Langtang Valley and Gosaikunda Trek

The side effects of acetazolamide include allergy. Avoid it if there is a history of a severe allergic reaction to acetazolamide or sulfa containing medications (mainly the sulphonamidetype antibiotics such as co-trimoxazole, Septrin™, Bactrim™). Note that if the sulfa allergy is mild (rash, diarrhoea, etc), test doses of acetazolamide (125 mg 12-hourly for 2 days) may be tried well before departure (but do not attempt this if the sulfa allergy is severe!). Most people with mild sulfa allergy can take acetazolamide.

Common side effects of acetazolamide include:

• Paraesthesiae (tingling) in lips, fingers, toes or other body parts and a metallic taste when drinking carbonated drinks are the most obvious. Both side effects are milder with lower doses and disappear on stopping the medication
• Acetazolamide can cause photosensitivity (sunburn more easily) so use hats, gloves, sunscreen
• Extra urine output. The effect of acetazolamide to increase urine output is mild (people pee more as part of the normal acclimatization process as they ascend)
• Rarer side effects include: flushing, headache, dizziness, nausea, diarrhoea, tiredness

Note: the medication acetozolamide used for Acute Mountain Sickness has to be obtained from a doctor on prescription. As its use for AMS is not officially recognized, some doctors may be reluctant to prescribe it for you. Showing your doctor this handout may help.

• 2 cotton t-shirts.
• 1 synthetic t-shirt.
• 2 long sleeve polyester, or other synthetic lightweight, light colour shirts for sunny days. V-neck zipper provides additional venting options which are good for changing temperatures.
• 1 expedition weight long underwear top.
• 1 soft shell jacket, water resistant, with insulation, underarm ventilation zippers. Full front zipper is preferable for ventilation.
• 1 hard shell with hood, waterproof, pay particular attention to venting options under / on the arms and inner chest pockets provide convenient access without taking off your pack, truly a great design option.
• 1 medium to heavy weight expedition down parka w/hood.
• 2 women sports bras Synthetic, no cotton!

• 4 pair of liner socks, synthetic or capilene
• 3 pair heavy weight socks to be worn over liner socks
• 1 pair light weight socks, a good option for the lower / warmer parts of the trail
• 1 pair light to medium weight water proof hiking/trekking boots. Ensure a good fit with layered socks and you have wore then before to get used to it (otherwise you will get lots of blister)
• 1 pair light trekking shoes or sneakers. Good for around the camp/lodges and in Kathmandu
• 1 pair hiking gaiters, good for keeping dust and rocks out of your shoes / boots as well as keep your feet dry as necessary (Optional)
• 1 pair sandals (Optional)

• Duffel or Rucksack bag (Wild Spirit will supply complimentary water and wind proof duffel/kit bag but one extra big duffel bag is necessary for non-trek items left at the hotel in Kathmandu)
• Daypack
• Down Jacket (Your own Down Jacket is recommended but Wild Spirit also supply complimentary down which need to be return at the completion of the trek)
• 4 seasons Sleeping bag (Your own sleeping bag is recommended but Wild Spirit also supply complimentary sleeping bags which need to be return at the completion of the trek)

• Anyone seriously ill with HACE or HAPE needing oxygen, treatment in a hyperbaric bag or dexamethasone or nifedipine, should descend immediately after treatment. As, even if they feel completely recovered, symptoms may rapidly re-appear with even mild exertion or further ascent.
• Cautious re-ascent may be considered once symptom-free for 4 weeks (ideally seek the advice of a doctor qualified in mountain medicine). Long haul jet flights should be avoided while symptomatic, unless oxygen is available
• If re-ascent is unavoidable (e.g. driving out of Tibet over high passes), give:
  • Acetazolamide 250 mg 12-hourly
  • If the original problem was HACE, add dexamethasone (4 mg 12-hourly)
  • If the problem was HAPE, add modified release nifedipine (20 mg 12-hourly)
  • Give oxygen while crossing passes
• If symptoms of AMS disappear and the person is feeling well (and has been off dexamethasone for at least 3 days), they may try re-ascending slowly while continuing to take acetazolamide. Otherwise, continue descending Acetazolamide (Diamox)

Acetazolamide increases the breathing rate at altitude and speeds up the acclimatization process. A dose takes 12 hours to become fully effective.

Acetazolamide does NOT mask the onset of AMS, HACE or HAPE. However, taking acetazolamide does not guarantee that altitude illness will not develop.

1. Prevention of AMS

Acetazolamide reduces the incidence of AMS, however routine preventative use for all trekkers on all treks is NOT recommended. It is recommended for those who have a past history of altitude illness, or for everyone when rapid height gain is unavoidable, such as:

• Any ascent to 5000m or more (e.g. Kilimanjaro 5895m) under 7 days: consider using 125 to 250 mg 12-hourly from the start of the ascent until back below 3000m
• Flying or driving rapidly to altitude (e.g. Lhasa 3660m, Leh 3500m, Cuzco 3470m, La Paz 3880m, etc): consider using 125 mg 12-hourly, start 24 hours before flying and continue for 2 or 3 days after arrival or the rest of the time at altitude. This is especially useful if the traveller’s itinerary does not allow for 2-3 rest days on arrival at altitude.

2. Treatment of altitude illness

If someone with mild AMS has a flexible schedule, the preferred option is to rest at the same altitude until symptoms disappear. This ideal approach is sometimes not possible on treks and the argument for prompt use of acetazolamide is stronger. In this situation, a person with persistent symptoms of mild AMS despite treatment should start acetazolamide (125 to 250 mg 12-hourly) as this offers the best chance to safely continue their trek (given that no-one should ascend with symptoms of altitude illness).

See treatment of more severe AMS, HAPE or HACE above.

3. Poor sleep, disturbed sleep or periodic breathing at altitude

Poor sleep is common at altitude; first, check warmth of sleeping bag, improve ground insulation, avoid caffeine, check peeing arrangement and offer reassurance to the anxious. A trial of acetazolamide is indicated for sleep disturbance at altitude, particularly if the insomnia is associated with periodic breathing. This is recognized by repeated cycles of normal or fast breathing followed by a long pause, then several gasping breaths. The sufferer often wakes feeling like they are suffocating. This can be frightening for the sufferer’s tent ‘buddy’!

In the morning the victim feels tired and unwell.

Acetazolamide is often called ‘the high altitude sleeping pill’ (125 mg one hour before going to bed. If the problem persists, increase the dose to 250 mg).

• 2-3 pairs nylon hiking shorts – Quick drying type, not cotton!
• Underwear, stay away from cotton
• 2 pair lightweight long underwear – capilene or other synthetic
• 1 pair soft shell pants – synthetic, full zip from top and bottom preferable
• 2 pair trekking pants, preferably that zip on/off at the knees so they double as shorts
• 1 pair hard shell pants. Waterproof / breathable, Gore-Tex or equivalent is best. Should zip from the top and bottom – this makes it easier to put on over boots without getting undressed should the weather change once you are underway for the day
• 1 pair cotton pants (loose jeans/khakis)
• 1 full length loose skirt. Women should plan to wear skirts or pants when walking around Kathmandu.
• All clothing should be kept dry using waterproof stuff sacks or large puncture resistant plastic bags.

• At altitude (above 2500m) some medications such as sedatives, strong painkillers, antihistamines and most sleeping tablets (except zopiclone and zolipidem) may depress breathing. This may make altitude illness more likely or more severe, especially at night. If you have to use any of these medications, consider giving acetozolamide (Diamox) 125 to 250 mg 12-hourly to stimulate breathing, and check the person frequently.
• At altitude, antimalarial medications may cause nausea and psychotic episodes
• Oral contraceptives (“the pill”) slightly increase the blood’s tendency to clot, so they should be avoided above 5000m
• Aspirin and NSAIDs (non-steroidal anti-inflammatory drugs, e.g. ibuprofen) may cause bleeding in the eye (retina) at high altitude (over 5000m) especially if coughing is present.

• Extra Strength Excedrin for altitude related headaches
• Ibuprofen for general aches and pains
• Immodium or Pepto bismol capsules for upset stomach or diarrhoea
• Diamox (commonly prescribed as Acetazolamide) 125 or 250mg tablets for altitude sickness. Please discuss with us before starting to take this medicine
• 1 small personal sized first-aid kit with blister treatments such as mole skin, band aids, some waterproof tape, anti-infection ointments, etc. Your guides will have more extensive medical gear, but you should have the basics for general use.

• Passport and extra passport photos (4 copies)
• Airline ticket(s)
• VISA (If required and acquired in advance)
• Immunization Record
• Durable wallet / pouch for travel documents, money & passport
• 2 Water bottles 1 litre wide-mouth Nalgene and 1 insulator
• Lip balm. At least SPF 20, 2 sticks. A string taped to the stick is helpful, to hang around your neck and some are now being sold with a cord already attached. Handy as it avoid you having to stop and look for it
• Sunscreen. SPF 40 is recommended and should be relatively new since it loses its’ effectiveness over time
• Pocket knife or small Swiss Army type
• Water purification Iodine tablets or Polar-pure crystals
• Toiletry kit. Be sure to include toilet paper stored in a plastic bag, hand wipes, and liquid hand sanitizer, towel, soap, etc
• 3-4 Large durable plastic bags, for keeping miscellaneous gear dry inside you pack. Also nice for separating clean from dirty laundry
• Nylon stuff sacks for food and gear storage
• Large zip lock bags are also useful for separating things and keeping them dry
• 2 bandanas
• Ear plugs

• 1 pair adjustable trekking poles. Although these are listed as optional these can be of great assistance to people who may think of themselves and generally clumsy or with bad knees, ankles, etc., especially when going downhill (Optional)
• Favourite snack foods, no more than 2 pounds (Optional)
• Paperback books, cards, MP3 player (there are a couple of stops where you could recharge. Avoid players with moving hardware as it may not function, remember, keep these items light weight (Optional)
• Binoculars (Optional)
• 1 light weight point & shoot camera or 1 large SLR. Digital cameras are ok, but you must keep the batteries warm when not in use (Optional)
• Hydration bladder with drinking tube and tube insulator (Optional)
• A pee bottle for men and pee funnel for woman, some swear by them to avoid that chilly late night trip (Optional)
• 1 small stainless steel thermos (Optional)

If someone is ill at altitude after a recent height gain, carry out a full secondary survey (especially level of consciousness and breathing rate), a ‘Lake Louise Score’ and the tests/examination for HACE and HAPE.

Because the victims of altitude illness often fail to take care of themselves, they are likely to develop hypothermia, dehydration and/or low blood sugar (due to not eating).

There comes a point when it is vital that the leader/doctor/companion starts making decisions for the victim (e.g. ordering immediate descent), even if the victim disagrees.

• Descent is the treatment of altitude illness. Prompt descent will begin to reverse the symptoms. Descend immediately if symptoms are severe, even if it means at night or in bad weather. Resting at the same altitude is only acceptable if the victim has mild AMS and is improving with treatment
• Oxygen: give oxygen, either as bottled oxygen or in a hyperbaric bag if the symptoms are severe and descent is not immediately possible (e.g. dangerous terrain or weather, not enough helpers to carry an unconscious victim, waiting for a helicopter) or the victim is too ill to move
• Rest is recommended even for mild symptoms. With more serious illness, if at all possible avoid even the slightest exertion, as just walking a few steps may make symptoms worse or reappear; carry the victim or, as a minimum, assist them to walk and carry their rucksack
• Keep the victim warm and hydrated, give occasional sugary drinks
• Prop the victim up in a semi-reclining position, as lying flat can make them feel worse
• If at any stage the victim has difficulty breathing, is turning blue or lapsing into unconsciousness, assist their breathing with mouth-to-mouth before they stop breathing.

• Shade hat or baseball cap – some people drape a bandana down the back of their head and then put a baseball cap on to hold it is place. This can be a flexible alternative while keeping the sun off your ears and neck.
• Warm wool or synthetic hat that cover your ears
• Balaclava – The lightweight, thinner variety
• Glacier glasses 100% UV protection with side shields and a hard-sided storage case (i.e. Julbo or Cebe). This is to protect your eyes from the stronger rays of the sun due to the thinner atmosphere which can cause a painful condition known as snow blindness. Regular sunglasses are not sufficient. If you wear prescription glasses, speak to your doctor about prescription glacier glasses, perhaps with transitional lenses
• Headlamp – Black Diamond and Petzl both make several good ones. Make sure to bring extra batteries and that they are lithium batteries so that they will last in the colder temperatures. These are indispensable for getting around at night, reading, etc., so don’t go cheap here
• Some people like ear-muffs; These are optional, a good hat, balaclava, and hooded jacket should really be sufficient, but this is a personal choice for some people (Optional)
• A neck warmer is another piece of gear for extra warmth if you feel you will need it (Optional)
  Hand
• 1 pair liner gloves thin wool or synthetic, useful alone on mild days or as a layer inside other gloves / mitts for additional warmth.
• 1 pair warm gloves (heavier fleece or wool).
• 1 Pair shell gloves or mitts Gore-Tex is preferred for keeping hands dry.
• Instant hand warmers are always nice in a pinch, but really shouldn’t be necessary on the trek. Bringing appropriate hand protection as recommended above, should be sufficient (Optional)

If the illness comes on after 4 days at a new altitude and/or does not respond to descent, oxygen, dexamethasone and/or nifedipine, reconsider your diagnosis:

• HACE may be difficult to distinguish from: migraine, meningitis, diabetic coma, CO poisoning
• HAPE may be difficult to distinguish from: pneumonia, asthma, pulmonary embolus (a blood clot from a DVT), heart attack, hyperventilation (panic attack)
• Hypothermia, dehydration or low blood sugar (due to not eating) share similar symptoms to altitude illness

Unless absolutely sure, treat as HACE or HAPE (or both) PLUS your alternative diagnosis.

Note: the basic treatment of all of these problems is roughly the same: re-warm, re-hydrate, ‘resugar’, re-oxygenate and descend.

The Climbing equipment is much more expensive to buy. So, please let us know if you want to rent the equipments at the additional cost of USD 250 per person. The Following equipments are essential for climbing Island peak.

• 1 Pair plastic shell mountaineering boots with high altitude liners
• 1 Pair of crampons (steel, no aluminium).
• 1 Alpine climbing harness.
• 1 Mountaineering axe with leash (sized properly for your height)
• 1 Ascender (right or left handed as appropriate)
• 1 Belay device (Black Diamond ATC or ATC Guide are good options)
• 2 D-Shaped locking carabiners
• 2 Non-locking carabiners
• 1 Pair expedition style gaiters (ensure fit over your boots)
• Neck gaiter
• Ski goggles (optional)
• Climbing helmet (optional)

• T-shirts (2).
• Light and expedition weight thermal tops.
• Fleece jacket or pullover.
• Fleece Wind-Stopper jacket (optional).
• Waterproof (preferably breathable fabric) shell jacket.
• 2 women sports bras, Synthetic, no cotton!

• 4 pairs of liner socks, synthetic or capilene.
• 3 pairs heavy weight socks to be worn over liner socks.
• 1 pair light weight socks, a good option for the lower / warmer parts of the trail.
• 1 pair light to medium weight water proof hiking/trekking boots. Ensure a good fit with layered socks and you have worn then before to get used to it (otherwise you will get lots of blister).
• 1 pair light trekking shoes or sneakers. Good for around the camp/lodges and in Kathmandu.
• 1 pair hiking gaiters, good for keeping dust and rocks out of your shoes / boots as well as keep your feet dry as necessary (Optional).
• 1 pair sandals (Optional).

• 4 seasons Sleeping bag (Optional/we can provide one if you need it but is to be returned after the trek)
• Duffel or Rucksack bag or suitcase (We will provide one complimentary ACE duffel bag for you to keep.)
• Daypack
• Down Jacket (Optional/we can provide if you need one but is to be returned after the trek)

• 1 pair liner gloves, thin wool or synthetic, useful alone on mild days or as a layer inside other gloves / mitts for additional warmth.
• 1 pair warm gloves (heavier fleece or wool).
• 1 pair shell gloves or mitts; Gore-Tex is preferred for keeping hands dry.
• Instant hand warmers are always nice in a pinch, but really shouldn’t be necessary on the trek. Bringing appropriate hand protection as recommended above, should be sufficient (optional).

• 2 pairs nylon hiking shorts – Quick drying type, not cotton!
• Underwear, stay away from cotton (4).
• 2 pairs lightweight long underwear – capilene or other synthetic.
• 1 pair soft shell pants – synthetic, full zip from top and bottom preferable.
• 2 pairs trekking pants, preferably that zip on/off at the knees so they double as shorts.
• 1 pair hard shell pants. Waterproof / breathable, Gore-Tex or equivalent is best. Should zip from the top and bottom – this makes it easier to put on over boots without getting undressed should the weather change once you are underway for the day.
• 1 pair cotton pants (loose jeans/khakis).
• All clothing should be kept dry using waterproof stuff sacks or large puncture resistant plastic bags.

(Please note our guide will also carry the first aid kit bag during the trek. However we still recommend you to bring your personal first aid kit as well)

• Extra Strength Excedrin for altitude related headaches.
• Ibuprofen for general aches and pains.
• Imodium or Pepto bismol capsules for upset stomach or diarrhea.
• Diamox (commonly prescribed as Acetazolamide) 125 or 250mg tablets for altitude sickness. Please discuss with us before starting to take this medicine.
• 1 small personal sized first-aid kit with blister treatments such as mole skin, band-aids, some waterproof tape, anti-infection ointments, etc. Your guides will have more extensive medical gear, but you should have the basics for general use.

• Passport and extra passport photos (4 copies).
• Airline ticket (Please make a copy and leave on at our office in KTM just in case if you need to change the date of your).
• Durable wallet / pouch for travel documents, money & passport.
• Lip balm. At least SPF 20, 2 sticks. A string taped to the stick is helpful, to hang around your neck and some are now being sold with a cord already attached. Handy as it avoids you from having to stop and look for it.
• Sunscreen. SPF 40 is recommended and should be relatively new since it loses its’ effectiveness over time.
• Pocket knife or small Swiss Army type.
• Water purification Iodine tablets or Polar-pure crystals.
• Toiletry kit. Be sure to include toilet paper stored in a plastic bag, hand wipes, and liquid hand sanitizer, towel, soap, etc.
• 2 bandanas.

• Favourite snack foods, no more than 2 pounds (Optional).
• Paperback books, cards, mp3 player (there are a couple of stops where you could recharge. Avoid players with moving hardware as it may not function. Remember, keep these items light weight (Optional).
• Binoculars (Optional).
• 1 light weight point & shoot camera or 1 large SLR. Digital cameras are ok, but you must keep the batteries warm when not in use (Optional).
• Hydration bladder with drinking tube and tube insulator (Optional).
• A pee bottle for men and pee funnel for woman, some swear by them to avoid that chilly late night trip (Optional).
• 1 small stainless steel thermos (Optional).

• Shade hat or baseball cap – some people drape a bandana down the back of their head and then put a baseball cap on to hold it in place. This can be a flexible alternative while keeping the sun off your ears and neck.
• Warm wool or synthetic hat that covers your ears.
• Balaclava – lightweight, thinner variety.
• Glacier glasses-100% UV protection with side shields and a hard-sided storage case (i.e. Julbo or Cebe). This is to protect your eyes from the stronger rays of the sun due to the thinner atmosphere which can cause a painful condition known as snow blindness. Regular sunglasses are not sufficient. If you wear prescription glasses, speak to your doctor about prescription glacier glasses, perhaps with transitional lenses.
• Headlamp – Black Diamond and Petzl both make several good ones. Make sure to bring extra batteries and that they are lithium batteries so that they will last in the colder temperatures. These are indispensable for getting around at night, reading, etc. so, don’t go cheap here.
• Some people like ear-muffs; These are optional; a good hat, balaclava, and hooded jacket should really be sufficient, but this is a personal choice for some people (optional).
• A neck warmer is another piece of gear for extra warmth if you feel you will need it (optional).