabs specific for this procoagulant protein, in a patient envenomated by a southern pacific that was producing that protein, the net effect would be likely be procoagulation, thus causing the thrombotic phenomena shown. However, we can’t be so sure it is just this snake species, as the references in the paper have numerous other cases of ischemic strokes after multiple other types of snakes.

Yes, these are rare events, but neither of those patients appeared to be so sick that they would have died without antivenom. Perhaps judicious application of antivenom should be considered until the etiology of these events is fully understood.

Catastrophic Acute Ischemic Stroke After Crotalidae Polyvalent Immune Fab(Ovine)-Treated Rattlesnake Envenomation
http://www.ncbi.nlm.nih.gov/pubmed/24864067