Deep vein thrombosis (DVT) – can occur in healthy people if they are immobile for long periods of time, this includes car journeys and ‘e-thrombosis’ caused by sitting still for too long at a desk or computer. Everyone should either try to walk around every couple of hours or exercise the calf and foot muscles; if that is not possible, then simply fidgeting can be beneficial as it gets the circulation moving.
However, it is air travel that is most closely associated with DVT particularly long-haul flights over six hours long. The actual number of people who get DVT from travelling on long-haul flights is unknown and is difficult to determine, as the condition can be symptomless and may not occur for some time after travel.
For people with a diagnosis of APS, although there is always a risk of DVT with air travel, there should not be any problems if you take the following points into consideration before flying.
If you are treated with 75mg aspirin daily
APS patients who only display low-grade symptoms, or have had previous miscarriages will be treated with 75mg aspirin daily. Aspirin alone should be sufficient for a short-haul flight less than six hours. If you have a flight lasting longer than six hours especially if it is an overnight flight, you should discuss with your GP or specialist whether an injection of heparin before the flight, in addition to your aspirin is worth considering. This may be appropriate for patients who have many cardiovascular risks such as being overweight, smoking, diabetes, high cholesterol or high blood pressure.
Many APS patients who have suffered a less severe clotting event such as a TIA or DVT, may also only be treated with 75-150mg aspirin daily. In these cases, it is recommended that you take an injection of heparin before your flight in addition to the aspirin, regardless of the duration of the flight.
If you need to inject with heparin
As heparin is not always stocked by smaller pharmacies and surgeries, you should make an appointment with your GP a few weeks before your flight so there is plenty of time to process the prescription. You should also ask your doctor to write a letter stating why you need to take heparin as you may need to explain why you are carrying needles when you fly.
On the day of the flight you must ensure you are carrying a copy of your prescription (this is the most important documentation) and the letter from your doctor. It is important that you have relevant contact information on these documents in case airport officials need to clarify your condition.
Heparin injections are individually packed syringes so are convenient to carry in your hand luggage. It is best to carry all the syringes you need on your person in case your hold luggage goes astray; in the UK it is necessary to put them in a clear plastic bag due to the current restrictions on liquids allowed in hand baggage.
You should take the injection as close to the time the flight leaves as possible. This is because heparin has an instantaneous effect, but only lasts for twelve hours which is sufficient for most short to medium haul destinations. If you have a twenty-four hour flight, you will need to inject for a second time after twelve hours.
Although all airports usually have a clinic where you can pay the medical team to administer the injection, it is simpler and more cost effective to do it yourself. You will need to find a private place where you are not disturbed; this could possibly be the disabled toilet or even just in a quiet area in the airport.
When you have finished, place the lid back on the syringe and put it back into its packaging, then hand it to a member of airport staff informing them there is a needle inside which should be disposed of safely. The whole process can be rather daunting for the first few times but, if you follow these guidelines, all should go smoothly and you will find it gets easier with practice.
If you are taking warfarin
Despite the former reluctance of the travel insurance industry to offer policies to APS patients, people who are being treated with warfarin are believed to be the safest on the plane in terms of risk of developing a DVT. However, it has been found that the ascent to altitude can adversely affect your INR and cause it to become lower than usual, so it is recommended that you take heparin syringes with you so you can inject yourself if your INR becomes too low after a flight.
For those people who do not self-test and have regular INR blood tests at an anticoagulation clinic, you should get your INR checked before you travel, take your yellow anticoagulation therapy booklet and an adequate supply of warfarin tablets. You should also let the clinic know how long you will be away. It is recommended that you have your INR tested after the outward flight and before the return flight home to ensure you are within your range; therefore, you will have to research the availability and location of anticoagulation clinics at your destination.
Travelling is often cited as one of the main reasons APS patients choose to self-test, and the hand-held monitor does allow more freedom as you can test your INR whenever and wherever you like. If you already self-test and manage your own medication, the same advice applies in that you should take enough heparin injections with you just in case your INR drops too low, take your yellow anticoagulation therapy booklet and an adequate supply of warfarin tablets. The monitor needs to be carried in your hand luggage and make sure you have enough testing strips with you. Take an INR reading before you fly and check again after the outward flight, then again before the return journey.
Travelling check list for patients on warfarin:
- Research the hospitals/clinics in the areas you intend to travel to.
- Make sure you have your up-to-date yellow anticoagulation book, prescription/letter for the heparin injections and insurance policy.
- Carry information about APS with you, ideally in the language of the country you are visiting.
- Buy a digital watch or set your mobile phone so you set an alarm to take your warfarin tablets at the correct intervals.
- Be aware of any changes in diet and drinks while you are away, as these can also affect your INR.
Whether you self-manage or visit the anticoagulation clinic, if you experience any symptoms you must get your INR checked as soon as possible in case you need to increase your dosage of warfarin or inject with heparin.
If you are pregnant
If you have APS and are pregnant, flying is considered safe as it is highly likely that you will be taking 75mg aspirin daily as well as heparin injections. The same guidelines apply as to all passengers taking heparin, but you should be aware that most airlines will only be prepared to carry you up to your 27th week of the pregnancy.
If you choose to fly after the 27th week, the risk of going into labour increases and you may need a letter from your consultant or midwife confirming your due date. Each airline has its own particular set of rules and cut off point when they refuse to carry you, so do check with your booking agent or airline website if booking online.
You should get travel insurance if you’re going abroad when pregnant as you may have to cancel the trip or go into hospital while away. Pregnant women are considered high risk by travel insurance companies, and most will not cover you if you have less than eight weeks until your due date when you return from your trip. Make sure the policy covers you for any eventuality such as early birth, medical care during labour, and expenses incurred if you do go into labour while away.
If you are disabled
Travelling can be a daunting experience if you have reduced mobility or are disabled, so you must ensure that you inform your booking agent so they can make sure the appropriate assistance and support is available at the airport. If you book online, you should check that the flight provider can also offer you the services you require.
Airport parking comparison tool, Parkat, provide an excellent guide to travelling if you have a disability or restricted mobility. The guide has been created to inform and advise you about the services available to make your journey as easy and pleasurable as possible.
When you are on the plane
- Wear loose, comfortable clothes.
- Consider buying flight socks (compression stockings) as research has shown they can reduce the risk of DVT and leg swelling during flights of four hours and more. However, they must be the right size and worn correctly.
- Store luggage overhead so you have room to stretch out your legs.
- Do anti-DVT exercises. Raise your heels, keeping your toes on the floor, and then bring them down. Do this ten times. Now raise and lower your toes ten times. Do it at least every half an hour or more often if you like.
- Walk around whenever you can, but at least every couple of hours.
- Drink plenty of water – this helps accelerate the blood flow.
- Do not drink too much alcohol as this can cause dehydration and immobility.
- Do not take sleeping tablets as these will cause immobility.
If you are travelling abroad it is wise to take out a travel insurance policy, but is essential you fully disclose your medical conditions to the insurance company, even if they do not ask. Failure to do so could lead to them rejecting a claim.
In the past, it was very difficult to find travel insurance for anyone with APS, even if the patient had minor events and was very stable. It seems that the underwriters for the travel insurance industry had deemed all patients uninsurable and a blanket ban was in place regardless of the patient’s medical history.
However, after our charity contacted the Association of British Insurers in 2011, there appears to have been a breakthrough and now a variety of different travel insurance companies are offering insurance to people with antiphospholipid syndrome.
How to inject with heparin fact sheet
Download and keep our factsheet on how to inject with heparin.