Avandia suspended – 23.09.10

The European Medicines Agency has recommended the suspension of the marketing authorisation for Avandia [rosiglitazone] and Avandamet – medicines used to treat Type 2 diabetes. This is as a result of accumulating evidence that Avandia increases the risk of heart disease and stroke to a point where its risks now outweigh its benefits.

These medicines will stop being available in the UK from October 21st 2010 and from this date all stocks will be recalled.

Any adverse side effects experienced by someone taking Avandia or Avandamet should be reported to the Medicines and Healthcare Products Regulatory Agency (MHRA).

People who are currently taking these medicines should make an appointment with their doctor to discuss suitable alternative treatments. You are advised not to stop these medicines without speaking to your doctor.

Doctors should stop prescribing Avandia and Avandia -containing medicines. People who are currently taking Avandia should be reviewed to have their treatment changed.

The suspension will remain in place unless the marketing authorisation holder can provide convincing data to identify a group of patients in whom the benefits of the medicines outweigh their risks. The Committee’s recommendation has now been forwarded to the European Commission for the adoption of a legally binding decision.

The U.S. Food and Drug Administration [FDA] also announced that it will significantly restrict the use of the diabetes drug Avandia (rosiglitazone) to patients with Type 2 diabetes who cannot control their diabetes on other medications.

The FDA will require that the manufacturers, GSK, develop a restricted access program for Avandia under a risk evaluation and mitigation strategy. This will require Avandia to be available to new patients only if they are unable to achieve glucose control on other medications and are unable to take Actos (pioglitazone), the only other drug in this class. Current users of Avandia who are benefiting from the drug will be able to continue using the medication if they choose to do so.

Doctors will have to attest to and document their patients’ eligibility; patients will have to review statements describing the cardiovascular safety concerns associated with this drug and acknowledge they understand the risks. The FDA anticipates that this strategy will significantly limit use of Avandia.

 

 

Background to the Safety of Avandia

There has been intense media coverage over the last few weeks of the scandal emerging around Avandia – a drug used to treat Type 2 diabetes, manufactured by drug giant GlaxoSmithKline (GSK).

Studies have shown that Avandia [also called rosiglitazone] causes an increased risk of stroke and heart failure. Manufacturer, GSK, continue to defend the drug despite already paying out millions of dollars in settlements to patients or their relatives in the US. Several more studies, published this year, have again demonstrated that Avandia causes an increased risk of stroke and heart failure.

IDDT has tried to keep Newsletter readers up to date with news about the safety of Avandia but decisions have taken too long and patients have been put at risk.

Avandia has been prescribed for the last ten years but now it has emerged that GSK knew that there were cardiac risks associated with the drug but chose to downplay these risks, before it became public knowledge.

It has been reported that the UK drug regulator, the Medicines and Healthcare Products Regulatory Authority was advised by the Commission on Human Medicines to withdraw Avandia last July because its “risks outweigh its benefits.” However, it remains on the market because the European Medicines Agency, which licenses drugs across Europe, has yet to reach a decision. The situation is similar in the United States.

This news is highly alarming and IDDT has already been contacted by several people taking Avandia, who have been deeply worried and have wanted to change their medication. The advice IDDT is giving is not to stop taking your medication but to go to see your doctor to discuss alternative treatment options. It may also be worth bearing in mind that one option you may be offered is Actos (pioglitazone). This comes from the same family of drugs as Avandia and concerns have also been expressed about the safety of Actos.

 

 

European Medicines Agency recommends suspension of Avandia, Avandamet and Avaglim

Anti-diabetes medication to be taken off the market

The European Medicines Agency today recommended the suspension of the marketing authorisations for the rosiglitazone-containing anti-diabetes medicines Avandia, Avandamet and Avaglim. These medicines will stop being available in Europe within the next few months.

Patients who are currently taking these medicines should make an appointment with their doctor to discuss suitable alternative treatments. Patients are advised not to stop their treatment without speaking to their doctor.

Doctors should stop prescribing rosiglitazone-containing medicines. Patients taking rosiglitazone-containing medicines should be reviewed in a timely manner to amend their treatment.

The current review of rosiglitazone by the Agency’s Committee for Medicinal Products for Human Use (CHMP) was initiated on 9 July 2010 following the availability of new studies questioning the cardiovascular safety of the medicine.

Since its first authorisation, rosiglitazone has been recognised to be associated with fluid retention and increased risk of heart failure and its cardiovascular safety has always been kept under close review. Consequently, the use of rosiglitazone was restricted to a second-line treatment and contra-indicated in patients with heart failure or a history of heart failure when it was first granted a marketing authorisation as Avandia in 2000.

Data from clinical trials, observational studies and meta-analyses of existing studies that have become available over the last three years have suggested a possibly increased risk of ischaemic heart disease associated with the use of rosiglitazone. Further restrictions on the use of these medicines in patients with ischaemic heart disease were introduced.

The availability of recent studies has added to the knowledge about rosiglitazone and overall, the accumulated data support an increased cardiovascular risk of rosiglitazone. In view of the restrictions already in place on the use of rosiglitazone, the Committee could not identify additional measures that would reduce the cardiovascular risk. The Committee therefore concluded that the benefits of rosiglitazone no longer outweigh its risks and recommended the suspension of the marketing authorisation of the medicines.

The suspension will remain in place unless the marketing authorisation holder can provide convincing data to identify a group of patients in whom the benefits of the medicines outweigh their risks.

The Committee’s recommendation has now been forwarded to the European Commission for the adoption of a legally binding decision.

 

PERSPECTIVE

FDA Regulatory Action on Rosiglitazone
September 23, 2010 | J. Woodcock, J.M. Sharfstein, and M. Hamburg | DOI: 10.1056/NEJMp1010788

Because of cardiovascular risk, the FDA is requiring the sponsor of the diabetes drug rosiglitazone to submit a Risk Evaluation and Mitigation Strategy (REMS). Under the REMS, the drug will be available to patients not already taking it only if they are unable to achieve glycemic control using other medications and, in consultation with their health care professional, decide not to take pioglitazone for medical reasons.

For Immediate Release: Sept. 23, 2010
Media Inquiries: Karen Riley, 301-796-4674; [email protected]
Consumer Inquiries: 888-INFO-FDA

FDA significantly restricts access to the diabetes drug Avandia
Makes regulatory decisions on RECORD and TIDE trials

The U.S. Food and Drug Administration today announced that it will significantly restrict the use of the diabetes drug Avandia (rosiglitazone) to patients with Type 2 diabetes who cannot control their diabetes on other medications. These new restrictions are in response to data that suggest an elevated risk of cardiovascular events, such as heart attack and stroke, in patients treated with Avandia.

“The FDA is taking this action today to protect patients, after a careful effort to weigh benefits and risks,” said FDA Commissioner Margaret A. Hamburg, M.D. “We are seeking to strike the right balance to support clinical care.”

Rosiglitazone also is available in combination with other diabetes medications, metformin under the brand name Avandamet or glimepiride under the brand name Avandaryl.

Avandia, manufactured by GlaxoSmithKline (GSK), is in a class of drugs known as thiazolidinediones, or TZDs. It is intended to be used in conjunction with diet and exercise to improve glucose (blood sugar) control in patients with Type 2 diabetes mellitus.

The FDA will require that GSK develop a restricted access program for Avandia under a risk evaluation and mitigation strategy, or REMS. Under the REMS, Avandia will be available to new patients only if they are unable to achieve glucose control on other medications and are unable to take Actos (pioglitazone), the only other drug in this class. Current users of Avandia who are benefiting from the drug will be able to continue using the medication if they choose to do so.

Doctors will have to attest to and document their patients’ eligibility; patients will have to review statements describing the cardiovascular safety concerns associated with this drug and acknowledge they understand the risks. The agency anticipates that the REMS will limit use of Avandia significantly.

“Allowing Avandia to remain on the market, but under restrictions, is an appropriate response, given the significant safety concerns and the scientific uncertainty still remaining about this drug,” said Janet Woodcock, M.D., director of the FDA’s Center for Drug Evaluation and Research.

Also today, the FDA ordered GSK to convene an independent group of scientists to review key aspects of the company’s clinical trial known as RECORD, which studied the cardiovascular safety of Avandia compared to standard diabetes drugs. During the course of the FDA’s review of the RECORD study, important questions arose about potential bias in the identification of cardiovascular events. The FDA is requiring this independent review to provide additional clarity about the findings.

In addition, the agency halted the GSK’s clinical trial known as TIDE and rescinded all of the regulatory deadlines for completion of the trial. The TIDE trial compares Avandia to Actos and to standard diabetes drugs.

Swine flu vaccine included in normal flu jabs

People with diabetes are treated as a priority for seasonal flu jabs.

This year the swine flu vaccine, H1N1, is mixed with the normal seasonal flu jab. Last year you had a choice about whether or not to have the swine flu vaccination. This year if you want to be protected against normal flu, you will not have a choice – you will also receive the swine flu vaccine.

The Medicines and Healthcare Regulatory Authority, which monitors vaccines, has given the H1N1 jab the all-clear after fears in Europe over the outbreaks of narcolepsy.

Following the release of information about the numbers of people with diabetes in hospital at any one time and the problems that can occur, IDDT has launched the Hospital Passport. This will help people with diabetes when they go into hospital by providing vital Information about their diabetes and how they manage their treatment. It also enables people to include information about all their medicines, their mealtimes, diet and any allergies.

We hope that people with diabetes will be able to take the opportunity of using the Hospital Passport whenever they are admitted to Hospital and that health professionals will give them to their patients.

IDDT receives many calls from people who have experienced difficulties while in hospital. The reasons for this are numerous but often it can be the change in mealtimes, restricted access to medication and food as well as the general stress of being unwell and away from their family and friends.

The latest National Diabetes Inpatient Audit [NaDIA] report published on May 17th 2012 shows that nearly one in three hospital patients with diabetes are affected by medication errors. This is a small improvement on last year. The audit examined bedside data for 12,800 patients and 6600 patient questionnaires, covering subjects including medication errors and patient harm over a seven day period in October 2011. It involved 11,900 patients in 212 English hospitals and 900 patients in 18 Welsh hospitals.

During the seven day audit period hospitals in England and Wales made at least one medication error in the treatment of 3700 inpatients. 32.4 per cent of patients (3,430) experienced at least one medication error in the previous seven days of their hospital stay. Patients with errors suffered with:

• More than double the number of hypos [low blood sugars] compared to people with errors.
• 65 patients developed ketoacidosis [DKA] during their hospital stay. This worse than last year when the number was 44. DKA occurs when blood glucose levels are consistently high which suggests that insulin treatment was not given for a significant period of time.

These figures highlight the need for greater support for people when they are admitted to hospital. The Hospital Passport provides essential information for hospital staff and will help them treat the patient immediately and effectively, minimising any further harm.

For copies of the FREE Hospital Passport e-mail [email protected] or phone IDDT on 01604 622837 or write to IDDT, PO Box 294, Northampton NN1 4XS.

IDDT Launch Patient Hospital Passports

9th October 2010

The charity, the Insulin Dependent Diabetes Trust (The Trust) launches their free patient ‘hospital passports’ at their Annual Conference in Birmingham. These ‘passports’, produced for people with diabetes, are intended for patients to take into hospital to provide hospital staff with vital information about their diabetes and how they manage their condition.

Jenny Hirst, The Trust’s co-chair commented; “As a patient focused organisation we are really concerned about the recent figures that show the high numbers of people in hospital with diabetes or diabetes-related conditions¹. At any given time at least 14% of the adult population (in England) who are being treated in hospital have diabetes. In 2009, of those treated with insulin, more than 33% had medication errors on their charts² and more than 25% of all patients experienced a hypo while in hospital. In addition, 1 in 30 required rescue with intravenous glucose or glucagon³ while in hospital.”

Jenny continued, “These are shocking statistics and highlight to us the need for greater patient support when they are admitted to hospital. Our new ‘Hospital Passport’ provides all the details of the patient’s diabetes and how they manage their treatment. This is essential information for hospital staff and will help them to treat the patient immediately and effectively, minimising any further harm

The Trust is also very aware of the difficulties that people with diabetes can experience in managing their condition while they are in hospital. The reasons for this are numerous but often it can be the change in mealtimes, restricted access to medication and food, as well as the general stress of being unwell and away from their family and friends. So the Trust hopes that patients will take the opportunity of using these ‘Passports’ whenever they are admitted into hospital.

The ‘Passports’ will be sent to all Trust members and they will also be available on request to non-members such as nursing and medical staff.

– ends –

Notes to Editors

1) How Many Patients have diabetes? An Analysis of Hospital Episode Statistics – Yorkshire & Humber Public Health Observatory. Diabetes Health Intelligence. June 2010.
2) Inpatient Diabetes Audit for 2009
3) Rapid Response Report by the National Patient Safety Agency [NPSA]

The Trust produces a wide variety of free information and is reliant totally on voluntary donations. For more information about the work of IDDT or to receive a FREE copy of the Hospital Passport please contact IDDT:
Telephone: 01604 622837
Email: [email protected]

For press enquiries please contact:

Veronica Wray
Direct: 020 8568 8546
Mobile: 07710 624454
Email: [email protected]

Research Grants

Research Grant Applications
IDDT Funded Research Findings
Participating in research – OK to Ask

IDDT Funded Research Findings

Report – the actions of insulin analogues

Differences in bioactivity between human insulin and insulin analogues approved for therapeutic use – compilation of reports from the past 20 years
Pluripotency-associated stem cell marker expression in proliferative cell cultures derived from adult human pancreas
Controversies in the use of insulin Analogues
Long-acting insulin analogues elicit atypical signaling events mediated by the insulin receptor and inslin-like growth factor-1 receptor
Insulin analogues display IGF-1-like mitogenic and antipoptotic activities in cultured cancer cells
Resistance exercise as an intervention to improve glucose homeostasis

Treatment Uncertainties in Type 1 diabetes
A Priority Setting Partnership – progress report

Update on progress – November 2010

Patient Choice in the Treatment of Diabetes: the role of information provision

Pilot Study
Literature Review
The antimicrobial effect of Fijian honeys against clinical isolates from diabetic foot ulcers

Marketing of insulin – a missed opportunity

16th December 2010

The Insulin Dependent Diabetes Trust [IDDT] comments that the Channel 4 News item [15.12.10] successfully highlighted the huge waste of valuable NHS funds, tax payers’ money, on the prescribing of newer synthetic insulins which have no proven benefits for the vast majority of people needing insulin treatment. It did point out that if half of those taking analogue insulins had been prescribed so-called human insulin, £250 million could have been saved over the last 5 years – money which could have been spent on better care for patients, for example, by removing the restrictions on essential blood glucose test strips or employing more specialist nurses to provide more and better education for people with diabetes.

The programme missed a valuable opportunity to address some very key issues. IDDT would like to know how the pharmaceutical companies have managed to persuade the NHS, doctors and nurses to prescribe very costly analogue insulins that have no proven benefits for the vast majority of patients? NICE guidance quite clearly states that analogue insulins should not be the first choice of insulin, so why has NICE guidance been ignored by prescribers and PCTs, who are usually only too ready to restrict spending on glucose test strips and other drugs? It is insufficient to say that insulin analogues have been ‘oversold’. The public need to know what marketing techniques are employed to cause prescribers to ignore evidence from research and subsequently make prescribing decisions that are not necessarily in the best interests of patients, the NHS or the taxpayer?

But most importantly, the programme did not address the fact that the long-term safety and efficacy have not been proved for insulin analogues. For one long-acting insulin at least, the European Medicines Agency has stated that ‘they cannot deny or confirm’ that there is an increased risk of tumours developing and more research is needed. If health professionals provided their patients with the truly informed choice of insulins to which they are entitled, would they really choose analogue insulins?

Jenny Hirst, Co-Chair of IDDT commented, “We heard the insulin manufacturers telling us that analogue insulins are better. Many health professionals believe they are better despite the lack of evidence from research. However, this was not balanced by any discussions about risks and adverse reactions, nor was there a patient perspective. Ultimately patients are the consumers and can be the victims of drug company policies!”

She continued, “IDDT believes that Channel 4 missed a valuable opportunity to investigate many issues that are the key to good healthcare. It is not simply about cost but as NICE advises, it is about cost effectiveness. People with diabetes need individualised treatment to suit their needs and to provide the best quality of life. This means being given an informed choice of treatment, including information about risks and benefits and the long-term safety of the various types of insulin, synthetic human, analogue and natural animal insulin.”

For press enquiries please contact:

Jenny Hirst
Direct: 01604 622837
Email: [email protected]

Withdrawal of Mixtard 30

Novo Nordisk plans to withdraw Mixtard 30
Nearest equivalent insulins to Mixtard 30
Humulin M3 injection pens – KwikPen available
IDDT opposes Mixtard 30 withdrawal

  News Release:

Marketing of insulin – a missed opportunity

Humulin M3 injection pens – KwikPen available

Following the discontinuation of Novo Nordisk’s human Mixtard 30, many people are, or already have been changed to Humulin M3 made by Eli Lilly. This is the nearest equivalent to Mixtard 30. Some people may have experienced difficulties in obtaining the standard pre-loaded injection pens of Humulin M3.

IDDT has contacted Eli Lilly who acknowledge that stocks of the standard pen are low and they are advising doctors and health professionals to prescribe the new pre-loaded KwikPen with Humulin M3. This was due to be introduced in March 2011 but Lilly have already brought it into the UK to meet demand.

IDDT has a CONFIDENTIAL Helpline to offer support to anyone affected by diabetes. This includes people with diabetes and their families, health professionals, employers and others.

Our aims are to offer understanding and support and to provide information to help people to live with diabetes.

HELPLINE telephone 01604 622837

IDDT is available from 9.30am to 4.30pm, Monday to Fridays.
The IDDT Helpline offers callers:

• A listening service
• Information
• Support
• Written information, as appropriate

What the IDDT Helpline does not offer to callers:

• It does not offer medical advice
• It does not offer the opportunity to speak to medically trained staff
• It does not offer counselling

We are here to help where we can!

Actraphane – are patients really at the centre of care?

19th January, 2011

Diabetes charity questions whether patients really are at the centre of care

In June 2010, when 90,000 people with diabetes were given 6 months notice that the type of insulin they had been successfully using, Mixtard 30, was to be discontinued by the manufacturer, Novo Nordisk, the Insulin Dependent Diabetes Trust [IDDT] wrote to the Secretary of State for Health, Mr Andrew Lansley, asking for his help.

IDDT highlighted the effects of this change of insulin and injection device on the health and wellbeing of 90,000 people, the pressure only six months notice would put on the NHS staff and the present and future increased costs to the NHS incurred by the change and the ongoing monitoring of those affected.

Jenny Hirst, Co-chair of IDDT comments, “We were surprised that Mr Lansley’s response showed so little understanding of the effects this withdrawal would have on patients but also on the NHS. He showed an unwillingness to take any action on behalf of patients, especially the most vulnerable groups – those with visual impairment and manual dexterity problems who, as a result of this withdrawal would lose the injection device that enabled them to self-inject and maintain their independence“.

IDDT investigated the situation further and discovered from the MHRA , the government’s own regulatory agency, that a similar or near identical insulin made by Novo Nordisk, Actraphane, is licensed in the UK and can be prescribed and dispensed under the NHS. The same injection devices are available as for Mixtard 30 and patients could then simply have been changed to Actraphane and continued to use the same injection device.

Jenny Hirst added, “Novo Nordisk may have commercial reasons for withholding this information, but patients have been badly let down by Mr Lansley and his Department. The failure to inform patients, and health professionals, that Actraphane is licensed in the UK has denied patients the informed choice of treatment to which they are entitled. Government policy of ‘patients being at the centre of care’ appears to have been ignored for 90,000 people with diabetes“.

IDDT has informed members of the availability of Actraphane and the availability of the injection device for people with visual impairment and manual dexterity difficulties. However, the Department of Health has failed to provide patients with a fully informed choice of treatment options and failed to put them at the centre of care.

For further information contact:

Jenny Hirst
Tel 01604 622837
or e-mail [email protected]
Website: www.iddtinternational.org

Proposed changes to the Driving Licence standards for Vision, Diabetes and Epilepsy

The Department of Transport has now issued a consultation document on changing UK driving standards for vision, diabetes and epilepsy as a result of the 2009 EU Directive. The consultation runs from Feb 3rd to April 28th 2011.

Remember these changes have not yet come into effect but it is a good idea to look at them now and if you want to offer comments to the DVLA, you can do so as follows:

Review the proposed changes (PDF)

If you would like to have your say, then you can do so online:

http://www.dft.gov.uk/dvla/consultations/currentconsultations.aspx

NHS Reforms – lobbying update

Thank you to all our supporters who have written to their MPs with concerns about the NHS reforms. As we know, doctors, nurses and others working in the NHS have expressed their objections through their professional organisations, but as ‘patients’ and the public it is important that we should also let MPs and government know that we are concerned about the reforms too.

Many of the responses from MPs followed Party lines, as to be expected, nevertheless, the majority followed up IDDT members’ questions and concerns by writing to the Minister responsible. It appears that the government is bowing to pressure and sections of the Health Bill are being delayed by the government’s three month ‘listening exercise’. According to press reports, this will take place to the end of May and the government is expected to return with legislation sometime in June. It remains to be seen whether ‘listening’ means that action will be taken or it is simply a cosmetic pause. We have to hope that at least it gives more time for consideration of the issues that are important when such fundamental changes are being made to the NHS.

According to the NHS Chief Executive, the deadline for GP consortia taking control of commissioning remains April 2013 but the three month listening exercise means that some organisational changes planned to take place in April 2012 will not happen before July 2012. These include:

• scrapping Strategic Health Authorities,
• handing the NHS Commissioning Board its full powers,
• starting the first phase of Monitor’s new powers,
• implementation of Health Watch England and handing over full powers of the NHS Trust Development Authority, Health Education England and Public Health England.

To track the progress of the Health and Social Care Bill visit: www.dh.gov.en/Publicationsandstatistics/Legislation/Actsandbills/HealthandSocialCareBill2011/index.htm

Almost all of us with access to the internet have heard of eBay, the online auction site, and quite a few of us have used it to buy and sell items – over 20 million people at the last count! What you may not realise is that every time you sell an item on e-bay you could raise money for IDDT. And it’s not difficult to do!

How do I donate by selling stuff on eBay?

1. Log on to www.ebay.co.uk
2. Once you are ready to sell your item, go to the Sell hub and select ‘Advanced Sell’. [If you’re stuck, you can get some tips on how to list.]
3. As you are filling out the details, look out for the charity box just below where you set your price. Select IDDT and the percentage of your final selling price that you would like to donate [between 10 and 100%].
4. A week after your item sells, Missionfish, eBay’s charity partner, will automatically collect the donation from you. You can also manage your donations through the ‘My Donations’ section of MY eBay under the ‘My account tab’. Any free credits will appear on your next invoice.

You Win – every time you list an item for charity, you’ll get a fee credit on your basic insertion and final value fees equal to the percentage you donate. So if you donate 50% of your selling price to a charity, eBay will waive 50% of your fees.

We Win – every time you sell an item Missionfish will collect your donation and after deducting a small fee to cover administration, pass your donation on to IDDT.

Something Else to consider

If you run a business that uses e-bay to sell then you can also register to donate to us, again with benefits; your listings are highlighted with a yellow and blue ribbon, your business is associated with a good cause and there are significant tax benefits.

For more information go to www.ebay.co.uk/ebayforcharity/sell.html and click on the link to businesses.

If you would like further information please contact Martin at IDDT on 01604 622837 or e-mail [email protected]

My Life with Diabetes – 61 years of Carb Counting

‘My Life with Diabetes’ by Tony Huzzey.
ISBN 078-1-907611-83-4 Price £9.99

This is a book by Tony Huzzey who was diagnosed with Type 1 diabetes when he was 12 years old – 61 years ago. IDDT can proudly claim that Tony has been a member of IDDT almost since we first formed and he is an inspiration to children and adults with Type 1 diabetes.

He has lead an enjoyable, successful and socially useful life which makes interesting reading in itself but he recounts his life with diabetes in a way that makes readers realise that his diabetes was just another facet of his life. It did not override his ambitions, his triumphs or his enjoyment of life. In the book he frequently suggests that parents of children with Type 1 diabetes should take note.

At 12 years old, Tony was treated by the famous Dr Laurence who himself had Type 1 diabetes. From the outset Tony was encouraged to ‘fight back’ by accepting personal responsibility for the maintenance of his own health and this he undoubtedly did! In 1950, the treatment of diabetes was very different from now and the overriding thing that struck me about Tony’s life was the relative simplicity of managing his diabetes successfully because he followed the rules and carb counting. I wondered if he followed the rules because of this simplicity which helped him to understand what was happening to his blood glucose levels and why. If so, are there some messages here for today’s treatment?

He managed his diabetes by the basic golden rules – twice daily insulin, carb counting and exercise. If his blood sugars were high, his first thought was not to inject more insulin which would have a knock on effect later, but to go for a walk or a cycle ride. Yes, the diet was somewhat restricted and not today’s philosophy of eat anything you like and match it with insulin – but it worked. He did not have to worry about injections at lunch time at school or at work, he ate similar amounts of carbohydrate at each meal and he used less aggressive animal insulin, so the pattern of his blood sugars was regular and predictable. And 61 years later he’s here telling us all about it.   

The book is well worth reading and perhaps provides parents of today’s generation of children with Type 1 diabetes with a different perspective of basic diabetes management, remembering that he did not have the luxury of blood glucose testing. Above all it shows how, with encouragement and self confidence, he led a fulfilling and happy life. Diabetes today must seem a huge burden to children, so much testing, so many injections and of course, the risks of hypos with tight control. Tony’s way may seem old-fashioned, but he does not come over as being under pressure in the same way that diabetes management seems to be to today’s children.

Note: If you would like a signed copy of Tony’s book, you can order it through IDDT by sending a cheque for £10.00 payable to Tony Huzzey to IDDT, PO Box 294, Northampton NN1 4XS.

New HbA1c units

A new measurement for HbA1c results is being introduced. It is intended that this measurement is going to be international so that all laboratories will be using the same measurements.

For the last 18 months, HbA1c results should have been reported in both the percentage measurement we are used to and in new units, mmols/mol, to give time for everyone to get used to the change. The intention was that from June 1st 2011, HbA1c results would be reported only in new units, mmols/mol. However, in many areas the dual reporting has not been happening, so it has been decided to postpone the changeover date to the new units until October 1st 2011.

The relationship between the current HbA1c and the new measurements will be:

HbA1c (DCCT) Current measurement (%)	HbA1c (IFCC) Measurement from October 2011 (mmol/mol)
6	42
7	53
8	64
9	75
10	86
11	97
12	108
13	119

• So if you are aiming for HbA1c targets of 6.5% and 7.5%, the new units will be 48mmol/mol and 59mmol/mol.
• Normal blood glucose [in someone without diabetes] is 4 – 6% but in the new units it will be 20 – 42mmol/mol.

To read an article by Dr David Levy on the change to the new HbA1c units, click on IDDT’s April Newsletter
https://www.iddt.org/wp-content/uploads/2011/04/IDDTNewsletter-Apr2011.pdf#page=12

NICE not recommending Lucentis for treatment of diabetes macular oedema

The National Institute for Clinical Excellence [NICE] issued final draft guidance on the use of Lucentis [Ranibizumab] in England and Wales. It has decid4ed not to recommend its use on the basis that it is ‘not a cost effective use of NHS resources’. Lucentis is a new treatment for diabetic macular oedema, which affects around 50,000 people with diabetes and leads to visual impairment and blindness if not treated.

Diabetic macular oedema is a swelling in the area of the retina that gives detailed vision. Laser treatment has been the standard treatment on the NHS for diabetic macular oedema for the last 25 years and while this does stop deterioration, it has not been shown to improve vision. Over time laser treatment can cause damage to the surrounding area of the retina. Lucentis can improve vision and improve quality of life.

NICE has rejected the use of Lucentis on the grounds of cost. The injections cost £742 per eye and some people will need several monthly injections. Ultimately the cost of looking after people with sight loss is far greater, not to mention the effect on people’s lives.

People already being treated with Lucentis should have the option to continue with their treatment until they or their doctor decide it is appropriate to stop. NICE has not yet issued final guidance and there is the opportunity for registered stakeholders to appeal against the decision. Final guidance is expected in August 2011.

Actos And The Risk Of Bladder Cancer – New Safety Warnings

As reported in IDDT’s July 2011 Newsletter, Actos [pioglitazone] has already been withdrawn in France prior to the conclusions of a review by the European Medicines Agency. This review was completed on July 2011.

In brief, the following applies to people already using Actos or Competact or where their use is being considered as treatment for Type 2 diabetes:

• Actos should not be used if there is a history of bladder cancer or blood in the urine that has not been investigated with tests.
• If you are already using or before starting treatment with Actos or Competact, your doctor should assess you for the risk factors stated below.
• In elderly patients, the use of Actos or Competact should be carefully considered because the risk of bladder cancer increases with age.
• Treatment with Actos or Competact should only be continued after 3 to 6 months if there is a benefit. Treatment should be stopped in patients who do not respond adequately to treatment with either of these drugs.
• Similar monitoring should also take place in people already taking Actos.

Here is the actual safety warning has issued by the MHRA.

Safety warnings and messages for medicines
22 July 2011

Pioglitazone (Actos) is used to treat type 2 diabetes, either on its own or in combination with other anti-diabetic medicines. Pioglitazone is also available as a combination tablet with metformin (Competact). A review of pioglitazone and a possible increased risk of bladder cancer conducted by the European Medicines Agency (EMA) concluded on 21 July 2011.

Risk of bladder cancer

The review found that there is a small increased risk of bladder cancer associated with pioglitazone use. It is not clear if the risk increases early in treatment or only after prolonged administration. However, with careful patient selection, the benefits of pioglitazone continue to outweigh the risks.

New recommendations

It is advised that pioglitazone should not be used in patients with a history of bladder cancer or in patients with uninvestigated visible blood in the urine. This applies to those being considered for pioglitazone treatment and those already receiving it.

Before starting pioglitazone treatment the following known risk factors for bladder cancer should be assessed in individual patients: age; current or past history of smoking; exposure to some occupational or chemotherapy agents such as cyclophosphamide; or previous radiation therapy to the pelvic region. Such risk factors should also be considered in those already receiving treatment as part of an overall evaluation of the safety and effectiveness of pioglitazone treatment in individual patients. Use in elderly patients should be considered carefully before and during treatment because the risk of bladder cancer increases with age.

Advice for healthcare professionals

Prescribers should review the safety and efficacy of pioglitazone in individuals after 3–6 months of treatment to ensure that only patients who are deriving benefit continue to be treated. Patients who are already receiving pioglitazone should also commence a similar programme of monitoring. Pioglitazone should be stopped in patients who do not respond adequately to treatment (eg, reduction in glycosylated haemoglobin, HbA1c).

A Direct Healthcare Professional Communication on the risk of bladder cancer with pioglitazone will be circulated shortly to healthcare professionals in the UK.

Advice for patients

Patients should not stop taking pioglitazone without consulting their doctor. Patients receiving pioglitazone should immediately report any visible blood in their urine or bladder problems such as pain while urinating or urgency to urinate, to their doctor. Patients receiving pioglitazone will have their treatments evaluated by their doctor at their next scheduled appointment.

Driving and Diabetes

Driving and the EU law
News release: EU changes night-time hypos driving rules for people with diabetes
Driving and hypoglycaemia – what are doctors being advised to do?
Test Strips – Department Of Health Warning For Doctors And Pharmacists
Vehicles You Can Drive
Insulin and Driving Taxis
Hypoglycaemia and Driving
Driving and Medicines
Driving and Visual Field Loss

Living with Diabetes

Driving and the EU law – updated June 2013

June 2013 Update

The DVLA reminds motorists when they should tell them they have diabetes

In June the DVLA issued a statement to remind motorists of the driving licence requirements if they have diabetes. It can be confusing, so here is what the DVLA said.

Group 1 – cars and motorbikes

• Motorists who control their diabetes by diet or tablets do not normally need to tell DVLA, but they do if they are on insulin.
• Motorists do not need to notify DVLA if they are on any non-insulin medication unless they have suffered from 2 episodes of severe hypoglycaemia within the last 12 months, developed impaired awareness of hypoglycaemia or suffer visual problems.

Group 2 – buses and lorries

• Motorists need to tell DVLA if you have any form of diabetes for which you take medication.
• If Group 2 motorists are on insulin, they need to:
  [i] provide 3 months of continuous meter readings every time they apply for a licence,

[ii] test their blood glucose no more than 2 hours before the start of their first journey of the day and every 2 hours while driving.

 

In case you are confused by the term non-insulin medication, IDDT assumes that this phrase is being used to not only cover tablets but also the newer injected drugs for Type 2 diabetes, Byetta and Victoza. These are injected but they are not insulin.

August 2012 Update

DVLA – YET More Confusion For Lgv Drivers!

The changes in the driving regulations were positive for people with vocational licences to drive buses or lorries [LV licenses] – they allowed people treated with insulin to apply for an LGV licence. However, IDDT has been informed by one of the Transport unions that applicants with diabetes are falling foul of the strict new criteria that were also introduced.

A man being treated with tablets who had been classed as fit to drive at his medical, had his licence LGV revoked because he could not prove that he had been testing his blood glucose levels twice daily for the last 3 months. He cannot re-apply for another 3 months which obviously is putting a strain on his livelihood. He feels dismayed that the DVLA did not do enough to make drivers aware of the strict criteria.

The Union fears that many LGV drivers with diabetes believe that the new regulations only apply to people taking insulin and that they could have a similar shock when they re-apply for their licences.

A further problem arises because many drivers are not being prescribed enough test strips to be able to test twice daily. In the example above, the driver was only receiving 50 strips a month – simple arithmetic shows this is not enough!

The Union tried on a number of occasions to obtain clarification from the DVLA and only after considerable time, did the DVLA respond with the following statement:

"There is a legal requirement that Group 2 (lorry and bus) drivers with diabetes who are either treated with insulin or with tablets which carry a risk of inducing hypoglycaemia must check their blood glucose (sugar) level at least twice daily and at times relevant to driving. For those drivers who are insulin treated, this must be done with a blood glucose meter with a memory function. DVLA will require drivers to sign a declaration confirming that they will do this. Failure to meet the monitoring requirement will lead to the revocation or refusal of their Group 2 licence."

In the light of this statement, it is essential for LGV drivers with Type 2 diabetes treated with tablets to be aware of the type of drug they are taking because the first line treatment is with metformin which is classed as NOT carrying the risk of causing hypoglycaemia. However, if treated with sulphonylureas, the second drug to be introduced if blood glucose control deteriorates, does carry the risk of hypoglycaemia.

IDDT’s advice to LGV drivers on tablets is as follows:

• If treatment is with metformin only, then they are not obliged to test twice daily for 3 months before applying or re-applying for their LGV licence.
• If treatment is with sulphonylureas or other drugs for Type 2 diabetes, then they must test twice daily for 3 months and when driving. They must use a meter with a memory so that they can prove they have complied with the regulations.
• If drivers are unclear which medication they are taking, they should check with their GP.
• Drivers must insist that their GP prescribes enough test strips to enable them to test at least twice daily and at additional times if necessary.

IDDT reminds LGV drivers on insulin or tablets which carry the risk of hypoglycaemia of the following regulations for an LGV licence to be granted:

• There has not been any severe hypoglycaemia event in the previous 12 months.
• The driver has full hypoglycaemic awareness.
• The driver must show adequate control of the condition by regular blood glucose monitoring, at least twice daily and at times relevant to driving.
• The driver must demonstrate an understanding of the risks of hypoglycaemia.
• There are no other debarring complications of diabetes.

IDDT has promised to give this situation as much publicity as possible in the light of the lack of information and publicity given by the DVLA.

June 2012 Update

On June 21st 2012 the DVLA issued new guidelines aimed at making it easier for drivers with diabetes treated with insulin to understand the new driving rules to comply with the European Directive introduced in 2011.

Along with many other organisations, IDDT complained to the DVLA and the Minister of Transport that the questions on the application form were not easy to understand and were misleading. This applied particularly to those about severe hypoglycaemia and as a result they have been giving the wrong answers, and so have their doctors. In some cases this has meant that licences have been lost unnecessarily.

The DVLA makes it clear that hypoglycaemia is classed as blood glucose levels below 4 mmols/l and the new form now asks the following questions relating to hypoglycaemia:

• If you have NOT experienced an episode of hypoglycaemia, are you aware of what the symptoms are?
• If you have had an episode of hypoglycaemia, do you get warning symptoms? If yes, are you always aware?
• Have you had more than one episode of severe hypoglycaemia in the last 12 months? Please only count episodes where you needed help. Do NOT count episodes where you were given help but cold have treated it yourself.

Further points to clarify some of the questions that IDDT has been asked are:

• You MUST sign the declaration that you will test before and every two hours when you drive. [This is to let the DVLA know that you understand that you have to test while driving.] This is a legal requirement and a licence will not be issued if this declaration is not signed.
• For numerous short journeys you do not have to test before each journey as long as you test every two hours while driving.

Type 2 diabetes and are treated with diet only

If you receive the medical assessment for [Diab 1] and you are treated with diet only, then you do not to complete section one. You should send the form back to the DVLA with a covering letter explaining your treatment is diet only./p>

However, if you have had laser treatment in both eyes [or the one remaining eye if you only have one eye] then you need to fill in Section 2 of the Diab 1 form.

Diabetes
Stress, Anxiety and Depression

Stress
Anxiety
Depression
Depression in Parents
GE insulin, Hypoglycaemia and Depression
Useful Research

 

Stress, Anxiety and Depression

Stress And Diabetes

Stress is a very frequently used word and tends to cover many things but while it may seem an over-used word, stress can be a very real problem and one that needs recognising. Most of us probably know that there is a ‘top ten’ list of things that are stressful – the death of someone close, moving house, divorce, etc. People with diabetes are just as likely to suffer these stressful situations as other people. In addition diabetes, its diagnosis or the diagnosis of complications are stressful events for many people. We also have to remember that it may be stressful for close relatives – spouses, partners, parents and siblings.

For people with diabetes, stress can affect blood sugars and although much of the medical literature says that stress makes the blood glucose levels rise, in some people stress appears to make blood sugars fall and cause are more hypos. It maybe that stress affects people in different ways or may be blood sugars just fluctuate more, whatever is the case, the message has to be to learn to know how stress affects you and your blood glucose levels.

How the body handles stress

The body handles stress in much the same way as it handles danger and there are three stages to this:

Fight or flight stage

Any danger or stress triggers the release of adrenaline and other hormones into the blood stream and it is these hormones that enable the body to defend itself. Breathing, the heart rate and blood pressure rise pumps more blood to the muscles so that they are ready for action. This is when the blood sugars rise. If the stress is eliminated at this stage, then the body relaxes and goes back to normal.

Resistance stage

Some stressful situations cannot be eliminated at the fight and flightstage, for example a job you hate but can’t leave or deteriorating health. At this stage the stress becomes chronic. The body continues to fight the stress by releasing high levels of the stress hormones even though the fight and flight responses have worn off and breathing and the heart rate may be normal. This is when symptoms appear such as anxiety attacks and/or mood swings – the feeling of being ‘stressed out’.

Exhaustion stage

This stage occurs when the effects of chronic stress affects health. The immune system does not work as efficiently so that people are vulnerable to infections. The continual long-term fight against stress reduces the body’s energy stores so that there is fatigue that may be followed by depression, sleeplessness and poor appetite. This is when blood sugars, blood pressure and cholesterol levels may become more difficult to control. There is also a risk of heart attack.

Stress and blood glucose levels

Under stress the body produces hormones, adrenaline being the one we have all heard of and it is often called the fight and flight hormone. These hormones cause the body to release stored glucose and fat for the extra energy that is required to deal with the stress but they can only be used providing the body has enough insulin. It is this sudden extra production of glucose in people with diabetes that causes the blood sugars to rise. This can be made worse by the way many people react to stress – by overeating or taking less exercise because of the lack of energy. It may be necessary to increase your insulin dose or alternatively take more exercise. Exercise will not only help to reduce your blood sugars but is also recommended as a method to help people cope with the stress itself.

Personality, stress and blood glucose levels

In a study, published in The Journal of Health and Social Behaviour, researchers examined the behaviour, personalities and blood sugar levels of 57 people with Type 1 diabetes and 61 with Type 2 diabetes. The participants were divided into two groups according to personality types – self-controlled types and reactive emotional types. The results showed:

• People with Type 1 diabetes appear to be more susceptible to physical harm from stress.
• Among the Type 1 group the self-controlling types had better blood glucose control under stress and the emotional, reactive types had worse control.
• In Type 2 diabetes where some insulin is still being produced, the body’s ability to automatically manage its own affairs is impaired but remains in tact.

There may be little that we can do about our personality but understanding ourselves and what is happening to us can help to reduce the effects of stress.

What is stress and how does it affect us?

An article by Dr David Lowenstern in ‘Reading Out’, the journal of the GBS Support Group explains this very well:

• Stress is something that interrupts our routines and causes us to change. It is disquieting and distressing.
• We develop routines and habits of doing things and anything unexpected or unfamiliar is a stressor.
• A stressor can be useful up to a point as it increases our performance and encourages us to strive and cope with difficult things. There may come a point when it becomes difficult and we can cope no longer. This can happen with long standing conditions or illnesses [like diabetes].

What happens when we get very stressed?

We have a stress reaction which may be an autonomic nervous system response, affecting our blood pressure, heart rate and causing sweating. But there may be other psychological effects that are not so easy to deal with, such as depression and frustration [diabetes can be very frustrating, as can be many long-term conditions!]

Depression and frustration are expressed in many different ways:

• We embellish things, fantasies run wild and we start feeling things that aren’t actually there [eg imagining the whole world is against us or that people are talking about us].
• We get anxious and worried about things that might happen.
• We get angry and very, very angry.

“How often are we encouraged to be angry?”

Dr Lowenstern points out that this is very rare because we become seen as rude and impolite and other people avoid us. But every time we feel anger and we don’t express it, we are actually being rude and impolite to ourselves.

The stiff upper lip, keeping things bottled up and doing the right and proper thing, is not necessarily the best thing to do because stress comes out in other ways. It builds up like steam in a pressure cooker with the vent closed and then it blows. This is what happens to us if we keep the stiff upper lip at a time of stress – our feelings and frustrations spill over and our families tell us we are very difficult to live with. This is something we cannot always see for ourselves.

Four main key ways to managing anger:

• Not misinterpreting other people’s behaviour to you as hostile.
• Identifying factors in your upbringing that predispose you to anger.
• Learning ways to express legitimate anger.
• Forgiving those that hurt you.

[American psychologist Leonard Ingram, Observer Magazine, May 21, 2000]

How do we cope with stress?

This depends on several factors:

• our own particular style of coping
• what kind of stress we are under
• the time scale
• our inherited ability to cope
• the availability of support
• how much control we can retain.

There are 4 main coping styles with stress or a crisis:

• Denial – when we don’t want to know about it, we are told but we shut our ears. This can be helpful because it gets us through the day and protects us but it can be obstructive and self-defeating. For example, the diagnosis of diabetes is stressful and can cause denial but if the denial extends to actually not taking the prescribed insulin then there is a very real problem.
• Regression – this is when we use what is tried and tested from the past. We become younger and tend to be child-like. Very competent people when faced with what, to them, is an awful situation can be reduced to crying like a baby – even though this doesn’t sort out the problem.
• Inertia – this is just giving up thinking, with statements like “What’s the point?” or “It’s all too hard”. Inertia does not get us very far, it’s infectious and may cause our family to give up too.
• Mature problem-solving – this is a mixture of expressing our feelings about what is going on, trying to realistically weigh up what is happening and finding some sort of acceptance of it within ourselves. It is not giving up, not losing all the fight within us but accepting the situation.

For many of us being able to talk and share our experiences or our worries is the way we deal with stress. Women are often far better at this than men because men tend to believe that they are strong or are expected to be strong. So men are much more likely to be the pressure cooker with the vent closed.

The clear message from Dr Lowenstern is:

“Keep talking, don’t be silent. If you feel like crying, cry and if you feel angry, be angry.

Don’t keep quiet as far as doctors are concerned – keep sticking up for yourselves and remind yourself that it is your body and your life and you have a say in it. Retain some sense of control of what is yours but at the same time recognise that there are some limitations, especially as you get older.”

Diabetes
Stress, Anxiety and Depression

Stress
Anxiety
Depression
Depression in Parents
GE insulin, Hypoglycaemia and Depression
Useful Research

 

Stress, Anxiety and Depression

Anxiety

There are over 100 symptoms of anxiety. Each person has a unique chemical make up so the type, number, intensity, and frequency of anxiety symptoms will vary from person to person. For example, one person may have just one mild anxiety symptom, whereas another may have all anxiety symptoms and to great severity.

What is anxiety?

• Anxiety is ‘being afraid’ and occurs as a result of perceived danger. This in turn activates a self- protection mechanism to alert us to and protect us from this perceived danger. Hence the body reacts and produces the symptoms of stress, as described in the ‘Stress’ section of this leaflet.
• Anxiety is a needed protection mechanism.
• Anxiety turns into a disorder when a person becomes physically, psychologically or emotionally symptomatic, fearful or distraught because of it. If it does become a disorder, it can be reversed.
• Anxiety is not something which is genetically inherited or an illness which can be contracted.

Essentially people with anxiety live more stressfully and fearfully than others and as a result the body produces symptoms of stress or ‘anxiety symptoms’.

The National Institute of Mental Health lists the six main categories of anxiety disorder as:

• Panic Attack Disorder (Anxiety Attack Disorder, Anxiety Attacks, Panic Attacks)
• Generalised Anxiety Disorder (GAD)
• Obsessive-Compulsive disorder
• Social Anxiety Disorder
• Phobias
• Post-Traumatic Stress Disorder

According to NHS Choices, if you are anxious as a result of a phobia or because of panic disorder, you will usually know what the cause is. For example, if you have claustrophobia (a fear of enclosed spaces), you know that being confined in a small space will trigger your anxiety.
However, if you have GAD, what you are feeling anxious about may not always be clear. Not knowing what triggers your anxiety can intensify your anxiety and you may start to worry that there will be no solution.

Anxiety conditions can generally be divided into two main categories:

• Circumstantial anxiety – this is when symptoms appear because of acute stressful events, circumstances or emotions. Examples include a relationship difficulty, job loss or job promotion, illness or death of a loved one, or heavy workload. A build up of stress often comes before an anxiety condition, most early stress conditions fall within this category. Once the event, circumstance, or emotion has passed, with sufficient self-help materials, rest, and time, most anxiety conditions in this category resolve on their own. 
• Chronic anxiety – this is when the symptoms come and go over an extended period of time, months to a year or more. Examples include, where the symptoms come and go at different stages of life or remain as a background throughout someone’s life. Chronic anxiety also has a deep-seated fear component. Many feel that they live in fear whenever their “episodes of illness” appear. Others may have it as a constant companion as they journey through life. Episodes can last a few weeks to many years. Some can remain constant throughout their life.

Within these two categories there are four types of anxiety:
Spontaneous anxiety or panic – anxiety or panic that occurs regardless of where a person is.
Situational or phobic anxiety or panic – anxiety or panic that occurs because of a particular situation or location.
Anticipatory anxiety or panic – anxiety or panic that occurs because of a thought that something “might” happen or a situation that “might” occur.
Involuntary anxiety or panic – anxiety or panic that occurs involuntarily, by itself, or “out of the blue” that hasn’t been preceded by spontaneous, situational, or anticipatory anxiety.

Symptoms of anxiety
General anxiety disorder can cause physical and psychological symptoms. They often develop slowly and vary in severity from person to person.
Psychological symptoms include:

• a change in behaviour and the way you think and feel about things
• restlessness
• a sense of dread
• feeling constantly ‘on edge’
• difficulty concentrating
• irritability
• impatience
• easily distracted.

These symptoms may cause people to withdraw from social contact [visiting family and friends] to avoid the feelings of worry or dread. It may be difficult and stressful to go to work and sick leave may be necessary. However, these actions can cause even more worry and add to the feeling of lack of self-esteem.

Physical symptoms
There are over 100 symptoms which include:

• dizziness
• drowsiness and tiredness
• pins and needles
• irregular heartbeat (palpitations)
• muscle aches and tension
• dry mouth
• excessive sweating
• shortness of breath
• stomach ache
• nausea
• diarrhoea
• headache
• excessive thirst
• frequent urinating
• painful or missed periods
• difficulty falling or staying asleep (insomnia)

Treatment
Many people can achieve some form of anxiety and symptom reduction on their own although the results may be temporary.
There are two main forms of treatment for generalised anxiety disorder:

• psychological therapy – this is often prescribed before medication. The main form is psychological treatment is cognitive behavioural therapy [CBT]. Evidence suggests that about 50% of people who have CBT recover and many others obtain some benefit. CBT mainly focuses on the problems that you are experiencing in the present, rather than events from the past. It teaches you new skills and helps you to understand how to react more positively to situations that would usually cause you anxiety. The National Institute for Health and Clinical Excellence [NICE] recommends that you should have a total of 16 to 20 hours of CBT over a period of four months. Your treatment will usually involve a weekly one- to two-hour session.
• medication – usually antidepressants. NICE [2011] says that you have the right to make informed decisions about their treatment and antidepressants are one option but decisions about their use need to be based on a shared problem assessment and a care plan that accounts for your preferences.

Depending on the circumstances, one of these treatments or a combination of both may be beneficial. No single treatment is best for everyone although there is evidence that psychological treatments last the longest.
Your GP should discuss all your treatment choices with you before you begin any form of treatment giving you the advantages and disadvantages of all and at the same time, discuss any possible risks or side effects. You can then make a decision with your GP about which treatment is most suitable for you, taking into account your circumstances and preferences. For example, some people may prefer psychological treatment such as counseling, in preference to treatment with antidepressants.

Exercise – it is well worth remembering that physical activity helps to relieve anxiety.