Annual eye exams with dilation (widening the pupils with medicine to offer a better view of the blood vessels inside of the eye) are recommended for all people who have diabetes.

The Hemoglobin A1c (HbA1c or glycohemoglobin) is a test that indicates how well blood sugar has been controlled during the past 3 months. This test measures the amount of sugar that is attached to red blood cells. Sugar becomes attached to these cells when there is excess sugar in the blood stream (when diabetes is not well controlled).

Studies have shown that the lower the HbA1c, the less the risk of developing diabetes complications over the long-term.

In nondiabetics, normal HbA1c levels are between 4-6% (your physician can tell you what the normal range is in the lab that he/she uses). According to the American Diabetes Association, a good target levels of HbA1c would be below 7%. However, some guidelines recommend individualizing HbA1c goals based on a person's age and health problems.

Lowering HbA1c levels even lower, to normal levels (less than 6%), decreases the risk of diabetes complications even further but increases the risk of hypoglycemic attacks (serious drops in blood sugar).

Diabetes pills are often effective for people with type II diabetes (a condition in which the pancreas is still able to make some insulin). Treatment often starts with one type of diabetes pill, but a second or third type of medication is frequently required as well to control blood sugar.

"Second generation sulfonylureas" are more effective than first generation (older) sulfonylureas and are the most commonly prescribed diabetes pill.

These drugs, however, tend to loose their effectiveness over time in people who take them and, each year, approximately 5 to 10% of individuals who use second generation sulfonylureas eventually need to add another type of diabetes drug.

Side effects of these sulfonylureas can include weight gain and hypoglycemia (drop in blood sugar).

There is some evidence to suggest that glyburide (DiaBeta, Micronase) is more likely to cause hypoglycemia (drop in blood sugar) than other second generation sulfonylurea pills.

Diabetes pills are often effective for people with type II diabetes (a condition in which the pancreas is still able to make some insulin). Treatment often starts with one type of diabetes pill, but a second or third type of medication is frequently required as well to control blood sugar.

The "first generation" (older) sulfonylureas are diabetes pills that stimulate the pancreas to secrete more insulin into the bloodstream. The first generation sulfonylureas are not as effective as more recently developed ("second generation") sulfonylureas (see above) and are not used as commonly.

"Non-sulfonylureas" are too short-acting to be used alone but may be prescribed to supplement the effects of other drugs, especially at mealtime. Studies suggest that Prandin (repaglinide) is similar in effectiveness to second generation sulfonylureas (Amaryl, Glucotrol, DiaBeta, Micronase, Micronized tablets, Glynase Prestab, more), but not as likely to cause low blood sugars. The "non-sulfonylureas" reach their peak effect in a shorter time and are shorter-acting than sulfonylureas and are usually taken right before a meal.

Because of the short duration of their effects, these drugs are not good for nighttime use.

Repaglinide (Prandin) may be more effective than neteglinide (Starlix)

Metformin tends to cause less weight gain than some of the available diabetes pills but side effects tend to be common.

Some of the more common side effects include: a metallic taste in the mouth, loss of appetite, nausea, bloating, gas, diarrhea. Side effects usually decrease with time. Taking metformin with alcohol increase the chance of an otherwise rare and serious side effect called "lactic acidosis" (a condition in which a substance called lactic acid builds up in the bloodstream and may cause deep and rapid breathing, vomiting, abdominal pain, and a feeling of being ill).

Pills that combine different diabetes medications are very common. Often, 2 to 3 different types of diabetes medications are necessary to control blood sugar and combining multiple medications into one pill is very convenient. Any of the available diabetes pills can be combined with each other.

Glucovance is a newer medication which combines both glyburide (a second generation sulfonylurea) and metformin into one pill for convenience.

Thiazolidinediones make the body more sensitive to the effects of insulin.

Thiazolidinediones can cause liver damage and liver blood tests are required at least every 2 months during the first year of taking these medications. They also may increase heart problems, so they are not a good choice for those with pre-existing cardiac disease.

Alpha-glucosidase drugs work by decreasing the rate at which carbohydrates (complex sugars) are absorbed from the digestive tract. These medications are moderately effective but very safe which makes them a good choice for elderly individuals.

Sugars are absorbed more slowly and blood sugars do not peak to as high a level.

Gassiness (flatulence) is a common side effect.

The American Diabetes Association recommends a target goal of pre-meal blood sugar between 100-140 mg/dL for older adults with diabetes. Pre-meal blood sugars in nondiabetic people are normally below 110 mg/dL.

Newer, short-acting insulins are very convenient and useful. They can be given 0-15 minutes before or after a meal compared to regular insulin which is given 30-45 minutes before a meal.

The fact that rapid-acting insulin can be given after the meal is means that individuals can wait to see how much they eat before determining the insulin dose.

Rapid-acting insulins provide great flexibility in meal schedules but require the tradeoff of more frequent injections.

Insulin pumps are devices that continuously deliver insulin through a small tube (or catheter) that is embedded under the skin. A new tube through which the insulin is pumped is inserted into the skin every 3 days.

Insulin pumps represent an alternative to multiple daily insulin injections. Studies show that they provide better blood sugar control and decrease the risk of attacks of dangerously low blood sugar.

They are expensive, and can get clogged or have mechanical malfunctions which sometimes leads to attacks of high blood sugar as well as causing irritation and infection at the site where the tube is placed under the skin.

More frequent dosing (more than 2 injections a day) allows people with diabetes to eat meals at varying times of day and provides better blood sugar control.

Typically, one injection of long-acting (ultralente) insulin is taken at night and 3 more rapid- or short-acting (lispro or regular) injections are taken during the day, with one injection before each meal.

Alternatively, instead of the one long-acting injection at bedtime, two doses of intermediate insulin can be taken - one in the morning and one at bedtime (in addition to the short-acting doses taken with meals). This approach is useful for people whose blood sugar dips too low at night with the long-acting (ultralente) insulin, or for those who have high morning blood sugars.

Another alternative is combining an intermediate and short-acting insulin with breakfast, a short-acting drug at dinner, and another intermediate-acting drug at bedtime (10-11 PM). A short-acting dose can be added as well at bedtime if blood sugar levels are high. Another short-acting dose can be added during the day if lunch or snack-time insulin levels are high.

Regular insulin is a short-acting drug that is typically taken 30-45 minutes before meals. When taken before breakfast, its effects usually last till lunch time. When taken before dinner, it tends to last until bedtime.

The advantage of a short-acting (regular) insulin in contrast to a rapid-acting (lispro) insulin is that its effects last longer; the disadvantage is that it doesn't take effect as quickly and must be administered before meals while the rapid-acting insulins can be taken with or right after meals when dose requirements can be more accurately estimated.

NPH and Lente insulins are intermediate-acting insulins that are typically taken twice a day - at night and in the morning. They cover a 12 hour period (approximately) and provide a reasonably steady dose of insulin. Lente is available in the U.S. but more commonly used in Europe.

Long-acting insulins may be taken once a day and provide a small, steady amount of insulin in the blood stream.

With twice-a-day dosing, injections are typically given in the morning and in the late afternoon just before dinner.

The morning dose often consists of an intermediate-acting insulin (NPH or lente) either alone, or mixed with a rapid (lispro) or short-acting (regular) insulin.

The evening dose combines a short-acting and an intermediate-acting insulin that provides coverage overnight.

One problem with twice-a-day dosing is that the evening dose peaks during the middle of the night when blood sugar tends to be at its lowest point and this increases the risk of nighttime hypoglycemic attacks (serious drops in blood sugar).

A single daily injection of an intermediate-acting insulin is not recommended for most people with diabetes who require insulin. More frequent insulin injections provide much better blood sugar control.

A sensor with an alarm device that can alert people about a low blood sugar level could be highly beneficial.

These types of devices are being developed and may be available soon.

Devices that are able to continuously monitor blood sugar are currently being developed. When they become available, they will allow much more precise control over blood sugar and will prevent serious episodes of both high and low blood sugar.

Maintaining a healthy weight is highly effective for improving blood sugar in individuals with type 2 diabetes.

Some people find that they no longer need diabetes medications after a moderate weight loss (10 to 20 pounds).

Because of the complexity of a diabetic diet, the American Diabetes Association recommends that people with diabetes consult yearly with a registered dietician who is experienced with this condition.

The approach to diet and to the insulin schedule often require adjustment as people with diabetes experience changes in lifestyle, nutritional habits and health over time. Nutritionists who are aware of the nutritional and lifestyle needs of diabetics can offer invaluable help for improving diabetes control.

The American Diabetes Association recommends blood sugar tests at least 3 or more times a day for those who take insulin. Usually 5-6 blood sugar tests and 2 urine tests (to measure glucose and ketones) per day are recommended.

People with type 2 diabetes who are not taking insulin typically test blood sugars less frequently - from a few times a week to once a day.

The accuracy of blood sugar testing depends on good technique. Have your clinician observe and evaluate your technique regularly to make sure that your measurements are accurate.