Workshop :Managing DM 2during Ramadan

DR.Obaid Almutairi

بسم الله الرحمن الرحيم

من وبينات للناس هدى القرآن فيه انزل الذي رمضان شهر

كان ومن فليصمه الشهر منكم شهد فمن والفرقان الهدى

اليسر بكم الله يريد اخر ايام من فعدة سفر على او مريضا

ما على الله ولتكبروا العدة ولتكملوا العسر بكم يريد وال

تشكرون ولعلكم ية - ألبقرة سورةآ هداكم

۱۸٥

A large number of Muslim patients with diabetes fast during Ramadan

1The Pew Forum on Religion & Public Life. http://www.pewforum.org/The-Future-of-the-Global-Muslim-Population.aspx (Accessed March 2013); 2Al-Arouj M et al. Diabetes Care 2010;33:1895–902; 3Salti I et al. Diabetes Care 2004;27:2306–11; 4IDF Diabetes Atlas 5th edition. www.idf.org/diabetesatlas/5e/the-global-burden (Accessed March 2013); 5Whiting DR et al. Diabetes Res Clin Pract 2011; 94: 311–21; 6Beshyah SA. Ibnosina J Med Biomed Sci 2009;1:58–60

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• The global prevalence of diabetes is projected to increase in emerging economies, including those with large Muslim populations4,5

• The pattern of daytime fasting and night-time meals and use of anti-diabetic treatment increases the risk of complications, including hypoglycaemia in patients with diabetes2,3

• Although the consensus from religious and medical leaders is that Muslims with diabetes are generally not obliged to fast6 many choose to do so2,3

1.6 billion

(2010)

2.2 billion

(2030)

Global Muslim population1

> 50 million people with diabetes are estimated to fast during Ramadan worldwide2,3

Fasting is a worldwide custom practiced for religious and cultural reasons1

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Religion Examples of fasting practices2–5

Muslim Ramadan: fasting during daylight hours for 29–30 days2,3

Jewish Yom Kippur and Tish’ah B’av: single days of fasting4

Hinduism Single days of fasting4

Christianity Ash Wednesday and Good Friday: single days of fasting4

Mormon Fasting once a month for a single day5

Healthy adult Muslims fasting during the month of Ramadan abstain from food, water, or use of oral medications between dawn and sunset for 29–30 days every year2,3

1Fasting can range from restricting certain foods to complete abstinence from all food and drink: 1Fazel M . J R Soc Med 1998;91:260–63;2Al-Arouj M et al. Diabetes Care 2010;33:1895–902; 3Salti I et al. Diabetes Care 2004;27:2306–11; 4Green V. Br J Nursing 2004;13:658–62; 5Horne BD et al. Am J Cardiol 2008; 102:814–19.

Risks associated with FASTING in patients with diabetes

Diabetes Care, volume 28, NUMBER 9, September 2005

EPI.DIA.R trial (EPIdemilogy DIAbetes in

Ramadan)

Multi-country epidemiological study (Algeria,

Bangladesh, Egypt, India, Indonesia, Jordan, Lebanon,

Malaysia, Morocco, Pakistan, Saudi Arabia, Tunisia & Turkey)

12,273 diabetic patients

Individuals who fast during Ramadan showed a

high rate of acute complications

Risks associated with FASTING in patients with diabetes

Diabetes Care, volume 28, NUMBER 9, September 2005

1. Hypoglycemia

2. Hyperglycemia

3. Diabetic ketoacidosis

4. Dehydration and

thrombosis

EPIDIAR study: fasting during Ramadan increases the risk of severe hypoglycaemia and hyperglycaemia in patients with T2DM

1Salti I, et al. Diabetes Care 2004;27:2306–11; 2Al-Arouj M, et al. Diabetes Care 2010;33:1895–9027

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57.5-fold increase* 5-fold increase

P<0.0001 P<0.0001

EPIDIAR = EPIdemiology of DIAbetes and Ramadan; T2DM = type 2 diabetes mellitus

11,173 patients with T2DM; 78.7% chose to fast for at least 15 days during Ramadan1

Higher risk of severe hypoglycaemic events† in overall population during Ramadan‡1,2

Higher risk of severe hyperglycaemic events† in overall population during Ramadan‡1,2

Pre-Ramadan During Ramadan

†Events requiring hospitalization in overall population with T2DM; ‡compared with previous months * There was a 7.5 fold difference of hypoglycaemia in overall population fasting during Ramadan. For patients who fasted for > 15 days difference was, 6.7 fold

Recommendations for Management of Diabetes During Ramadan

Ramadan

Consensus

Conditions associated with “Very High”, “High”, “Moderate” & “Low” risk for adverse events in diabetic patients deciding

to fast RAMADAN

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• Female patient aged 47 years• Type 2 diabetes diagnosed 4 years ago• Poor compliance with diet and exercise regimen

Case study 1

Current treatmentMetformin, 850 mg twice daily SU once daily

BMI 29 kg/m2

Weight 82 kg

HbA1c 8.7%

FBG 9 mmol/L (162 mg/dL)

Diabetes Care, volume 28, NUMBER 9, September 2005

a. Medical Assessment:

• 1-2 months before RAMADAN

• Specific attention to the: well-being of the patient Glycemia BP lipids

• Specific medical advice for those who wish to fast against medical recommendations

MANAGEMENT Pre-RAMADAN medical assessment & educational counseling

Diabetes Care, volume 28, NUMBER 9, September 2005

a. Medical Assessment:

• During this assessment, necessary

changes in the diet or medication

regimen should be made so that the

patient initiates fasting while being on

stable and effective program

MANAGEMENT Pre-RAMADAN medical assessment & educational counseling

Diabetes Care, volume 28, NUMBER 9, September 2005

b. Educational Counseling:

• Educate the patient and his family on: Signs & symptoms of hypoglycemia

BG monitoring

Meal planning

Physical activity

Medication administration

Management of acute complications

MANAGEMENT Pre-RAMADAN medical assessment & educational counseling

e. Breaking the fast:

• Immediately if hypoglycemia occurs

(BG<60mg/dL, 3.3 mmol/L)

• If BG<70mg/dL, 3.9 mmol/L in the few hours after the start of the fast

• If BG exceeds 300 mg/dL, 16.7 mmol/L

• Sick days

MANAGEMENT

General Considerations

Diabetes Care, volume 28, NUMBER 9, September 2005

a. Individualization

b. Frequent monitoring of glycemia

• Patient must have the means to

monitor his BG multiple times daily

• Very important with patients using

insulin

MANAGEMENT

General Considerations

c. Nutrition:

• Healthy and balanced diet

• Maintain constant body mass

• Avoid ingesting large amount of

carbohydrate and fat (common

practice)

MANAGEMENT

General Considerations

c. Nutrition:

• “Complex” carbohydrates are advisable at

the predawn meal (delay in absorption)

• Simple carbohydrates more appropriate at

the sunset meal

• Increase liquid intake during non-fasting

hours

• Delay predawn meal as much as possible

MANAGEMENT

General Considerations

d. Exercise:

• Maintain normal level of physical activity

• Excessive physical activity: increased risk of hypoglycemia (especially before Iftar)

• Tarawih are to be considered as part of the daily exercise

MANAGEMENT

General Considerations

Treatment before Ramadan Treatment during Ramadan

Oral anti-diabetic agents Ensure adequate fluid intake

Biguanides Metformin 1 g at sunset meal and 500 mg at predawn meal

TZDs, AGIs, or incretin-based therapies No change needed

Sulphonylureas once a day Dose should be given before sunset meal. Adjust dose based on glycaemic control and hypoglycaemia risk

Sulphonylureas twice a day Half the usual morning dose at predawn meal and usual dose at sunset meal

Insulin Ensure adequate fluid intake

Premixed or intermediate-acting insulintwice daily

Consider change to long-acting or intermediate insulin in the evening, and short or rapid-acting insulin with meals; take usual dose at sunset meal and half usual dose at predawn meal

Considerations for anti-hyperglycaemic treatment for fasting patients with T2DM

Al-Arouj M et al. Diabetes Care 2010;33:1895–902

TZD = thiazolidinedione; AGI, alpha-glucosidase inhibitor;T2DM = type 2 diabetes mellitus; SU = sulphonylureas

Treatment considerations:

• The choice of oral anti-diabetic agent should be individualized with consideration to the risk of hypoglycaemia

• Newer pharmacological agents have lesser hypoglycaemic potential & may have specific advantages during Ramadan

• Caution is advised when using old Su groups

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• Female patient aged 47 years• Type 2 diabetes diagnosed 4 years ago• Poor compliance with diet and exercise regimen

Case study 1

Current treatmentMetformin, 850 mg twice daily SU once daily

BMI 29 kg/m2

Weight 82 kg

HbA1c 8.7%

FBG 9 mmol/L (162 mg/dL)

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• Male patient aged 61 years• Type 2 diabetes diagnosed 16 years ago• Motivated to maintain busy lifestyle

Case study 2

Current treatmentLong Acting Insulin Analog 32 units/dayMetformin 1 g BID

BMI 31 kg/m2

Weight 88 kg

HbA1c 8.0%

FBG 5.6 mmol/L (100 mg/dL)

Thank You