dm and ramadhan-dr hanisah arsyad

MANAGEMENT OF MANAGEMENT OF DIABETES DURING DIABETES DURING RAMADANRAMADAN

Dr Hanisah ArshadFamily Medicine SpecialistKlinik Kesihatan BakriMuar District of Health

www.fms-malaysia.org

IntroductionRisk associated with fasting in

Diabetics patientDiabetis Patient……Is it possible

to fast?How to manage Diabetes

patients who decide to fast?


Muslim Population and DMMuslim Population and DMWorld wide• 1.1 -1.5 billion of Muslim• Diabetes prevalence 4- 6%• EPIDIAR study 1422/2011 – 43% T1DM and

79% T2DM fasting during Ramadan• 40-50 million people with DM fasting

Malaysia• Prevalence of T2DM above 30 yrs old 14.9%

( NHMS 2006)• Estimated 2 million Malaysian had T2DM• 1.2 million are Muslim


RamadhanRamadhan 9 month of Islamic lunar calendarDuration 29 – 30 daysDuration of daily fast

- Malaysia 14 hrs- Other countries may up to 20 hours

Meal consumption - 2 meals- after sunset ( Iftar) and before dawn (

Sahur)


Puasa Ramadan -WAJIB

“ Wahai orang-orang yang beriman ! Kamu diwajibkan berpuasa sebagaimana diwajibkan atas orang-orang yang dahulu daripada kamu, supaya kamu bertakwa ”. (Ayat 183, Surah Al Baqarah)


Diabetis Patient……Diabetis Patient……Is it possibble to fast?Is it possibble to fast?


Memang puasa itu wajib! tetapi punya kelonggaran

“(Puasa yang diwajibkan itu ialah) beberapa hari yang tertentu; maka sesiapa di antara kamu yang sakit, atau dalam musafir, (bolehlah ia berbuka), kemudian wajiblah ia berpuasa sebanyak (hari yang dibuka) itu pada hari-hari yang lain; dan wajib atas orang yang tidak terdaya berpuasa (kerana tua dan sebagainya) membayar fidyah iaitu memberi makan orang miskin. Maka sesiapa yang dengan sukarela memberikan fidyah, maka itu adalah satu kebaikan baginya” Ayat 184, Surah Al Baqarah


Diabetes is exempted for fastingIt is a chronic metabolic disorder

- at risk of complicationBUT…. Many pt with DM insist to

fastENSURE ….. Aware the potential

risk…….Appropiate advice

given


Risks Associated With Risks Associated With Fasting in Diabetes PatientsFasting in Diabetes Patients


Epidemiology of Diabetes and Epidemiology of Diabetes and Ramadhan 1422/2001 (EPIDIAR) Ramadhan 1422/2001 (EPIDIAR) StudyStudy• Large epidemiological study• Population based• Conducted in 13 Islamic country, involved

12,243 diabetes patients

• Results:1. Increased risk of severe hypoglycemia were more frequent during Ramadhan

2. Fivefold increase of severe hyperglycemia

EPIDIAR Study,Diabetes Care 27:2306-2311, 2004www.fms-malaysia.org

Other risk associated with fasting

3. Diabetic ketoacidosis - esp in T1DM

4. Dehydration - due to limitation of fluid intake, hot climate, osmotic diuresis

5. Thrombosis - due to hypercoagulable state ( increase clotting factors, reduced anticoagulant


Fasting not allowed:Fasting not allowed:

1. Poorly controlled type I or type II diabetic patients2. Diabetic patients known to be incompliant in terms of

diet , drug regimens and daily activity3. Diabetic patients with serious complications such as

unstable angina or uncontrolled hypertension4. Patients with a history of diabetic ketoacidosis5. Diabetic patients will inter-current infections6. Elderly patients with any degree of alertness

problems7. Two or more episodes of hypoglycemia and/or

hyperglycemia during Ramadan.8. Gestational DM on Insulin therapy9. Less than 12 years


Allow fasting in: 1. Patients who do not have the

mentioned criteria2. Patient who accept medical advisement.

Encourage fasting in: Overweight NIDDM patients whose

diabetes is stable with weight levels 20% above the ideal weight or body mass index (body weight, kg/height, meters squared) greater than 28.


How to manage Diabetes How to manage Diabetes patients who decide to patients who decide to fast?fast?


1.Pre ramadan medical assessment 1.Pre ramadan medical assessment and educational counsellingand educational counselling1.1 Pre Ramadan medical assessment

- look for overall well being - glucose control, BP control, lipids control - advice the potential risk

1.2 Educational counseling/ Ramadan focus education - VERY IMPORTANT to patients and family - educate on self care, sign and sx of hypo/hyperglicemia, BG monitoring, meal planning, drug admin, management of acute complication


2. Ramadan Focus 2. Ramadan Focus EducationEducation2.1 Care must be individualized

Management plan differ for each patient

2.2 Frequent monitoring of glucose levelBefore sahur, 2hrs after Sahur2hrs before Iftar, 2 hrs after Iftar


2.3 NutritionIS A CHALLENGE…………


Tips on nutrition/dietTips on nutrition/diet1. Iftar

- don’t delay Iftar- limit intake of high sugar/ high fat food →weight gain- break fast with dates/ tamar 1-2 seeds- take main meal later ( around Isyak prayer) → complex carbo, ↑fibre, ↓ salt, a lot water

2. Sahur - have Sahur as late as possible → to avoid long fasting- eat adequate balance meal- drink a lot of water


Sabda Rasulullah s.a.w.;

“Senantiasalah umatku berada dalam kebaikan selama mereka menyegerakan berbuka dan melambatkan sahur”.(Riwayat Imam Ahmad dari Abu Zarr r.a.)

2.4 Exercise - maintain normal physical activity- avoid excessive physical activity

2.5 Breaking the fast – immediately- when having hypoglycemia symptoms- hypoglycemia ( BG < 3.5 mmol/l)- BG reaches < 3.9 mmol/l in the first few hours of fasting- BG > 16 mmol/l

Recommendation for Mx of Diabetes During Ramadan, Diabetes Care, 28:2305- 2311, 2005


CPG in Insulin Therapy by MOH, 2010 www.fms-malaysia.org

Treatment regime Treatment regime adjustment..adjustment..


Patient on diet controlNo change neededAdequate fluid intake


Patient on OHAPatient on OHA

In general, insulin sensitizer associated with lower risk of hypoglycemia

1. Sulphonylurea ( ↑insulin secretion) - use with caution - use Chlorpropamide is CI - SU 2x/ day eg: Glibenclamide, Gliclazide → full dose at Iftar, half dose during sahur - SU once daily eg: Gliclazide MR → dose given at Iftar


2. Metformin ( insulin sensitizer)- 2/3 given at Iftar, 1/3 at sahur

3. Glitazones (rosiglitazone, pioglitazone) - No change in dose required

4. Short acting insulin secretagogue

- Repaglinides, Nateglinides - can be taken twice during Iftar and Sahur


Insulin adjustmentInsulin adjustment

Short acting insulin + intermediate

Humulin N, Insulitard

Humulin 30/70, Mixtard 30/70

CPG in Insulin Therapy, MOH 2010www.fms-malaysia.org

Management of people with diabetes wanting to fast during Ramadan, BMJ 2010;340:c3053 www.fms-malaysia.org

ConclusionConclusion1. Fasting during Ramadan for Diabetes

patients carries a risk – discuss the risk with the patient

2. Patients who insists on fasting should undergone assessment and receive appropriate education.

3. The management plan should be highly individualized and close follow up is essential


'RAMADHAN' akan dtg menziarahi kita sekeluarga bila2 masa sahaja lagi. Dia dtg bersama isterinya iaitu REZEKI dan juga 2 anaknya ...SAHUR dan IFTAR serta 3 org cucunya iaitu RAHMAT,BARAKAH dan KEAMPUNAN.Mereka akan pulang selepas 30 hari dgn menaiki pesawat TAQWA airlines.


dm and ramadhan-dr hanisah arsyad

Documents