Tolbutamide

Tolbutamide is a first generation sulfonylurea oral hypoglycaemic drug sold under the brand name Orinase. This drug may be used in the management of type II diabetes if diet alone is not effective. Tolbutamide stimulates the secretion of insulin by the pancreas. Since the pancreas must synthesize insulin in order for this drug to work, it is not effective in the management of type I diabetes. It is not routinely used due to a higher incidence of adverse effects compared to newer second generation sulfonylureas, such as glyburide.

Glipizide

Glipizide is an oral medium-to-long acting anti-diabetic drug from the sulfonylurea class. It is classified as a second generation Sulfonylurea, which means that it undergoes enterohepatic circulation. The structure on the R2 group is a much larger cyclo or aromatic group compared to the 1st generation sulfonylureas. This leads to a once a day dosing that is much less than the first generation, about 100 fold.

Mechanism of action is produced by blocking potassium K+ channels in the Beta cells of the Islets of Langerhans. By partially blocking the K+ channels, you will increase the time the cell spends in the Calcium release stage of cell signaling leading to an increase in calcium. The increase in Calcium will initiate more Insulin release from each Beta cell.

It is available under the brand name Glucotrol® by Pfizer, originally available in 1984. Pfizer sells Glucotrol in doses of 5 and 10 milligrams and Glucotrol XL (an extended release form of glipizide) in doses of 2.5, 5, and 10 milligrams. Other companies sell generic forms of glipizide, most commonly extended release tablets of 5 and 10 milligrams.

Gliclazide

Gliclazide is an oral hypoglycaemic (anti-diabetic drug) and is classified as a sulfonylurea. It is marketed as Diamicron MR®.

Form and Composition:

Each modified-release tablet contains 30 mg of gliclazide.

Indication:

Type 2 diabetes.

Dosage:

30 to 120 mg depending on response, once daily with breakfast, including in elderly patients or those with mild-to-moderate renal failure

Properties:

Hypoglycaemic sulfonylurea, restoring first peak of insulin secretion, increasing insulin sensitivity. glycaemia-independent hemovascular effects, antioxidant effect. No active circulating metabolites.

Contraindications:

type 1 diabetes, hypersensitivity to sulfonylureas, severe renal or hepatic failure, pregnancy and lactation, miconazole coprescription.

Interactions:

Hyperglycaemic action may be caused by danazol, chlorpromazine, glucocorticoids, progestogens, ß-2 agonists. Its hypoglycaemic action may be potentiated by phenylbutazone, alcohol, fluconazole, ß-blockers, possibly ACE inhibitors.

Adverse effects:

Hypoglycaemia, gastrointestinal disturbance (reported), skin reactions (rare), hematological disorders (rare), hepatic enzyme rises (exceptional).

Overdosage:

Possible severe hypoglycaemia requiring urgent IV glucose and monitoring.

Glibenclamide

Glibenclamide (INN), also known as glyburide (USAN), is an anti-diabetic drug in a class of medications known as sulfonylureas, used in the treatment of type II diabetes. The drug works by inhibiting ATP-sensitive potassium channels in pancreatic beta cells. This inhibition causes cell membrane depolarization, opening of voltage-dependent calcium channels, thus triggering an increase in intracellular calcium into the beta cell which stimulates insulin release. It is sold in doses of 1.25mg, 2.5mg and 5mg, under the trade names Diabeta®, Glynase® and Micronase® in the United States and Daonil®, Semi-Daonil® and Euglucon® in the United Kingdom.

It is also sold in combination with metformin under the trade name Glucovance®.

The drug is contraindicated in pregnant women. It is also a major cause of drug induced hypoglycaemia.

Recently published data suggests that glibenclamide is associated with significantly higher annual mortality when combined with metformin than other insulin secreting medications, after correcting for other potentially confounding patient characteristics. The safety of this combination has been questioned.

SULPHONYLUREAS

Sulphonylureas are used to treat non-insulin dependent (type 2) diabetes.

Glibenclamide (Gliben, Semi-Daonil, Daonil, Apo-Gliibenclamide)

Glicazide (Diamicron)

Glipizide (Glipid, Minidiab)

Tolbutamide (Diatol)

TREATING HYPOGLYCAEMIA

Hypoglycaemia (low blood glucose) occurs when blood glucose levels fall below 4 mmol/L. It is commonly referred to as a 'hypo'.

Although exercise lowers the blood glucose level, it will normally not cause hypoglycaemic episodes in otherwise healthy people.

Symptoms of hypoglycaemia

Hypoglycaemia can make you feel:

- tired
- pale
- clammy/sweaty
- weak/faint
- hungry
- agitated

Diabetes-Related Hypoglycaemia

• If you think your blood glucose is low, check it and treat the problem right away.
• To treat hypoglycaemia, have a serving of a quick-fix food, wait 15 minutes, and check your blood glucose. Repeat the treatment until your blood glucose is above 4 mmol/L.
• Keep quick-fix foods in the car, at work�anywhere you spend time.
• Be careful when you are driving. Check your blood glucose frequently and snack as needed to keep your level above 4 mmol/L.

Hypoglycaemia Unrelated to Diabetes

• In reactive hypoglycaemia, symptoms occur within 4 hours of eating. People with this condition are usually advised to follow a healthy eating plan recommended by a registered dietitian.
• Fasting hypoglycaemia can be caused by certain medications, critical illnesses, hereditary enzyme or hormonal deficiencies, and some kinds of tumours. Treatment targets the underlying problem.

INSULIN

Insulin is the first line treatment for type 1 diabetes mellitus. The aim of insulin treatment is to control blood glucose levels.

Insulin is also used in diabetes type 2 when diet and/or oral therapy have failed to achieve control.

There are 3 main types of insulin preparations, classed by their duration of action.

• Short-acting insulins:

- Soluble insulin (eg. Hypurin Bovine Neutral, Humulin S, Actrapid, Insuman Rapid)
- Insulin aspart (NovoRapid)
- Insulin lispro (Humalog)

• Intermediate-acting insulins:

- Insulin demetir (Levimir)
- Insulin gargine (Lantus)
- Insulin zinc suspension (eg. Hypurin Bovine Lente, Monotard)
- Isophane insulin (eg. Insulatard, Humulin I, Insuman Basal)

• Long-acting insulins:

- Insulin zinc suspension, crystalline (Ultratard)
- Protamine zinc insulin (Hypurin Bovine Protamine Zinc)

A combination of short-acting and intermediate-acting insulins may be used to control blood glucose in diabetic patients -- duration of action varies considerably from one patient to another and needs to be assessed individually.

GLUCOPHAGE (METFORMIN)

DRUG NAME: metformin

USE: Oral antidiabetic agent

This medicine is indicated for non-insulin dependent (type 2) diabetes. It is also used in some cases of polycystic ovary syndrome (unlicensed use).

It works by inhibiting glucose production (gluconeogenesis) and increasing peripheral utilisation of glucose.

Metformin is the drug of choice in overweight patients in whom strict dieting has been unsuccessful or has failed to control diabetes.

Hypoglycaemia (low blood glucose) does not usually occur with metformin.

Contrainidcations:

- kidney impairment (may provoke lactic acidosis)
- recent heart attack
- liver impairment
- general anaesthesia (stop 2 days before anaesthesia)
- pregnancy
- breast feeding

Side effects:

Gastro-intestinal side-effects are common initially (anorexia, nausea, vomiting, diarrhoea, abdominal pain). May also cause a metallic taste.

Rarely: lactic acidosis, decreased vitamin B12 absorption, itch, weals, hepatitis.

Interactions:

- enhances anticoagulant effect of warfarin
- increases risk of lactic acidosis with alcohol
- risk of hypoglycaemia with cimetidine

EXERCISE AND DIABETES

What you need to know about Physical Activity and Diabetes

Diabetes means that your blood glucose (also called blood sugar) is too high. Your body uses glucose for energy. But having too much glucose in your blood can hurt you. When you take care of your diabetes, you'll feel better. You'll reduce your risk for problems with your kidneys, eyes, nerves, feet and legs, and teeth. You'll also lower your risk for a heart attack or a stroke. You can take care of your diabetes by

• being physically active


• following a healthy meal plan


• taking medicines (if prescribed by your doctor)

What can a physically active lifestyle do for me?

Research has shown that physical activity can

• lower your blood glucose and your blood pressure


• lower your bad cholesterol and raise your good cholesterol


• improve your body's ability to use insulin


• lower your risk for heart disease and stroke


• keep your heart and bones strong


• keep your joints flexible


• lower your risk of falling


• help you lose weight


• reduce your body fat


• give you more energy


• reduce your stress

Physical activity also plays an important part in preventing type 2 diabetes. A major government study, the Diabetes Prevention Programme (DPP), showed that a healthy diet and a moderate exercise programme resulting in a 5 to 7 percent weight loss can delay and possibly prevent type 2 diabetes.

What kinds of physical activity can help me?

Four kinds of activity can help. You can try

• being extra active every day


• doing aerobic exercise


• doing strength training


• stretching

Be Extra Active Every Day

Being extra active can increase the number of calories you burn. There are many ways to be extra active.

• Walk around while you talk on the phone.


• Play with the kids.


• Take the dog for a walk.


• Get up to change the TV channel instead of using the remote control.


• Work in the garden or rake leaves.


• Clean the house.


• Wash the car.


• Stretch out your chores. For example, make two trips to take the laundry downstairs instead of one.


• Park at the far end of the shopping center lot and walk to the store.


• At the grocery store, walk down every aisle.


• At work, walk over to see a co-worker instead of calling or emailing.


• Take the stairs instead of the elevator.


• Stretch or walk around instead of taking a coffee break and eating.


• During your lunch break, walk to the post office or do other errands.

Do Aerobic Exercise

Aerobic exercise is activity that requires the use of large muscles and makes your heart beat faster. You will also breathe harder during aerobic exercise. Doing aerobic exercise for 30 minutes a day, most days of the week, provides many benefits. You can even split up those 30 minutes into several parts. For example, you can take three brisk 10-minute walks, one after each meal.

If you haven't exercised lately, see your doctor first to make sure it's OK for you to increase your level of physical activity. Talk with your doctor about how to warm up and stretch before exercise and how to cool down after exercise. Then start slowly with 5 to 10 minutes a day. Add a little more time each week, aiming for 150 to 200 minutes per week. Try

• walking briskly


• hiking


• climbing stairs


• swimming or taking a water-aerobics class


• dancing


• riding a bicycle outdoors or a stationary bicycle indoors


• taking an aerobics class


• playing basketball, volleyball, or other sports


• in-line skating, ice skating, or skate boarding


• playing tennis


• cross-country skiing


• other things I can do: ______________________
_________________________________________

Do Strength Training

Doing exercises with hand weights, elastic bands, or weight machines two or three times a week builds muscle. When you have more muscle and less fat, you'll burn more calories because muscle burns more calories than fat, even between exercise sessions. Strength training can help make daily chores easier, improving your balance and coordination, as well as your bones' health. You can do strength training at home, at a fitness center, or in a class. Your health care team can tell you more about strength training and what kind is best for you.

Stretch

Stretching increases your flexibility, lowers stress, and helps prevent muscle soreness after other types of exercise. Your health care team can tell you what kind of stretching is best for you.

Can I exercise any time I want?

Ask your health care team about the best time of day for you to exercise. Consider your daily schedule, your meal plan, and your diabetes medications in deciding when to exercise.

If you exercise when your blood glucose is above 300, your level can go even higher. It's best not to exercise until your blood glucose is lower. Also, exercise is not recommended if your fasting blood glucose is above 250 and you have ketones in your urine.

Are there any types of physical activity I shouldn't do?

If you have diabetes complications, some exercises can make your problems worse. For example, activities that increase the pressure in the blood vessels of your eyes, such as lifting heavy weights, can make diabetic eye problems worse. If nerve damage from diabetes has made your feet numb, your doctor may suggest that you try swimming instead of walking for aerobic exercise.

Numbness means that you may not feel any pain from sores or blisters on your feet and so may not notice them. Then they can get worse and lead to more serious problems. Make sure you exercise in cotton socks and comfortable, well-fitting shoes that are designed for the activity you are doing. After you exercise, check your feet for cuts, sores, bumps, or redness. Call your doctor if any foot problems develop.

Can physical activity cause low blood glucose?

Physical activity can cause hypoglycaemia (low blood glucose) in people who take insulin or certain diabetes pills, including sulfonylureas and meglitinides. Ask your health care team whether your diabetes pills can cause hypoglycaemia. Some types of diabetes pills do not.

Hypoglycaemia can happen while you exercise, right afterward, or even up to a day later. It can make you feel shaky, weak, confused, irritable, hungry, or tired. You may sweat a lot or get a headache. If your blood glucose drops too low, you could pass out or have a seizure.

However, you should still be physically active. These steps can help you be prepared for hypoglycaemia:

Before Exercise

• Be careful about exercising if you have skipped a recent meal. Check your blood glucose. If it's below 100, have a small snack.


• If you take insulin, ask your health care team whether you should change your dosage before you exercise.

During Exercise

• Wear your medical identification or other ID.


• Always carry food or glucose tablets so that you'll be ready to treat hypoglycaemia.


• If you'll be exercising for more than an hour, check your blood glucose at regular intervals. You may need snacks before you finish.

After Exercise

• Check to see how exercise affected your blood glucose level.

What should I do first?

Check with your doctor. Always talk with your doctor before you start a new physical activity programme. Ask about your medications�prescription and over the counter�and whether you should change the amount you take before you exercise. If you have heart disease, kidney disease, eye problems, or foot problems, ask which types of physical activity are safe for you.

Decide exactly what you'll do and set some goals. Choose

• the type of physical activity you want to do


• the clothes and items you'll need to get ready


• the days and times you'll add activity


• the length of each session


• your warm up and cool down plan for each session


• alternatives, such as where you'll walk if the weather is bad


• your measures of progress

Find an exercise buddy. Many people find that they are more likely to do something active if a friend joins them. If you and a friend plan to walk together, for example, you may be more likely to do it.

Keep track of your physical activity. Write down when you exercise and for how long in your blood glucose record book. You'll be able to track your progress and to see how physical activity affects your blood glucose.

Decide how you'll reward yourself. Do something nice for yourself when you reach your activity goals. For example, treat yourself to a movie or buy a new plant for the garden.

What can I do to make sure I stay active?

One of the keys to staying on track is finding some activities you like to do. If you keep finding excuses not to exercise, think about why. Are your goals realistic? Do you need a change in activity? Would another time be more convenient? Keep trying until you find a routine that works for you. Once you make physical activity a habit, you'll wonder how you lived without it.

DIABETIC RETINOPATHY

What is diabetic retinopathy?

Diabetic retinopathy is a complication of diabetes and a leading cause of blindness. It occurs when diabetes damages the tiny blood vessels inside the retina, the light-sensitive tissue at the back of the eye. A healthy retina is necessary for good vision.

If you have diabetic retinopathy, at first you may notice no changes to your vision. But over time, diabetic retinopathy can get worse and cause vision loss. Diabetic retinopathy usually affects both eyes.

What are the stages of diabetic retinopathy?

Diabetic retinopathy has four stages:

1. Mild Nonproliferative Retinopathy. At this earliest stage, microaneurysms occur. They are small areas of balloon-like swelling in the retina's tiny blood vessels.


2. Moderate Nonproliferative Retinopathy. As the disease progresses, some blood vessels that nourish the retina are blocked.


3. Severe Nonproliferative Retinopathy. Many more blood vessels are blocked, depriving several areas of the retina with their blood supply. These areas of the retina send signals to the body to grow new blood vessels for nourishment.


4. Proliferative Retinopathy. At this advanced stage, the signals sent by the retina for nourishment trigger the growth of new blood vessels. This condition is called proliferative retinopathy. These new blood vessels are abnormal and fragile. They grow along the retina and along the surface of the clear, vitreous gel that fills the inside of the eye.

   By themselves, these blood vessels do not cause symptoms or vision loss. However, they have thin, fragile walls. If they leak blood, severe vision loss and even blindness can result.

Who is at risk for diabetic retinopathy?

All people with diabetes--both type 1 and type 2--are at risk. That's why everyone with diabetes should get a comprehensive dilated eye exam at least once a year. Between 40 to 45 percent of Americans diagnosed with diabetes have some stage of diabetic retinopathy. If you have diabetic retinopathy, your doctor can recommend treatment to help prevent its progression.

During pregnancy, diabetic retinopathy may be a problem for women with diabetes. To protect vision, every pregnant woman with diabetes should have a comprehensive dilated eye exam as soon as possible. Your doctor may recommend additional exams during your pregnancy.

How does diabetic retinopathy cause vision loss?

Blood vessels damaged from diabetic retinopathy can cause vision loss in two ways:

1. Fragile, abnormal blood vessels can develop and leak blood into the center of the eye, blurring vision. This is proliferative retinopathy and is the fourth and most advanced stage of the disease.


2. Fluid can leak into the center of the macula, the part of the eye where sharp, straight-ahead vision occurs. The fluid makes the macula swell, blurring vision. This condition is called macular oedema. It can occur at any stage of diabetic retinopathy, although it is more likely to occur as the disease progresses. About half of the people with proliferative retinopathy also have macular oedema

Does diabetic retinopathy have any symptoms?

Diabetic retinopathy often has no early warning signs. Don't wait for symptoms. Be sure to have a comprehensive dilated eye exam at least once a year.

What are the symptoms of proliferative retinopathy if bleeding occurs?

At first, you will see a few specks of blood, or spots, "floating" in your vision. If spots occur, see your eye care professional as soon as possible. You may need treatment before more serious bleeding occurs. Haemorrhages tend to happen more than once, often during sleep.

Sometimes, without treatment, the spots clear, and you will see better. However, bleeding can reoccur and cause severely blurred vision. You need to be examined by your eye care professional at the first sign of blurred vision, before more bleeding occurs.

If left untreated, proliferative retinopathy can cause severe vision loss and even blindness. Also, the earlier you receive treatment, the more likely treatment will be effective.

How are macular oedema and diabetic retinopathy detected?

Macular oedema and diabetic retinopathy are detected during a comprehensive eye exam that includes:

• Visual acuity test. This eye chart test measures how well you see at various distances.


• Dilated eye exam. Drops are placed in your eyes to widen, or dilate, the pupils. Your eye care professional uses a special magnifying lens to examine your retina and optic nerve for signs of damage and other eye problems. After the exam, your close-up vision may remain blurred for several hours.


• Tonometry. An instrument measures the pressure inside the eye. Numbing drops may be applied to your eye for this test.

Your eye care professional checks your retina for early signs of the disease, including:

• Leaking blood vessels.


• Retinal swelling (macular oedema).


• Pale, fatty deposits on the retina--signs of leaking blood vessels.


• Damaged nerve tissue.


• Any changes to the blood vessels.

If your eye care professional believes you need treatment for macular oedema, he or she may suggest a fluorescein angiogram. In this test, a special dye is injected into your arm. Pictures are taken as the dye passes through the blood vessels in your retina. The test allows your eye care professional to identify any leaking blood vessels and recommend treatment.

How is a macular oedema treated?

Macular oedema is treated with laser surgery. This procedure is called focal laser treatment. Your doctor places up to several hundred small laser burns in the areas of retinal leakage surrounding the macula. These burns slow the leakage of fluid and reduce the amount of fluid in the retina. The surgery is usually completed in one session. Further treatment may be needed.

A patient may need focal laser surgery more than once to control the leaking fluid. If you have macular oedema in both eyes and require laser surgery, generally only one eye will be treated at a time, usually several weeks apart.

Focal laser treatment stabilizes vision. In fact, focal laser treatment reduces the risk of vision loss by 50 percent. In a small number of cases, if vision is lost, it can be improved. Contact your eye care professional if you have vision loss.

How is diabetic retinopathy treated?

During the first three stages of diabetic retinopathy, no treatment is needed, unless you have macular oedema. To prevent progression of diabetic retinopathy, people with diabetes should control their levels of blood sugar, blood pressure, and blood cholesterol.

Proliferative retinopathy is treated with laser surgery. This procedure is called scatter laser treatment. Scatter laser treatment helps to shrink the abnormal blood vessels. Your doctor places 1,000 to 2,000 laser burns in the areas of the retina away from the macula, causing the abnormal blood vessels to shrink. Because a high number of laser burns are necessary, two or more sessions usually are required to complete treatment. Although you may notice some loss of your side vision, scatter laser treatment can save the rest of your sight. Scatter laser treatment may slightly reduce your colour vision and night vision.

Scatter laser treatment works better before the fragile, new blood vessels have started to bleed. That is why it is important to have regular, comprehensive dilated eye exams. Even if bleeding has started, scatter laser treatment may still be possible, depending on the amount of bleeding.

If the bleeding is severe, you may need a surgical procedure called a vitrectomy. During a vitrectomy, blood is removed from the center of your eye.

What happens during laser treatment?

Both focal and scatter laser treatment are performed in your doctor's office or eye clinic. Before the surgery, your doctor will dilate your pupil and apply drops to numb the eye. The area behind your eye also may be numbed to prevent discomfort.

The lights in the office will be dim. As you sit facing the laser machine, your doctor will hold a special lens to your eye. During the procedure, you may see flashes of light. These flashes eventually may create a stinging sensation that can be uncomfortable.

You will need someone to drive you home after surgery. Because your pupil will remain dilated for a few hours, you should bring a pair of sunglasses.

For the rest of the day, your vision will probably be a little blurry. If your eye hurts, your doctor can suggest treatment.

What is a vitrectomy?

If you have a lot of blood in the center of the eye (vitreous gel), you may need a vitrectomy to restore your sight. If you need vitrectomies in both eyes, they are usually done several weeks apart.

A vitrectomy is performed under either local or general anaesthesia. Your doctor makes a tiny incision in your eye. Next, a small instrument is used to remove the vitreous gel that is clouded with blood. The vitreous gel is replaced with a salt solution. Because the vitreous gel is mostly water, you will notice no change between the salt solution and the original vitreous gel.

You will probably be able to return home after the vitrectomy. Some people stay in the hospital overnight. Your eye will be red and sensitive. You will need to wear an eye patch for a few days or weeks to protect your eye. You also will need to use medicated eyedrops to protect against infection.

Are scatter laser treatment and vitrectomy effective in treating proliferative retinopathy?

Yes. Both treatments are very effective in reducing vision loss. People with proliferative retinopathy have less than a five percent chance of becoming blind within five years when they get timely and appropriate treatment. Although both treatments have high success rates, they do not cure diabetic retinopathy.

Once you have proliferative retinopathy, you always will be at risk for new bleeding. You may need treatment more than once to protect your sight.

What can I do if I already have lost some vision from diabetic retinopathy?

If you have lost some sight from diabetic retinopathy, ask your eye care professional about low vision services and devices that may help you make the most of your remaining vision. Ask for a referral to a specialist in low vision. Many community organisations and agencies offer information about low vision counselling, training, and other special services for people with visual impairments. A nearby school of medicine or optometry may provide low vision services.

What can I do to protect my vision?

The NEI urges everyone with diabetes to have a comprehensive dilated eye exam at least once a year. If you have diabetic retinopathy, you may need an eye exam more often. People with proliferative retinopathy can reduce their risk of blindness by 95 percent with timely treatment and appropriate followup care.

A major study has shown that better control of blood sugar levels slows the onset and progression of retinopathy. The people with diabetes who kept their blood sugar levels as close to normal as possible also had much less kidney and nerve disease. Better control also reduces the need for sight-saving laser surgery.

This level of blood sugar control may not be best for everyone, including some elderly patients, children under age 13, or people with heart disease. Be sure to ask your doctor if such a control programme is right for you.

Other studies have shown that controlling elevated blood pressure and cholesterol can reduce the risk of vision loss. Controlling these will help your overall health as well as help protect your vision.

What should I ask my eye care professional?

You can protect yourself against vision loss by working in partnership with your eye care professional. Ask questions and get the information you need to take care of yourself and your family.

What are some questions to ask?

About my eye disease or disorder...

• What is my diagnosis?
• What caused my condition?
• Can my condition be treated?
• How will this condition affect my vision now and in the future?
• Should I watch for any particular symptoms and notify you if they occur?
• Should I make any lifestyle changes?

About my treatment...

• What is the treatment for my condition?
• When will the treatment start and how long will it last?
• What are the benefits of this treatment and how successful is it?
• What are the risks and side effects associated with this treatment?
• Are there foods, drugs, or activities I should avoid while I'm on this treatment?
• If my treatment includes taking medicine, what should I do if I miss a dose?
• Are other treatments available?

About my tests...

• What kinds of tests will I have?
• What can I expect to find out from these tests?
• When will I know the results?
• Do I have to do anything special to prepare for any of the tests?
• Do these tests have any side effects or risks?
• Will I need more tests later?

Other suggestions

• If you don't understand your eye care professional's responses, ask questions until you do understand.
• Take notes or get a friend or family member to take notes for you. Or, bring a tape recorder to help you remember the discussion.
• Ask your eye care professional to write down his or her instructions to you.
• Ask your eye care professional for printed material about your condition.
• If you still have trouble understanding your eye care professional's answers, ask where you can go for more information.
• Other members of your health care team, such as nurses and pharmacists, can be good sources of information. Talk to them, too.

Today, patients take an active role in their health care. Be an active patient about your eye care.

DIABETES TESTING AND CONTROL

Taking Care of Your Diabetes Every Day

1. Follow Your Meal Plan
2. Be Physically Active
3. Take Your Diabetes Medicine Every Day
4. Check Your Blood Glucose as Recommended
5. Take Other Tests for Your Diabetes

Do four things every day to lower high blood glucose:

• Follow your meal plan.
• Be physically active.
• Take your diabetes medicine.
• Check your blood glucose.

Experts say most people with diabetes should try to keep their blood glucose level as close as possible to the level of someone who doesn't have diabetes. The closer to normal your blood glucose is, the lower your chances are of developing damage to your eyes, kidneys, and nerves.

Check with your doctor about the right range for you.

Your health care team will help you learn how to reach your target blood glucose range. Your main health care providers are your doctor, nurse, diabetes educator, and dietitian.

A diabetes educator is a health care worker who teaches people how to manage their diabetes. Your educator may be a nurse, a dietitian, or another kind of health care worker.

A dietitian is someone who's specially trained to help people plan their meals.

The next sections of this guide will tell you more about the four main ways you take care of your diabetes: Follow your meal plan, by physically active, take your diabetes medicine, and check your blood glucose.

1. Follow Your Meal Plan

People with diabetes don't need to eat special foods. The foods on your meal plan are good for everyone in your family! Try to eat foods that are low in fat, salt, and sugar and high in fiber such as beans, fruits, vegetables, and grains. Eating right will help you

• reach and stay at a weight that's good for your body
• keep your blood glucose in a desirable range
• prevent heart and blood vessel disease

Your daily meal plan should include foods from these groups:

People with diabetes should have their own meal plan. Ask your doctor to give you the name of a dietitian who can work with you to develop a meal plan. Your dietitian can help you plan meals to include foods that you and your family like to eat and that are good for you too. Ask your dietitian to include foods that are heart-healthy to reduce your risk of heart disease.

ACTION STEPS If you use insulin Follow your meal plan. Don't skip meals, especially if you've already taken your insulin, because your blood glucose may go too low. If you DON'T use insulin Follow your meal plan. Don't skip meals, especially if you take diabetes medicine, because your blood glucose may go too low. It may be better to eat several small meals during the day instead of one or two big meals.

2. Be Physically Active

Physical activity is good for your diabetes. Walking, swimming, dancing, riding a bicycle, playing baseball, and bowling are all good ways to be active. You can even get exercise when you clean house or work in your garden. Physical activity is especially good for people with diabetes because

• physical activity helps keep weight down
• physical activity helps insulin work better to lower blood glucose
• physical activity is good for your heart and lungs
• physical activity gives you more energy

Before you begin exercising, talk with your doctor. Your doctor may check your heart and your feet to be sure you have no special problems. If you have high blood pressure or eye problems, some exercises like weightlifting may not be safe. Your health care team can help you find safe exercises.

Try to be active almost every day for a total of about 30 minutes. If you haven't been very active lately, begin slowly. Start with 5 to 10 minutes, and then add more time. Or exercise for 10 minutes, three times a day.

If your blood glucose is less than 100 to 120, have a snack before you exercise.

When you exercise, carry glucose tablets or a carbohydrate snack with you in case you get hypoglycaemia (low blood sugar). Wear or carry an identification tag or card saying that you have diabetes.

ACTION STEPS If you use insulin See your doctor before starting a physical activity programme. Check your blood glucose before, during, and after exercising. Don't exercise when your blood glucose is over 240 or if you have ketones in your urine. Don't exercise right before you go to sleep, because it could cause hypoglycaemia (low blood sugar) during the night. If you don't use insulin See your doctor before starting a physical activity programme.

3. Take Your Diabetes Medicine Every Day

Insulin and diabetes pills are the two kinds of medicines used to lower blood glucose.

If You Use Insulin

You need insulin if your body has stopped making insulin or if it doesn't make enough. Everyone with type 1 diabetes needs insulin, and many people with type 2 diabetes do too.

Insulin can't be taken as a pill. You'll give yourself shots every day or use an insulin pump. An insulin pump is a small machine that connects to narrow tubing, ending with a needle just under the skin near the abdomen. Insulin is delivered through the needle.

Keep extra insulin in your refrigerator in case you break the bottle you're using. Don't keep insulin in the freezer or in hot places like the glove compartment of your car. Also, keep it away from bright light. Too much heat, cold, or bright light can damage insulin.

If you use a whole bottle of insulin within a month, you can keep that bottle at room temperature. If you don't use a whole bottle of insulin within one month, then store it in the refrigerator.

If You Take Diabetes Pills

If your body makes insulin, but the insulin doesn't lower your blood glucose, you may need diabetes pills. Some pills are taken once a day, and others are taken more often. Ask your health care team when you should take your pills.

Be sure to tell your doctor if your pills make you feel sick or if you have any other problems. Remember, diabetes pills don't lower blood glucose all by themselves. You'll still want to follow a meal plan and be active to help lower your blood glucose.

Sometimes, people who take diabetes pills may need insulin shots for a while. If you get sick or have surgery, the diabetes pills may no longer work to lower your blood glucose.

You may be able to stop taking diabetes pills if you lose weight. (Always check with your doctor before you stop taking your diabetes pills.) Losing 10 or 15 pounds can sometimes help you reach your target blood glucose level.

If You Don't Use Insulin or Take Diabetes Pills

Many people with type 2 diabetes don't need insulin or diabetes pills. They can take care of their diabetes by using a meal plan and exercising regularly.

4. Check Your Blood Glucose as Recommended

You'll want to know how well you're taking care of your diabetes. The best way to find out is to check your blood to see how much glucose is in it. If your blood has too much or too little glucose, you may need a change in your meal plan, exercise plan, or medicine.

Ask your doctor how often you should check your blood glucose. Some people check their blood glucose once a day. Others do it three or four times a day. You may check before and after eating, before bed, and sometimes in the middle of the night.

Your doctor or diabetes educator will show you how to check your blood using a blood glucose meter. Your health insurance or Medicare may pay for the supplies and equipment you need.

5. Take Other Tests for Your Diabetes Urine Tests

You may need to check your urine if you're sick or if your blood glucose is over 240. A urine test will tell you if you have ketones in your urine. Your body makes ketones when there isn't enough insulin in your blood. Ketones can make you very sick. Call your doctor right away if you find moderate or large amounts of ketones, along with high blood glucose levels, when you do a urine test. You may have a serious condition called ketoacidosis. If it isn't treated, it can cause death. Signs of ketoacidosis are vomiting, weakness, fast breathing, and a sweet smell on the breath. Ketoacidosis is more likely to develop in people with type 1 diabetes.

You can buy strips for testing ketones at a drug store. Your doctor or diabetes educator will show you how to use them.

The A1C Test

Another test for blood glucose, the A1C, also called the haemoglobin A1C test, shows what your overall blood glucose was for the past 3 months. It shows how much glucose is sticking to your red blood cells. The doctor does this test to see what your blood glucose is most of the time. Have this test done at least twice a year.

Ask your doctor what your A1C test showed. A result of under 7 usually means that your diabetes treatment is working well and your blood glucose is under control. If your A1C is 8 or above, it means that your blood glucose may be too high. You'll then have a greater chance of getting diabetes problems, like kidney damage. You may need a change in your meal plan, physical activity plan, or diabetes medicine.

Talk with your doctor about what your target should be. Even if your A1C is higher than your target, remember that every step toward your goal helps reduce your risk of diabetes problems.

Keep Daily Records

By keeping daily records of your blood glucose checks, you can tell how well you're taking care of your diabetes. Show your blood glucose records to your health care team. They can use your records to see whether you need changes in your diabetes medicines or in your meal plan. If you don't know what your results mean, ask your health care team.

Things to write down every day in your record book are

• results of your blood glucose checks
• your diabetes medicines: times and amounts taken
• if your blood glucose was very low
• if you ate more or less food than you usually do
• if you were sick
• if you found ketones in your urine
• what kind of physical activity you did and for how long

ACTION STEPS If you use insulin Keep a daily record of your blood glucose numbers the times of the day you took your insulin the amount and type of insulin you took whether you had ketones in your urine If you DON'T use insulin Keep a daily record of your blood glucose numbers the times of the day you took your diabetes pills your physical activity

DIABETES Explained

What is diabetes?

Diabetes means that your blood glucose (often called blood sugar) is too high. Your blood always has some glucose in it because your body needs glucose for energy to keep you going. But too much glucose in the blood isn't good for your health.

How do you get high blood glucose?

Glucose comes from the food you eat and is also made in your liver and muscles. Your blood carries the glucose to all the cells in your body. Insulin is a chemical (a hormone) made by the pancreas. The pancreas releases insulin into the blood. Insulin helps the glucose from food get into your cells. If your body doesn't make enough insulin or if the insulin doesn't work the way it should, glucose can't get into your cells. It stays in your blood instead. Your blood glucose level then gets too high, causing pre-diabetes or diabetes.

What is pre-diabetes?

Pre-diabetes is a condition in which blood glucose levels are higher than normal but are not high enough for a diagnosis of diabetes. People with pre-diabetes are at increased risk for developing type 2 diabetes and for heart disease and stroke. The good news is if you have pre-diabetes, you can reduce your risk of getting diabetes. With modest weight loss and moderate physical activity, you can delay or prevent type 2 diabetes and even return to normal glucose levels.

What are the signs of diabetes?

The signs of diabetes are

• being very thirsty
• urinating often
• feeling very hungry or tired
• losing weight without trying
• having sores that heal slowly
• having dry, itchy skin
• losing the feeling in your feet or having tingling in your feet
• having blurry eyesight

You may have had one or more of these signs before you found out you had diabetes. Or you may have had no signs at all. A blood test to check your glucose levels will show if you have pre-diabetes or diabetes.

What kind of diabetes do you have?

People can get diabetes at any age. There are three main kinds.

Type 1 diabetes, formerly called juvenile diabetes or insulin-dependent diabetes, is usually first diagnosed in children, teenagers, or young adults. In this form of diabetes, the beta cells of the pancreas no longer make insulin because the body's immune system has attacked and destroyed them. Treatment for type 1 diabetes includes taking insulin shots or using an insulin pump, making wise food choices, being physically active, taking aspirin daily (for some), and controlling blood pressure and cholesterol.

Type 2 diabetes, formerly called adult-onset diabetes or noninsulin-dependent diabetes, is the most common form of diabetes. People can develop type 2 diabetes at any age�even during childhood. This form of diabetes usually begins with insulin resistance, a condition in which fat, muscle, and liver cells do not use insulin properly. At first, the pancreas keeps up with the added demand by producing more insulin. In time, however, it loses the ability to secrete enough insulin in response to meals. Being overweight and inactive increases the chances of developing type 2 diabetes. Treatment includes using diabetes medicines, making wise food choices, being physically active, taking aspirin daily, and controlling blood pressure and cholesterol.

Some women develop gestational diabetes during the late stages of pregnancy. Although this form of diabetes usually goes away after the baby is born, a woman who has had it is more likely to develop type 2 diabetes later in life. Gestational diabetes is caused by the hormones of pregnancy or a shortage of insulin.

Why you need to take care of your diabetes

After many years, diabetes can lead to serious problems in your eyes, kidneys, nerves, and gums and teeth. But the most serious problem caused by diabetes is heart disease. When you have diabetes, you are more than twice as likely as people without diabetes to have heart disease or a stroke.

If you have diabetes, your risk of a heart attack is the same as someone who has already had a heart attack. Both women and men with diabetes are at risk. You may not even have the typical signs of a heart attack.

You can reduce your risk of developing heart disease by controlling your blood pressure and blood fat levels. If you smoke, talk with your doctor about quitting. Remember that every step toward your goals helps!

Later in this guide, we'll tell you how you can try to prevent or delay long-term problems. The best way to take care of your health is to work with your health care team to keep your blood glucose, blood pressure, and cholesterol in your target range.

ACE INHIBITORS (ACEIs)

ACE Inhibitors (ACEIs), or inhibitors of Angiotensin-Converting Enzyme, are a group of pharmaceuticals that are used primarily in treatment of hypertension and congestive heart failure, in most cases as the drugs of first choice.

Use

Indications for ACE inhibitors include:

• Prevention of cardiovascular disorders
  
• Congestive heart failure
  
• Hypertension
  
• Left ventricular dysfunction
  
• Prevention of nephropathy in diabetes mellitus

In several of these indications, ACE inhibitors are used first-line as several agents in the class have been clinically shown to be superior to other classes of drugs in the reduction of morbidity and mortality.

ACE inhibitors are often combined with diuretics in the control of hypertension (usually a thiazide), when an ACE inhibitor alone proves insufficient; and in chronic heart failure (usually furosemide) for improved symptomatic control. Thus there exists, on the market, combination products combining an ACE inhibitor with a thiazide (usually hydrochlorothiazide) in a single tablet to allow easy administration by patients.

Side effects

Common adverse drug reactions (=1% of patients) include: hypotension, cough, hyperkalemia, headache, dizziness, fatigue, nausea, renal impairment

A persistent dry cough is a relatively common adverse effect believed to be associated with the increases in bradykinin levels produced by ACE inhibitors, although the role of bradykinin in producing these symptoms remains disputed by some authors. Patients who experience this cough are often switched to angiotensin II receptor antagonists.

Rash and taste disturbances, infrequent with most ACE inhibitors, are more prevalent in captopril and is attributed to its sulfhydryl moiety. This has led to decreased use of captopril in clinical setting, although it is still used in scintigraphy of the kidney.

Renal impairment is a significant adverse effect of all ACE inhibitors, and is associated with their effect on angiotensin II-mediated homeostatic functions such as renal bloodflow. ACE inhibitors can induce or exacerbate renal impairment in patients with renal artery stenosis. This is especially a problem if the patient is also concomitantly taking an NSAID and a diuretic - the so-called "triple whammy" effect - such patients are at very high risk of developing renal failure.

Some patients develop angioedema due to increased bradykinin levels. There appears to be a genetic predisposition towards this adverse effect in patients who degrade bradykinin slower than average.

Groups

Sulfhydryl-containing ACE inhibitors

• Captopril (Capoten ®), the first ACE inhibitor

Dicarboxylate-containing ACE inhibitors

This is the largest group, including:

• Enalapril (Vasotec®/Renitec®)
  
• Ramipril (Altace®/Tritace®/Ramace®/Ramiwin®)
  
• Quinapril (Accupril®)
  
• Perindopril (Coversyl®)
  
• Lisinopril (Lisodur®/Lopril®/Prinivil®/Zestril®)
  
• Benazepril (Lotensin®)

Phosphonate-containing ACE inhibitors

• Fosinopril (Monopril®)

Contraindications

The ACE inhibitors are contraindicated in patients with:

• Previous angioedema associated with ACE inhibitor therapy
  
• Renal artery stenosis (bilateral, or unilateral with a solitary functioning kidney)

ACE inhibitors should be used with caution in patients with:

• Impaired renal function
  
• Aortic valve stenosis or cardiac outflow obstruction
  
• Hypovolaemia or dehydration
  
• Haemodialysis with high flux polyacrylonitrile membranes

ACE inhibitors are ADEC Pregnancy category D, and should be avoided in women who are likely to become pregnant. In the U.S., ACE inhibitors are required to be labelled with a "black box" warning concerning the risk of birth defects when taking during the second and third trimester. It has also been found that use of ACE inhibitors in the first trimester is also associated with a risk of major congenital malformations, particularly affecting the cardiovascular and central nervous systems.

Potassium supplementation should be used with caution and under medical supervision owing to the hyperkalaemic effect of ACE inhibitors.

DIABETES

Diabetes is increasing world wide. This section covers some of the common problems diabetics face, and how to better manage the condition.

ACE INHIBITORS

ACE Inhibitors are used to treat high blood pressure, heart conditions and kidney problems. This article profiles their use and side effects.

DIABETES

Diabetes is a growing problem world wide. This article provides a thorough overview of both type 1 and type 2 diabetes.

DIABETES TESTING AND CONTROL
This article outlines the benefits of regular testing and good control of sugar levels to reduce long term complications.

DIABETIC RETINOPATHY
This is an important and preventable cause of visual loss in diabetics. Regular checks are essential for early prevention.

EXERCISE AND DIABETES
Controlling diabetes and exercising can be a balancing act. This article gives helpful advice on how people with diabetes can exercise safely.

GLUCOPHAGE

This medicine is used to treat type 2 diabetes. This article offers a profile of the drug and its properties.

INSULIN

There are several different types of insulin from new fast acting products to ones that can take about four hours to work. This article looks at the various types and how to use them.

SULPHONYLUREAS

These medicines are used to treat Type 2 diabetes. This article details how they work and how they should be taken.

TREATING HYPOGLYCAEMIA
The prevention of hypoglycaemia can be a balancing act for people with diabetes. This article looks at how to prevent and treat an episode of hypoglycaemia.