Glucophage

As of the date this booklet was printed, the list of UC participating pharmacies shown below was current. If you want to confirm which pharmacies are currently on this list, please contact the BC Pharmacy at 800-700-2541. UC DAVIS: Medical Partners of Davis Pharmacy 2660 Covell Blvd. Davis CA. 95616 Phone: 530-747-3051 Pharmacy Hours: M-F ; 9: 00 a.m. - 5: 00 p.m. Closed Sat, Sun, Holidays UC Davis Medical Center Pharmacy 2315 Stockton Blvd. Sacramento, CA 95817 Phone: 916-734-3305 Pharmacy Hours: M-F 9AM - 6PM Sat Sun Holiday 9AM - 5PM UCI: UCI Med Center Specialty Pharmacy 101 The City Drive Irvine, CA 92868 Phone: 714-456-5480 Pharmacy Hours: M-F, 9-5 UCI Family Health Center Pharmacy 101 The City Drive Irvine, CA 92868 Phone: 714-480-2400 Pharmacy Hours: M-F, 9-5 UCLA: UCLA Pharmacy Med Plaza 1st Floor 200 UCLA Med Plaza, Ste. 135 LA, CA 90095 Phone: 310-794-1193 Pharmacy Hours: M-F ; 8: 30 a.m.-6: 00 p.m. UCLA Pharmacy Med Plaza 4th Floor 200 UCLA Med Plaza, Ste. 426, LA, CA 90095 Phone: 310-794-7456 Pharmacy Hours: M-F ; 8: 30 a.m.-6: 00 p.m. UCLA Pharmacy - Main Outpatient Pharmacy 10833 Le Conte Avenue Los Angeles, CA 90095 Phone: 310-206-4242 Pharmacy Hours: M-F ; 8: 00 a.m.-5: 30 p.m. Sat Sun Holiday 8: 00 a.m.-5: 00 p.m. UCSD: The Edith & William Perlman Ambulatory Care Pharmacy 9350 Campus Point Dr., Rm. P-106, La Jolla, CA 92037-7729 Phone: 858-657-8610 Pharmacy Hours: M-F ; 8: 30 a.m.-6: 00 p.m. Closed Fri, Sat, Sun, Holidays UCSD Medical Center Pharmacy 200 West Arbor Drive San Diego, CA 92103 Phone: 619-543-3279 Pharmacy Hours: M-F ; 9 a.m. - 7 p.m. Sat., Sun, Holidays ; 9 a.m - 5: 30 p.m. UCSD Cancer Center Pharmacy 220 Dickinson St., Rm 163 San Diego, CA 92103-8766 Phone: 619-543-6679 Pharmacy Hours: M-Th ; 8: 30 a.m.-5: 00 p.m. Closed Fri, Sat, Sun, Holidays and actoplus.

The formulary beginning on the next page provides coverage information about some of the drugs covered by HealthPlus Senior. If you have trouble finding your drug in the list, turn to the Aplhabetical Index that begins on page 57. Remember: This is only a partial list of drugs covered by HealthPlus Senior. If your prescription is not in this partial formulary, please visit our web site at healthplus or call Customer Service at 1800-332-9161, Monday through Friday, 9: 00 a.m. through 6: 00 p.m. TTY TDD users should call 1-800-992-5070 for additional help. For your convenience a Glossary of the Drug Categories begins on page 96. The first column of the chart lists the drug name. Brand-name drugs are capitalized e.g., GLUCOPHAGE ; and generic drugs are listed in lower-case italics e.g., metformin ; . The information in the "Notes" column tells you if HealthPlus Senior has any special requirements for coverage of your drug. Requirements Limits Abbreviation Key: AG DO Age Restrictions. Individuals of a limited age range are eligible for the medication under the pharmacy benefit. Dose Optimization Program. Certain strength tablets require prior authorization to encourage selection of medications strengths for once daily dosing as opposed to multiple doses per day. Female Gender Restriction. Medication is a covered benefit for females only. Male Gender Restriction. Medication is a covered benefit for males only. Prior Authorization Required. Specific criteria must be met before medication is covered under the pharmacy benefit. The criteria are based on appropriate utilization of recommended first-line medications prior to selection of the prior authorization medication. Quantity Limits. The maximum number of units of medications dispensed per month is limited to a pre-determined quantity. Specialty Pharmacy Product. This product must be purchased from a specialty pharmacy provider. Please contact HealthPlus Pharmacy Services at 877 ; 710-0993 for specialty pharmacy provider information. Pehla such Nirogi Kaya is one of the saying. It means healthy body is the most important pleasure of life. Good health leads to productive, happy, and a long life. Both the body and mind need to be healthy. And our relation with the society should also be healthy. People often think health is linked to medicines, doctors and hospitals only. This is not always true. Hospitals and doctors are necessary when we fall sick. But first we need to take care of our body. You can prevent diseases, promote health and prolong life and actos.
Unremitting low back pain radiating to Rt hip and down posterolateral thigh, searing, "flash-like" Change in position triggered the shooting component, 10 pain, thereby limiting all physical activity, essentially bed-ridden. Saddle distribution numbness but no incontinence. Meds: Oxycontin 80mg q12, flexoril 10mg TID, Neurontin 300mg TID, celebrex 200mg day, prednisone 5mg day, glucophage and glyburide. Charge density distribution helps to investigate details of intramolecular chemical bonding and intermolecular interactions, that, in many cases, are the important reasons of such phenomena as polymorphism, formation of solvates and hydrates, solubility, and, as a result, of pharmacological activity. Piperazine is a pharmacophore that is widely used for combinatorial synthesis of potential drugs. Piperazine forms several hydrates that contains different amount of water. We investigated charge density distribution in the piperazine hydrates and compared their characteristics, related to electronic structure of these materials, to their physical properties and pharmacological activity. 10.02.04 A New Biological Insight for the Organic Compounds C6H12O5 Hamilton Napolitano1, Ademir Camargo1, Jahyr Theodoro2, Marcelo Castilho2 & Javier Ellena2, 1Cincias Exatas e Tecnolgicas, UEG & 2Instituto de Fsica de So Carlos, USP. Leishmaniasis is a tropical disease caused by a protozoal parasite of the order Kinetoplastid. Looking for new bioactive substances, potentially useful against leishmaniasis, we used both PRTase adenine phosphoribosyltransferase from L. tarentolae and parasite L. major as a model system to screen the inhibitory capacity of one quercitol compound from Brazilian plant. The data collection was performed using Enraf Nonius KappaCCD at room temperature. The structure was analyzed from 1425 reflections with I 2 I ; and refined to R1-values of 0.033. The molecules are joined in crystal structure through five twice classical OH.O hydrogen bonds linking the atoms O4H4.O5i [i -x + 3, 0.5 + y, z + 1], O5H5.O2ii [ii x, y, 1 + z], O2H2.O4iii [iii x + 2, y-0.5, -z], O1H1.O3iv [iv x-1, y, z] and O3H3.O1v [v -x + 2, 0.5 + y, 51 and avandamet.
Late breaker Study design At the 12th Conference on RetroviThe study was designed so that patients ruses and Opportunistic Infections CROI ; , were randomized to receive one of four held in Boston in February, the first interim doses of TMC-114, either once daily or results of the Phase II studies with TMC- twice daily. Every TMC-114 dose, within 114--C202 conducted in the U.S. ; and each arm, was boosted with ritonavir C213 conducted outside the U.S. ; --was Norvir ; . The fi ft h arm served as a control, highly newsworthy and was presented as a meaning that the physician picked the best "late breaker". regimen from already available antivirals. The study was carried out in the U.S., The background antiviral agents were all Europe and South America. Three-hundred chosen by the physician based on genotyppatients were enrolled in each study; how- ing and treatment history, to provide the ever, data from the study participants who most optimum therapy. reached the timeline for this analysis was presented here 497 patients ; . Having par- Results ticipated as a lead investigator in this Phase At 24 weeks of treatment, the results II trial, I have great confidence in describ- showed significant improvements in all ing these results. TMC-114 arms compared to the control. Looking at the control group fi rst, 71% Background were on single boosted protease inhibitors Uniquely, in the laboratory, TMC-114 and 27% on double boosted; viral loads only has shown to be sensitive to almost all pro- decreased by 0.27 logs. This is not a signifitease inhibitor PI ; mutations. It also binds cant drop. to the protease substrate chemical ingreIn contrast, of the TMC-114 treatment dient ; evenly across the volume of cleavage arms, the lowest dose 400 mg, once daily ; sites so that it becomes embedded in the demonstrated a highly significant 1.28 substrate. Moreover, it does so at higher log drop. The 800 mg once-daily and 400 magnitudes than other PIs, so that it stays mg twice-daily doses resulted in a 1.4 log within the substrate like glue. decrease in HIV-RNA, while the patients on the 600 mg twice-daily administration The Phase II study demonstrated a 1.85 log decline in viral Among the patients in the study, 89% load. were male with an average of 44 years of Also, patients taking the 600 mg dose age; 74% were Caucasian and 14% were twice daily demonstrated a rise in 75 CD4 + African American. All had triple class HIV T-cells versus a 15 cell increase in the control drug experience, and their HIV had resis- arm. Approximately 47% of the patients in tance mutations from each class of antiviral. the study were also were taking T-20, which The most frequent protease inhibitor used was evenly balanced throughout each treatduring the failed regimen at baseline was ment arm. T-20 is the only approved drug Kaletra, with many of the participants hav- in the latest class of HIV antivirals, fusion ing previous Kaletra use. inhibitors. ; tpan Positively Aware March April 2005. NDA 21-410 S-022 Page 6 Studies using single oral doses of metformin hydrochloride tablets of 500 mg to 1, 500 mg, and 850 mg to 2, 550 mg, indicate that there is a lack of dose proportionality with increasing doses, which is due to decreased absorption rather than an alteration in elimination. Distribution: Rosiglitazone maleate: The mean CV% ; oral volume of distribution Vss F ; of rosiglitazone is approximately 17.6 30% ; liters, based on a population pharmacokinetic analysis. Rosiglitazone is approximately 99.8% bound to plasma proteins, primarily albumin. Distribution: Metformin hydrochloride: The apparent volume of distribution V F ; of metformin following single oral doses of 850 mg metformin hydrochloride averaged 654 358 L. Metformin is negligibly bound to plasma proteins. Metformin partitions into erythrocytes, most likely as a function of time. At usual clinical doses and dosing schedules of metformin, steady-state plasma concentrations of metformin are reached within 24 to 48 hours and are generally 1 mcg ml. During controlled clinical trials, maximum metformin plasma levels did not exceed 5 mcg ml, even at maximum doses. Metabolism and Excretion: Rosiglitazone maleate: Rosiglitazone is extensively metabolized with no unchanged drug excreted in the urine. The major routes of metabolism were N-demethylation and hydroxylation, followed by conjugation with sulfate and glucuronic acid. All the circulating metabolites are considerably less potent than parent and, therefore, are not expected to contribute to the insulin-sensitizing activity of rosiglitazone. In vitro data demonstrate that rosiglitazone is predominantly metabolized by cytochrome P450 CYP ; isoenzyme 2C8, with CYP2C9 contributing as a minor pathway. Following oral or intravenous administration of [14C]rosiglitazone maleate, approximately 64% and 23% of the dose was eliminated in the urine and in the feces, respectively. The plasma half-life of [14C]related material ranged from 103 to 158 hours. Metabolism and Excretion: Metformin hydrochloride: Intravenous single-dose studies in normal subjects demonstrate that metformin is excreted unchanged in the urine and does not undergo hepatic metabolism no metabolites have been identified in humans ; nor biliary excretion. Renal clearance is approximately 3.5 times greater than creatinine clearance which indicates that tubular secretion is the major route of metformin elimination. Following oral administration, approximately 90% of the absorbed drug is eliminated via the renal route within the first 24 hours, with a plasma elimination half-life of approximately 6.2 hours. In blood, the elimination half-life is approximately 17.6 hours, suggesting that the erythrocyte mass may be a compartment of distribution. Special Populations: Renal Impairment: In subjects with decreased renal function based on measured creatinine clearance ; , the plasma and blood half-life of metformin is prolonged and the renal clearance is decreased in proportion to the decrease in creatinine clearance see WARNINGS, also see GLUCOPHAGE prescribing information, and CLINICAL PHARMACOLOGY, Pharmacokinetics ; . Since metformin is contraindicated in patients with renal impairment, administration of AVANDAMET is contraindicated in these patients. Hepatic Impairment: Unbound oral clearance of rosiglitazone was significantly lower in patients with moderate to severe liver disease Child-Pugh Class B C ; compared to healthy subjects. As a result, unbound Cmax and AUC0-inf were increased 2- and 3-fold, respectively. Elimination half-life for rosiglitazone was about 2 hours longer in patients with liver disease, compared to healthy subjects. Therapy with AVANDAMET should not be initiated if the patient exhibits clinical evidence of active liver disease or increased serum transaminase levels ALT 2.5X upper limit of normal ; at baseline see PRECAUTIONS, Hepatic Effects ; . No pharmacokinetic studies of metformin have been conducted in subjects with hepatic insufficiency. Geriatric: Results of the population pharmacokinetics analysis n 716 65 years; n 331 65 years ; showed that age does not significantly affect the pharmacokinetics of rosiglitazone. However, limited data from controlled pharmacokinetic studies of metformin hydrochloride in healthy and avandia.

This list is a brief summary and not a complete list of medications covered A&B Otic Dilantin Opti-Pranolol Abilify Ditropan XL Oramorph SR Accolate Dovonex Pentasa Accu-Chek Comf. Curve Dynabac Phenergan Suppositories Accutane E.E.S. PHisoHex Acetasol HC Effexor XR Plavix Actonel Efudex Povidine Iodine Soap Adderall Generics & Adderall XR Emend DoD quantity limits apply ; Pred Forte 5ml only ; Advair Epi-Pen Premarin Aggrenox Ery-Tab Premarin Vaginal Cream Alomide Eskalith Prempro Alphagan P & Brimonidine Alphagan Gen ; Est-Ring Prenavite Ambien not Ambien CR ; Evista Primidone Androderm patches Flonase Prometrium Antabuse Florinef Proscar Aricept Flovent HFA Pulmicort Flexhaler Armour Thyroid Floxin Otic Drops Pulmicort Nebulizer Asacol Geocillin QVar Astelin Nasal Spray Geodon Reminyl Atrovent HFA Glucogon Kit Requip Atrovent Nasal Glucophags XR Risperdal Risperdal M requires PA ; Augmentin Suspension Glucotrol XL Ritalin LA Avandamet Grifulvin V Rowasa Avandaryl Gris-PEG Serevent Diskus Avandia Imitrex max 9 30 days ; Seroquel Avelox Isopto Homatropine Sinemet CR Avita Isopto Hyoscine Singulair Aygestin Kytril max 8 tabs per 30 days ; Spriva Lantus Stalevo Azilect Azmacort Levaquin Synthroid Bactroban cream oint is generic ; Levitra Tapazole Bellamine S Levothroid Tequin Betoptic S Levoxyl Tobradex Cafergot Lindane Tobrex Ointment Canasa Lithobid Toprol XL CHFonly ; Carafate Suspension Livostin Tricor Casodex Lovenox Trusopt Catapres Patches Lovolog Uniphyl 400mg only Cellcept Lumigan Urocit-K Cerumenex Menest Uroxatral Ciloxan Metadate CD Ursodiol Climara Metrogel 1% Vagifem Colestid Granules Miacalcin Valtrex Colestid Tabs Micardis & Micardis HCT Vantin Comtan Mirapex Vigamox Concerta MS Contin Viroptic Coreg please use for CHFonly ; Namenda Vytorin Cosopt Nephplex Xalatan Coumadin Nephrocaps & Nephrovites Zaditor Creon 10 Nexium Zarontin Cyclogyl Niaspan Zocor Cytomel Niferex Forte 150 Zoloft 1 2 tabs ; Depakote & Depakene NitroDur patches Zomig max 8 30 days ; Depo-Testosterone Nizoral Shampoo Zonolon Detrol LA not regular Detrol ; Novolin Zovirax Ointment Didronel Ocuflox Zymar Diflucan Omeprazole Zyprexa.

Undesirable effects In post marketing data and in controlled clinical studies, adverse event reporting in patients treated with Glucohage SR was similar in nature and severity to that reported in patients treated with Glucopbage immediate release. The following undesirable effects may occur with metformin. Frequencies are defined as follows: very common: 1 10; common 1 100, 1 uncommon 1 000, 1 100; rare 1 10, 000, 1 000; very rare 1 10, 000 and isolated reports. Metabolism and nutrition disorders very rare: Decrease of vitamin B12 absorption with decrease of serum levels during long-term use of metformin. Consideration of such aetiology is recommended if a patient presents with megaloblastic anaemia. very rare: Lactic acidosis see 4.4. Special warnings and precautions for use ; . Nervous system disorders Common: Taste disturbance Gastrointestinal disorders very common: Gastrointestinal disorders such as nausea, vomiting, diarrhoea, abdominal pain and loss of appetite. These undesirable effects occur most frequently during initiation of therapy and resolve spontaneously in most cases. A slow increase of the dose may also improve gastrointestinal tolerability. Hepatobiliary disorders: Isolated reports: Liver function tests abnormalities or hepatitis resolving upon metformin discontinuation. Skin and subcutaneous tissue disorders very rare: Skin reactions such as erythema, pruritus, urticaria and glucotrol.
I i. Snihova pisnya. Snow Folks. Paperback Audiocassette ; . Hryhor Gulutzan, Lena. Sembaliuk, Larisa, illustrator. Edmonton, Kazka Productions UBS, YC ; , 1982. Ukr Eng. ISBN 0929056-01-9. .95 ; The book and audiocassette tell the story of a snow Grandma and Grandpa who come to life and dance a traditional Ukrainian dance. Their fate in the warm sun can be predicted. A music sheet is included. Suggested use: K-6. i. Spivanyk. Paperback ; . Hayvoronsky, Mykhaylo. Kyiv, Muzychna Ukrayina UBS ; , 1993. 126 p. Ukr. .95 ; This Ukrainian song book was originally compiled and published in Saskatoon in 1946. It contains songs and music for special occasions, themes and holidays. Suggested use: K-12, Reference. ii . Spivuchi skarby. Sing Along Treasures. Book Audiocassette ; . Hryhor Gulutzan, Lena; Zwozdesky, Gene, music. Edmonton, Kazka Productions, 1989. Ukr Eng. ISBN 0-929056-04-3. .95 ; Colorfully illustrated book with music sheet and cassette tape, including songs for all seasons and holidays. Easter, St. Nicholas Day, weddings and birthdays are included. Suggested use: K-9. i. Sviato Rizdva. Ukrainian Christmas. CD, Audiocassette ; . Tymyc, Bohdan. Montreal, Yevshan Communications UBS, YC ; , 1981. Ukr. .95 CD, .98 Audiocassette ; Christmas carols and shchedrivky are presented by popular Ukrainian musicians. An excellent recording with a fresh, new approach. Suggested use: K-12. i. Svitanok. Ukrainian Songbook for Children. Magus, Helene. Cheladyn, Larisa, illustrator. Edmonton, Ukrainian Bilingual Association UBS, UCC-SPC ; , 1982. 115 p. Ukr. .50 ; A collection of 58 children's songs under the headings of osin', zyma and strilets'ki pisni. This songbook includes words, music, harmonic accompaniment. Outline drawings illustrate the content of the songs. Suggested use: K-6.
Higher than the risk in patients taking metformin. A later report from Sweden 9 ; concluded that discontinuing metformin in aging patients when they developed renal or cardiovascular disease could further reduce the risk of lactic acidosis. The labeling of Glucophagr reflected a belief that metformin had the potential to cause lactic acidosis, but that the risk could be mitigated by careful selection of patients. To help allay concerns about the safety of metformin, Bristol-Myers Squibb committed to perform a large study the Comparative Outcomes Study of Metformin Intervention Versus Conventional Approach [COSMIC] ; , comparing 1 year of treatment with metformin to "usual care" with other antidiabetic agents. The results of this study have recently become available 10 ; . There were no meaningful differences in safety outcomes between the 7, 227 patients who received metformin and the 1, 505 patients who received usual care. There were no cases of lactic acidosis in either group. Two large government-supported studies provide an impressive body of evidence to support the safety and effectiveness of metformin 11, 12 ; . In addition, several manufacturers other than BristolMyers Squibb have performed studies in which a new drug was used in combination with metformin or compared with metformin. Metformin is now indicated for use in combination with every other oral antidiabetic agent and insulin and is the only oral agent available in fixed-dose and prandin.

Glycemia and increased risk of T2DM. The very few studies that have looked into the effect of Vitamin D replacement on glycemic control in T2DM have shown conflicting results. A key finding in our study is that we did not find any significant correlation between Vitamin D status and glycemic control even after separating data for T2DM from T1DM. Notably, replacement with Vitamin D did not show a trend towards improved glycemic control. The small number of subjects with follow-up data and not accounting for the influence of subject characteristics and other treatments known to affect glycemic control, may limit our finding. However, our finding is in line with an intervention study, in which another preparation of Vitamin D was used for replacement therapy. In this double-blinded, placebo-controlled, crossover trial of 1, 25dihydroxyvitamin D[1, 25] OH ; 2D] therapy in 20 subjects with T2DM and Vitamin D insufficiency, Vitamin D replacement, had no major effect on glucose homeostasis, similar to the finding in our study. Conclusions: Vitamin D status does not seem to be directly associated with glycemic control in subjects with DM. Replacing Vitamin D to sufficient levels did not show a trend to improved glycemic control, although the small number of subjects with follow-up data limits this finding. Further analysis regarding glycemic excursion, as well as separating T2DM from T1DM might allow for more specific insights as to the impact of Vitamin D replacement on insulin resistance and glycemic control in T2DM. Abstract #264 DELAYED PROGRESSION OF DIABETIC NEPHROPATHY BY TZD, METFORMIN, AND RAMIPRIL Lee Pletts Goscin, MD, PhD, Kathryn Rooth, BS, Gabriel Valle, MD, and Paul DiMarco, MD Objective: Demonstrate judicious use of small doses of TZD, Metformin and Ramipril delays progression of Diabetic Nephropathy. Case Presentation: A 62-year-old male with NIDDM for 10 years with coronary artery disease treated by triple bypass was in reasonable diabetic control with diet, exercise and sulfonylurea. His labs measured: HgbA1C, 6.5; Cr, 1.4; K, 5.5; 24-hr Protein, 516 mg; and CrCl, 88 ml min. Renal insufficiency precluded use of Metformin. Ace Inhibitors or an ARB with or without a diuretic were not tolerated due to Hyperkalemia. In 1998, a TZD, Resulin, became available and the patient was placed on it. Gradually, Creatinine was reduced and Potassium stayed about 5.2. Metformin was added when Creatinine was 1.3. A two-week trial of Ramipril did not worsen the Hyperkalemia so Ramipril 2.5mg ; was continued. After Rezulin was unavailable the patient was switched to Avandia. The Gemfibrizol was changed to a statin. With this triple therapy his renal situation improved steadily. In 2005, the Creatinine was 1.1, and 24-hr Proteinuria was 915 mg. In 2006 the 24-hr Protein is 788 mg, with Creatinine of 1.1; Potassium, 4.9; and HgA1C of 6.3, nine years since it was first detected at 516 mg. Discussion: After a short time on Rezulin, without apparent significant lab improvements, the patient was then able to tolerate at first Glucophage and then Ramipril. He was then continued on small doses of TZD, Metformin and Ramipril for several years. The HOPE trial showed that Ramipril is known to reduce the rates of death from cardiovascular causes: MI, revascularization procedures, cardiac arrest, heart failure, and complications related to diabetes 1 ; . The EMPIRE trial also showed combination therapy of TZD and Metformin was at least as effective in improving HbA1C as Metformin monotherapy. It showed greater reductions in FPG levels, and had a better tolerability profile compared with the maximal effective doses of Meformin therapy 2 ; . Metformin is known to decrease endogenous glucose production. TZDs are known to increase peripheral glucose disposal and decrease glucose production. They reduce insulin resistance through the peroxisome proliferator-activated receptor PPAR ; 3 ; . Together TZD and Metformin are synergistic in lowering both fasting and post prandial glucose by 18%. Conclusions: The progression of diabetic nephropathy and the need for dialysis were postponed if not eliminated in this patient with the combination of TZD, Metformin and Ramipril. The effect has remained for nine years. Also, the patient had coronary bypass in 1995 and remains symptom free for eleven years. This triple therapy may also be beneficial in reversing CAD.

The virus is in infectious quantities in blood. It can be found in other body fluids vaginal fluid and semen ; but at levels too low to be considered likely to transmit infection, although this cannot be ruled out. HCV was assumed to be chiefly transmitted by blood contact, with little sexual transmission. Recent studies are changing opinion on this.21 Transmission within heterosexual couples appears rare.22 Having HIV makes transmission of HCV more likely. Growing numbers of gay and bisexual men are picking up HCV sexually, especially those with HIV and or who engage in unprotected anal intercourse or fisting. The greatest risk seems to come from sex involving trauma or contact with blood, as seen during unprotected anal sex, fisting also rimming ; . The presence of ulcerative infections such as syphilis also makes the spread of HCV easier. How is hepatitis C prevented? Transmission is greatly reduced by the use of condoms for penetrative sex, latex gloves for fisting and, for rimming, dental dams or condoms cut into squares or non-microwavable cling film ; . The sharing of injecting equipment, snorting paraphernalia including banknotes ; or razors, toothbrushes, nail cutters, etc. should also be avoided. During acupuncture, piercing or tattooing, needles and other equipment should be sterile and or disposable and or come from a sterile packet. With HIV positive pregnant women Caesarean section reduces mother to baby transmission of HCV. Evidence is inconclusive as to whether breast feeding is a risk.23 Undiluted bleach will effectively deal with blood spills. Table 3--Recommended changes to treatment regimen in patients with type 2 diabetes who fast during Ramadan Before Ramadan Patients on diet and exercise control Patients on oral hypoglycemic agents Biguanide, metformin 500 mg three times a day, or sustained release metformin glucophage R ; TZDs, pioglitazone or rosiglitazone once daily Sulfonylureas once a day, e.g., glimepiride 4 mg daily, gliclazide MR 60 mg daily Sulfonylureas twice a day, e.g., glibenclamide 5 mg or gliclazide 80 mg, twice a day morning and evening ; Patients on insulin 70 30 premixed insulin twice daily, e.g., 30 units in morning and 20 units in evening During Ramadan No change needed modify time and intensity of exercise ; , ensure adequate fluid intake Ensure adequate fluid intake Metformin, 1, 000 mg at the sunset meal Iftar ; , 500 mg at the predawn meal Suhur ; No change needed Dose should be given before the sunset meal Iftar adjust the dose based on the glycemic control and the risk of hypoglycemia Use half the usual morning dose at the predawn meal Suhur ; and the full dose at the sunset meal Iftar ; , e.g., glibenclamide 2.5 mg or gliclazide 40 mg in the morning, glibenclamide 5 mg or gliclazide 80 mg in evening Ensure adequate fluid intake Use the usual morning dose at the sunset meal Iftar ; and half the usual evening dose at predawn Suhur ; , e.g., 70 30 premixed insulin, 30 units in evening and 10 units in morning; also consider changing to glargine or detemir plus lispro or aspart and lotrisone. Generally, Blue Cross of California will only approve your request for an exception if the alternative medication is included on the plan's drug list, the low-tiered drug or additional utilization restrictions would not be as effective in treating your condition and or would cause you to have adverse medical effects. You should contact us to ask for an initial coverage decision for a drug list, tiering or utilization restriction exception. When you are requesting a drug list, tiering or utilization restriction exception, you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of your request. 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Insulin or a sulfonylurea than in patients treated with metformin Glucophage ; . It may be that hyperinsulinemia increases cancer risk, or that metformin is protective. Another explanation could be that, although cancer is related to certain medication use, it is not caused by their use. We need a controlled study to answer these questions. LOE 2b.

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