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Workshop : Managing DM 2 during Ramadan DR.Obaid Almutairi بسم هللا الرحمن الرحيم شهر رمضان الذي انزل فيه القرآن هدى للناس وبينات من الهدى والفرقان فمن شهد منكم الشهر فليصمه ومن كان مريضا او على سفر فعدة من ايام اخر يريد هللا بكم اليسر وال يريد بكم العسر ولتكملوا العدة ولتكبروا هللا على ما هداكم ولعلكم تشكرون آيةسورة ألبقرة ۱۸٥ A large number of Muslim patients with diabetes fast during Ramadan Global Muslim population1 1.6 billion 2.2 billion (2010) (2030) > 50 million people with diabetes are estimated to fast during Ramadan worldwide2,3 • 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 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 3 Fasting is a worldwide custom practiced for religious and cultural reasons1 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; 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. 4 2Al-Arouj Risks associated with FASTING in patients with diabetes 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 Diabetes Care, volume 28, NUMBER 9, September 2005 Risks associated with FASTING in patients with diabetes 1. Hypoglycemia 2. Hyperglycemia 3. Diabetic ketoacidosis 4. Dehydration and thrombosis Diabetes Care, volume 28, NUMBER 9, September 2005 EPIDIAR study: fasting during Ramadan increases the risk of severe hypoglycaemia and hyperglycaemia in patients with T2DM 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 Incidence (events/100 patients/month) P<0.0001 P<0.0001 4 6 7.5-fold increase* 3 3 5 4 2 1 3 2 0.4 1 1 0 0 Pre-Ramadan †Events 5 5-fold increase During Ramadan 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 EPIDIAR 7 = EPIdemiology of DIAbetes and Ramadan; T2DM = type 2 diabetes mellitus 1Salti I, et al. Diabetes Care 2004;27:2306–11; 2Al-Arouj M, et al. Diabetes Care 2010;33:1895–902 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 Case study 1 • Female patient aged 47 years • Type 2 diabetes diagnosed 4 years ago • Poor compliance with diet and exercise regimen BMI 29 kg/m2 Weight 82 kg HbA1c 8.7% FBG 9 mmol/L (162 mg/dL) Current treatment Metformin, 850 mg twice daily SU once daily MANAGEMENT Pre-RAMADAN medical assessment & educational counseling 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 Diabetes Care, volume 28, NUMBER 9, September 2005 MANAGEMENT Pre-RAMADAN medical assessment & educational counseling 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 Diabetes Care, volume 28, NUMBER 9, September 2005 MANAGEMENT Pre-RAMADAN medical assessment & educational counseling 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 Diabetes Care, volume 28, NUMBER 9, September 2005 MANAGEMENT General Considerations 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 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 Diabetes Care, volume 28, NUMBER 9, September 2005 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 d. Exercise: General Considerations • 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 Considerations for anti-hyperglycaemic treatment for fasting patients with T2DM 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 insulin twice 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 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 TZD = thiazolidinedione; AGI, alpha-glucosidase inhibitor;T2DM = type 2 diabetes mellitus; SU = sulphonylureas Al-Arouj M et al. Diabetes Care 2010;33:1895–902 Case study 1 • Female patient aged 47 years • Type 2 diabetes diagnosed 4 years ago • Poor compliance with diet and exercise regimen BMI 29 kg/m2 Weight 82 kg HbA1c 8.7% FBG 9 mmol/L (162 mg/dL) Current treatment Metformin, 850 mg twice daily SU once daily Case study 2 • Male patient aged 61 years • Type 2 diabetes diagnosed 16 years ago • Motivated to maintain busy lifestyle BMI 31 kg/m2 Weight 88 kg HbA1c 8.0% FBG 5.6 mmol/L (100 mg/dL) Current treatment Long Acting Insulin Analog 32 units/day Metformin 1 g BID 24 Thank You