Editor

David Mendosa is a freelance journalist and consultant on diabetes. Since 1995, his Web site, www.mendosa.com, has become one of the largest about diabetes. He publishes '"Diabetes Update'" online each month and is a coauthor of the book "What Makes My Blood Sugar Go Up and Down."

Like comedian Rodney Dangerfield, glucose tablets and gels "don't get no respect." That's not good grammar, but nothing else better captures the low regard that many of us have for this wonderful product.

...glucose...is the sugar that our bodies use the fastest.

Maybe it's the cost. None of the five manufacturers make expensive tablets or gels, and one brand of glucose tablets lists for less than a dime per tab. We might respect them more if they cost as much as, for example, test strips.

Maybe it's the taste. Glucose tabs may look like candy, but they certainly don't taste as good. Actually, that's intentional. They don't taste bad, but they are medicine. You don't want to continually eat them, and not have them when you need them.

Maybe it's their over-the-counter status. You can buy them in most drug stores and on the Internet without a prescription. All glucose tabs and gels are essentially pure glucose. This is the sugar that our bodies use the fastest. When our blood glucose levels drop below 60 or 70 mg/dl, we are at risk of hypoglycemia and need to take quick action.

The easiest strategy to remember is "the rule of 15." Paddock Laboratories of Minneapolis, the only company that makes both glucose tablets and gels, recommends that we take 15 grams of glucose when we go low, wait 15 minutes, and then take 15 more grams of glucose—if necessary. The available tabs are four or five grams each, and the gels are 15 or 24 grams. If we take too much, we can yo-yo to quite high blood glucose levels.

The article, "Products for Treating Low Blood Sugar," part of the American Diabetes Association's Resource Guide 2003 and a supplement to Diabetes Forecast, concurs with the rule of 15 and provides much more information.

The other companies making glucose tabs are Becton Dickinson of Franklin Lakes, New Jersey, Wal-Mart Stores of Bentonville, Arkansas, and Can-Am Care of Chazy, New York. Can-Am Care, formerly a subsidiary of Inverness Medical, doesn't have a Web site, but sells glucose tabs both as drugstore brands and under its own name in other drugstores. ICN Pharmaceuticals http://www.nitebite.com/IGnutrition.html in Costa Mesa, California, makes glucose gel.

Glucose tabs and gels aren't just for people with type 1 diabetes. Anyone who uses insulin—about 40 percent of people with type 2 diabetes—are also at risk of "an insulin reaction," where we take too much insulin for the amount of food we consume.

The sulfonylurea drugs can also cause hypoglycemia. Except for the alpha-glucosidase inhibitors Precose and Glyset, other drugs for people with type 2 diabetes rarely, if ever, cause hypoglycemic reactions. Because Precose and Glyset slow the digestion of complex sugars, people who take either of these drugs should always treat lows with glucose, which is a simple sugar.

Actually, complex sugars don't work fast enough for anyone who has gone low. The recommendation that always irritates me the most is to drink orange juice, which is mostly two complex sugars, sucrose and fructose.

For years the standard list has included a half glass of orange juice, sugar cubes, three or four Life Savers, a half cup of Coke or Pepsi, and two tablespoons or raisins. But none of these can compare with glucose tabs or gels in convenience, knowing how much to take, and especially speed.

Whatever you do, don't wait until it's too late to take one of these great products. When someone loses consciousness, never give that person anything to eat or drink. Instead, give him or her a glucagon injection or immediately get that person to the nearest emergency room.

All of us susceptible to hypoglycemia really need to keep one of these products next to our beds, in our cars, and purses or briefcases. Treat your body and your glucose tabs or gels with respect and, as the Boy Scouts say, be prepared.

The American Diabetes Association originally published this article on its Web site as one of my “About the Internet” columns.

The Insulin Pumpers mailing list that took shape this year is certainly highly specialized. But for those people with diabetes who are looking for the tightest possible control, if offers knowledgeable advice from pumpers and their parents. That candy meant more to him than anyone could imagine.

For Rose Lulla, the mailing list encouraged her to find an endocrinologist who would put her 10-year-old son Ravi on a pump. "Doctors here in Omaha, Nebraska, don't have much interest in putting kids younger than 12 or 13 on the pump," she tells me.

Ravi had got his diagnosis on his seventh birthday. In October his mother and he joined the Insulin Pumpers mailing list, and about two weeks later he began to use a pump.

Ravi's use of the pump not only give him tight control but also have unexpected emotional rewards. Days after he began to use a pump, one of his classmates noticed that he was eating the five M&Ms that the teacher occasionally hands out as a treat, Ms. Lulla says.

Thinking that Ravi had diabetes and couldn't eat candy, the classmate was stunned, until Ravi explained how the pump allowed him to cover the additional carbohydrate. "I think those five pieces of candy meant more to him than anyone could imagine," Ms. Lulla says.

"Ravi's classmates are thrilled for him," she continues. "They are so excited that after three years he could finally eat lunch with the class in the lunchroom as opposed to earlier in the classroom. " Before starting on the pump, Ravi's meal schedule had to be fit around his multiple injections—not around the usual school day.

In Palo Alto, California, Michael Robinton understands how Ravi and Ms. Lulla feel. Mr. Robinton runs the mailing list because his 14-year-old daughter Lily has been pumping for the past three years. She currently maintains a hemoglobin A1c of about 6.75, he says.

"I was touched by Ravi's story," Mr. Robinton says. "It reminds me of Lily's request for McDonald's apple pie on the way home from the endo's office, when she got her pump filled with insulin for the first time," he says.

Although pump users still need to follow a meal plan, they can better accommodate snacks that would be hard to fit in with conventional insulin therapy.

Mr. Robinton, whose business already had an Internet address, took over management of the list a few months ago when it needed a home. Glenn Yoder in Foster City, California, originated the list, "but my computer skills ran out," he says.

Mr. Yoder, 65, has been on insulin for 37 years, including three years on a pump. "My hemoglobin A1c is in the high 6s and low 7s," he says with satisfaction. "Before the pump it was running at 12."

The list started as a group of America Online members. Mr. Yoder searched AOL's member profiles for "insulin pumpers" and wrote them. "Almost everybody was interested in it, and it took off and spread by word of mouth."

Until recently Insulin Pumpers was a closed list with about 20 members. But after moving to the Internet and finding a home on Mr. Robinton's site, it has grown to a membership today of about 100.

The easiest way to join the Insulin Pumpers list is through its Web page at http://www.insulin-pumpers.org/ and click on "Join Insulin-Pumper's and other mail lists" and then click on "Join."

One requirement of this mailing list that many others don't have is to send the list a personal profile. The profiles are available on-line in a "members only" area of the Web site. Also available on-line in this closed area are archived message going back to May. Mr. Robinton is also building the site's collection of answers to frequently asked questions.

All this is to help find answers for those interested in pumping themselves or for their children. It worked so well for Ms. Lulla that she says, "I was encouraged by other parents of kids on pumps to get Ravi's endocrinologist to say yes to the pump. I want to be that same thing to other parents." That sort of community support is what mailing list do best, and the Insulin Pumpers list does it very well indeed.

The American Diabetes Association originally published this article on its Web site as one of my “About the Internet” columns.

If you have erectile dysfunction, you don’t have to shop for the increasingly rare rhinoceros horn or the often deadly Spanish fly, which is made from the remains of the blister beetle. There are hundreds of other reputed aphrodisiacs, but none have been found to work.

What about Viagra, Levitra, and Cialis?
You don’t even have to inject a drug into your penis, which was the best thing that Western medicine had to offer just eight years ago. Before that, the best you could do was either use a pump to draw blood into your penis or a penile implant, which meant the surgical placement of plastic rods in your penis.

Ouch!

Now, we have a choice of three quite effective and well tested oral drugs for erectile dysfunction (often described by the acronym ED). They are not aphrodisiacs, because they will not increase sexual drive. They work by blocking an enzyme called phosphodiesterase-5, or PDE-5. This helps the smooth muscles in the penis to relax, which effectively increases blood flow, allowing an erection. But for them to be effective, sexual stimulation is also required.

ED is the consistent or recurrent inability of a man to attain and/or maintain a penile erection sufficient for sexual performance. Obviously an intensely private matter, it is not something that we have begun to talk about in public until quite recently. Consequently it is a common health condition among men that is largely untreated. And it has only since Viagra (sildenafil citrate) came on the market in April 1998 that we have begun to realize how many men suffer from ED.

The best estimates are that some degree of ED affects more than one half of all men over the age of 40—perhaps 152 million men worldwide and 30 million men in the United States alone. Despite this high prevalence, nine out of 10 men in the U.S. have not yet sought treatment from a physician.

ED is three times more prevalent among men who have diabetes than in the general population. More than half of men with diabetes notice the onset of ED within 10 years of their diagnosis. It occurs in nine percent of men with diabetes between age 20 and 29 years and rises to 95 percent by age 70.

Surprisingly, ED is more common among men with type 2 diabetes than among those with type 1, according to Martyn A. Vickers, MD, Chief of Surgery, Togus (Maine) VA Medical Center, and Associate Professor of Urology, University of Massachusetts Medical Center. He writes in “Phosphodiesterase type 5 inhibitors for the treatment of erectile dysfunction in patients with diabetes mellitus,” International Journal of Impotence Research (2002) 14, 466-471; abstract online at PubMed. Some 46 percent of men with type 2 diabetes have ED. This compares with 32 percent of those with type 1 diabetes.

So add ED to your list of common complications of diabetes. ED is often a manifestation of neuropathy. Like peripheral neuropathy, to which ED is often related, there is no “one size fits all” treatment. But unlike peripheral neuropathy, we now have in our arsenal three drugs that are effective for most men.

These three drugs are closely related:

• Viagra Most well known and available in the U.S. for the past five years is Viagra (sildenafil citrate), which Pfizer Inc. produces. The product’s official website is http://www.viagra.com. The biggest difference among these drugs is how long they last. “Take Viagra about one hour before you plan to have sex,” the Viagra website http://www.viagra.com/consumer/general/importantInfo.asp says. “Beginning in about 30 minutes and for up to 4 hours, Viagra can help you get an erection if you are sexually excited.”
• Levitra, pronounced Luh-VEE-trah, (vardenafil HCl), obtained FDA approval in August 2003 and became available in the U.S. later that month. Bayer AG and GlaxoSmithKline plc co-developed and co-promote it. The product’s official website is http://www.levitra.com. “Maximum observed plasma concentrations after a single 20 mg dose in healthy volunteers are usually reached between 30 minutes and 2 hours (median 60 minutes after oral dosing),” according to the product’s official website at http://www.univgraph.com/bayer/inserts/levitra.pdf.
• Cialis, pronounced see-AL-iss, (tadalafil), obtained FDA approval in November 2003 and became available in December. In February 2003 it was launched in Europe. Eli Lilly and Company, partnering with the drug’s original developer, ICOS, market it in a joint development venture. The product’s website is http://www.cialis.com/index.jsp. In Europe this drug already has a catchy nickname. It’s known there as “le weekend” pill. The product’s label says that Cialis can improve erectile function for up to 36 hours.

This is the only drug where I was able to find a curve of its effectiveness. Source of graphic: http://www.univgraph.com/bayer/inserts/levitra.pdf

Aside from how long these three drugs work, they are chemically similar and have similar side effects. Apparently, the biggest difference is that men using Viagra are more likely to experience temporary abnormalities of color vision. Additionally, taking Viagra with food decreases its effectiveness by 29 percent, while food has little if any effect on Levitra or Cialis.

They are even priced close to each other. Price is an important consideration, especially if your health insurance plan doesn’t include these drugs in its formulary.

The best legitimate prices I have been able to find come from Drugstore.com. This online pharmacy lists 10 Viagra tablets of 100 mg each at $87.99. Strangely, the 25 mg and 50 mg tablets list for the same price.

Likewise, Drugstore.com lists 10 Levitra tablets of 20 mg each at $87.99. The 2.5 mg, 5 mg, and 10 mg tablets list for the same price. The Drugstore.com price for 10 Cialis tablets of 5 mg, 10 mg, or 20 mg each is nearly the same—$89.99.

Spam offering Viagra, Levitra, and/or Cialis is rampant. But another strange pricing situation is that the prices at which spammers offer these drugs are far higher.

None of these drugs is inexpensive. Generic versions of prescription drugs are generally much less expensive, so you might be tempted to buy a generic version of Viagra, Levitra, or Cialis.

That could be a serious mistake. All generic versions of these drugs are manufactured abroad—often in third-world countries—and none of them have FDA approval.

A fourth new drug for ED, Uprima (apomorphine HCl), works on the brain and nervous system to trigger an erection. An FDA advisory committee is concerned about its safety, and it is not for sale in the United States. It is, however, marketed in Europe and Latin America. Uprima was developed and marketed by TAP Pharmaceutical Products Inc., a joint venture between Abbott Laboratories and Takeda Chemical Industries Ltd.

The company’s website is http://www.tap.com.

Which one of these drugs is right for you? That’s a question that you are going to have to answer yourself.

Dr. Vickers, whose study I link above, attempted to compare Viagra, Levitra, and Cialis on the basis of their Phase 3 trials of efficacy and safety for the general population and specifically for men with diabetes. However, criteria for inclusion, exclusion, classification of ED, dosing methodology, and duration of the studies varied too much to make valid comparisons possible.

Eventually, some researcher might publish head-to-head comparative trials of these drugs. Meanwhile, any of them look like they are better than the alternative.

Update
Tim Cady reminds me that the pump—which is painless—works in many cases where these new drugs are ineffective.
Most insurance plans and Medicare provide coverage

If you are a person with diabetes, there are a few things you should know about traveling on commercial airlines.

The Federal Aviation Administration, in an effort to make US air travel more secure, has implemented new measures that impact anyone who must travel by air with insulin and syringes. The following guidelines were issued in October, 2001:

• Passengers may board with insulin and syringes only if they can produce a vial of insulin with a professional, pharmaceutical pre-printed label;
• Lancets for testing blood glucose levels are allowed as long as they are capped and brought on board with a glucose meter that has the manufacturer’s name embossed on the meter;
• Because of forgery concerns, prescriptions and letters of medical necessity will no longer be accepted;
• FAA security measures apply to travel within the United States only. For international flights, consult with the airline.

The FAA and the American Diabetes Association are strongly urging each passenger with diabetes to call their airline carrier at least one day in advance to confirm current policy, which may vary from airline to airline. For further information from the FAA, call 1-866-289-9673.

Holiday gatherings and parties pose a special challenge for people with diabetes, but with proper planning, you can keep your blood glucose (sugar) within the normal range while having a good time.

The following tips can help you manage your diabetes:

• Eat a low calorie, healthy snack before leaving home. That way, you won’t be as hungry when you get to the party and you won’t overeat.
• Have a plan for what, when, and how much you will eat. Check out the foods being offered at the party, and choose those that fit in with your meal plan.
• Bring your favorite healthy dish to the party.
• Eat slowly, and enjoy every bite. By eating slowly, you reduce your chances of eating too much.
• Drink water, the healthy, no-calorie snack.

Diabetes is a disease that may affect all organs of the body, including the sex organs.

As many as 55% of the men and 35% of the women with diabetes experience sexual problems due to diabetic neuropathy, or loss of feeling as a result of poor blood circulation.

Diabetic neuropathy means that sensitive nerve endings are destroyed by too much glucose (sugar) in the blood.Over time, this can affect a man’s ability to achieve and maintain an erection. This is called impotence.

Women may have trouble becoming aroused which results in vaginal dryness. Tell your doctor right away if you have any of these symptoms.

There are medications available that may help you, and even devices for men that can be used to overcome impotence.

People with diabetes control their blood glucose (sugar) levels in many different ways. Some people inject insulin, some take oral medications, while others with type 2 diabetes control their diabetes through diet and exercise.

There are some people, however, who choose insulin pump therapy. An insulin pump is about the size of a pager and is usually worn on a belt or carried in a pocket. There is no surgery required to use an insulin pump. The pump holds a syringe of insulin and thin tubing is attached to the end of the syringe. At the end of the tubing is a needle that is easily inserted into the skin near the patient’s stomach.

The pump is programmed to deliver insulin through the tube in the amount that is needed. Your doctor must decide if your diabetes can best be controlled through the use of an insulin pump. Insurance companies also have requirements that must be met before they will pay for the insulin pump. If you think you may be interested in using an insulin pump, talk to your doctor or a diabetes educator.

The nerves in your body carry messages back and forth between your brain and other parts of your body. All of your nerves together make up your nervous system. For a person with diabetes, high blood sugar over time can damage the blood vessels that bring oxygen to some nerves. The damaged nerves stop sending messages, or may send messages too slowly or at the wrong time. Diabetic neuropathy (ne-ROPuhthee) is the medical name for damage to the nervous system from diabetes.

Damage to your nerves can cause your arms, hands, legs or feet to feel numb. You may not be able to feel pain, heat, or cold when you should, or you may feel shooting pains or burning and tingling. Often worse at night, the symptoms can make it hard to sleep.

Nerve damage can change the shape of your feet. You may want to ask your doctor about special shoes for people with diabetes to protect your feet from developing sores or blisters from poorly fitting shoes.

Medicare or other insurance plans may pay for special shoes. Controlling your blood glucose (sugar) will help prevent or delay nerve damage and may help you to live a healthier, longer life.

Stress can make it harder for a person to control their diabetes. When a person is under a lot of stress, certain hormones are released. This is called the “Fight or Flight” response. For a person with diabetes, this response does not work well. Insulin is not always able to let the extra energy released by the body into the cells and as a result, blood glucose (sugar) rises.

Making things worse, many kinds of stress are not short-term threats. For example, it may take many months to recover from surgery. Stress hormones that usually deal with short-term threats will stay on for a longer time and the result is long-term high blood glucose.

Long-term causes of stress can be in your mind, such as worrying about taking a test. Your mind reacts to a nondangerous event as if it were a real threat, and the body pumps out stress hormones that cause blood sugar to rise.

For some people with diabetes, relaxation therapy seems to help. Learning how to relax can be an important part of blood glucose control. If you are experiencing stress, ask your doctor to recommend a course of action that you can take.