Download - 2nd Amiri Diabetes Conference 2014

Dr, I have Diabetes,
Can I fast?
Dr Majedah AbdulRasoul
Assistant Professor
Pediatric Department Faculty of Medicine
Kuwait University
Learning Outcomes
• Understand what happens in diabetics and nondiabetics during fasting
• Improve knowledge and understand “ safe fast”
during Ramadan
• Be able to empower patients to make the right
decision to avoid risks associated with fasting
during Ramadan
Muslims around the World
• As of 2010, over 1.6 billion or about 23.4% of
the world population are Muslims *
• Growing by ~ 3% per year.
*The Future of the Global Muslim Population. Pew Research Centre. 27 January 2011.
Ramadan
“O You who believe, fasting is
prescribed to you as it was
prescribed to those before
you so that you can learn
Taqwa. For a number of days,
but for those who are ill, or
on a journey, these days
should be made up from days
later”
Surrah AlBaqara 2: 183
Ramadan
• The 9th months of the Islamic calendar
• Fasting in Ramadan is one of the 5 main pillars
of Islam
• Complete fasting during daylight hours for one
full Lunar month (29-30days) , for up to 20
hours depending on the geographical location.
Exception from fasting
‘ Ramadan is the (month) in which was sent down the
Quran as a guide to mankind, also clear ( Signs) for
guidance and judgment (between right and wrong).
So every one of you who is present (at his home)
during that month should spend it fasting, but if any
one is ill, or on a journey, the prescribed period
(should be made up) by days later. Allah intends
every facility for you; He does not want to put to
difficulties. (He wants you) to complete the
prescibed period, and to glorify Him in that he has
guided you; and perchance ye shall be grateful’.
Surrah AlBaqara 2: 185
Exception from fasting
• Illness – Chronic
• Diabetes
• Those who can not understand the purpose of fastingmentally challenged
• Frail elderly
• Travelers
• Women during menstruation, pregnancy, lactation
• Pre-pubertal children
Exception from fasting
• Many patients with diabetes insist on fasting during
Ramadan, thereby creating a medical challenge for
themselves and their healthcare providers
• It is important that medical professionals be aware of
potential risks associated with fasting during Ramadan
and approaches to decrease those risks
• A large epidemiological study of Muslims with diabetes in
13 Muslim countries (the EPIDIAR study) showed that 43%
of patients with type 1 and 79% of those with type 2
diabetes fasted during Ramadan.
Diabetes Care 2004; 27:2306
Back to Basics: CHO
• Carbohydrate metabolism in healthy persons:
• Most of the studies show slight decrease in serum glucose to 3.2-3.9
mmol/L in adults few hors after fasting
• This may vary depending on:
• Food habits
• Differences in metabolism
• Differences in energy regulation
• The fall in glucose cease due to:
• Serum insulin decrease
• Serum glucagon and GH increase
Increase glycogenlysis
Increase gluconeogenesis
Decrease glycogenesis
DeGroot and Jameason 2004
Am J Med 200; 199: 341
Back to Basics: Lipids
• Variable results
• Serum total cholesterol and triglycerides may decrease in the first
days of fasting, then rise to pre fasting levels
• Increase in HDL-C
• Effect may be variable depending on quality and quantity of food
consumed.
• Increase in Apo A-1concentration in both normal and diabetics.
Am J Clin Nutr 1982; 30: 351
Saudi Med J 1986; 7: 561
Eur J Clin Nutr 2000; 54:508
What happens in Diabetics
Most studies are in Type 2
• Blood glucose variation in patients with diabetes
• It may fall, nit change, or rise
• The variation is due to the amount and type of food consumed
and/or decreased physical activity
• HbA1c values showed no change or even improvement during
Ramadan.*
• The amount of fructosamine, insulin, C-peptide also has been
reported no change before and during Ramadan fasting
*Int J Clin Pract 2010; 64: 1095
*BMJ,2010; 340: 1407-1411
Ann Saudi Med 1994; 14:139
BMJ 1993; 307: 292
So, Can patients with
Diabetes Fast?
The bulk of literature indicates that fasting
Ramadan is safe for the majority of type 2 diabetic
patients with proper education and diabetic
management.
No Fasting
• 18 yrs old teenager
• Type 1 diabetes since the age of 12yrs
• On NPH and Actrapid
• Because he can not get Lantus
• Testing his blood glucose at home 2-3 times per day
• Mean HbA1c this year is 9.4 (was 9.8% last year)
• He came to you in Shaaban asking about fasting this year.
What will you do?
Your recommendations:
• No fasting for patients with type 1 diabetes.
• More so if:
• Poor control
• On NPH
• Coming close to Ramadan
• Have high risk for hyperglycemia, DKA, and hypoglycemia
Risks associated with fasting
in T1DM
• Hypoglycemia:
• 2-4% of mortality in patients with T1DM
• More with hypoglycemia unawareness, poor glycemic control and
recurrent hypoglycemia in the past needing hospitalization
• EPIDIAR study:
•
•
4.7- fold increase in severe hypoglycemia ( needing hospitalization) in
patients with T1DM
3-14 events /100 people/month
Diabetes Care 2004; 27:2306
Risks associated with fasting
in T1DM
• Hyperglycemia: No information linking repeated yearly
episodes of short-term hyperglycemia and diabetes-related
complications during Ramadan.
• Deteriorate, improve, no change
• EPIDIAR study:
• 3 fold increase in severe hyperglycemia with or without ketoacidosis
in patients with T1DM (from 5 to 17 events /100 people/month.
• Due to excessive reduction of insulin to prevent hypoglycemia,
increase intake of food and sugar drinks.
Diabetes Care 2004; 27:2306
Risks associated with fasting
in T1DM
• Diabetic Ketoacidosis:
• More in patients with poorly controlled diabetes before Ramadan*
• The risk is increased because of decreased insulin dose (assuming
that food intake is reduced)
• Risk for dehydration
• Dose reduction in response to acute infection
• However, it remains non-conclusive
• 1.8% of T1DM patients developed DKA during Ramadan, same as nonfasting months.**
*Diabetes Care 2004; 27:2306
** Abusrewil et al 2003 Jamahiriya Med J; 2:99
Risks associated with fasting
in T1DM
• Dehydration and thrombosis:
• Increased incidence of retinal vein occlusion
• However, coronary artery events or stoke were not increased in
Ramadan
• Limitation of fluid intake can lead to dehydration
• Hot and humid climates  increase the risk
• Also, hyperglycemia  osmotic diuresis  fluid and electrolyte
imbalance
Risk Categories for Fasting
Ramadan In Diabetics: Very High Risk
• T1DM
• Severe Hypos within
the last 3 months
• History of recurrent
hypos
• Hypo unawareness
• Acute illness
• Chronic Dialysis
• Sustained poor control
• DKA within the last 3
months
• Pregnancy
• Hyperosmolar
hyperglycemic coma in
the last 3 months
• Intensive physical
labor
Risk Categories for Fasting
Ramadan In Diabetics: High Risk
• Moderate
hyperglycemia:
Average BG 8.5-16.5,
HbA1c 7.5-9%
• Advanced
marcovascular
complications
• Renal Insufficiency
• Co-morbid conditions
aggravating the above
• Living alone
• Old age with ill health
• Drugs affecting
mentation
Risk Categories for Fasting
Ramadan In Diabetics: Mod / Low
Moderate Risk
Low Risk
• Well controlled treated
with short acting
insulin, secretagogues
• Well controlled
diabetes treated with
lifestyle modification,
metformin, acarbose,
TZD.
• 13 yrs old boy
• Type 1 diabetes since the age of 5 yrs
• On MDI
• Glargine and Novorapid 4-5 times
• Testing his blood glucose at home 4-6 times per day
• Mean HbA1c this year improved from 8.5% to 7.1%
• This year he wanted to fast for the first time
• He came to you in Rajab with his desire to fast
What will you do?
Your recommendations:
• No fasting for patients with type 1 diabetes.
• More than 75-80% of our children with type 1 diabetes choose
to fast, despite the recommendation, specially if:
• they have been fasting before diagnosis
• Have younger siblings who fast
• Friends who fast
• If they did not bring the issue of fasting, you should.
General consideration:
• Assess physical well being
• Weight on the 50th centile – was 25-50th last yr
• Height of the 75th centile – same centile for yrs
• Assessment of metabolic control
• HBGM 4-6 per day
• Fasting 5-8mmol/L, occasional 9mmol/L
• Bed time 10mmol/L
• 1-2 hypos (at school) over the last month, managed by juice
• No admission for DKA since the last 3 yrs
Your Opinion Now?
• Your recommendation : No Fasting
• If despite recommendation he decide to fast:
• Discuss s/s of low blood sugar
• Review management of hypoglycemia
• Check if they have glucagon
• Review diet routine with dietician
• Check blood sugar 4-6 per day
• Break the fast of blood glucose less than 4mmol/L
• Break the fast if blood sugar is more than 13, specially with ketones
•
•
and act with hyperglycemia protocol.
May need revision of insulin dose (lantus) in fasting and adjust dose
of meal bolus
See after 1 week in Ramadan
What does the literature say?
• A study on 20 patients on MDI
• mean age of 12.4 yrs (fasting), 10.5 yr (not fasting)
• Fasting was for 12.5 hours
• Change in weight, HbA1c, lipid profile before anf after
Ramadan
• Results:
• No statistical
difference in HbA1c (9,2 &9.4% vs 9.13
&10%, p=0.9), weight or fasting lipids
• No patient called the helpline and none had intercurrent
illness or ketosis
AlAlwan etal 2010; Int J Diabetes Mellitus
What does the literature say?
• A study on 28 patients ( Amiri Hosp, & Royal London Hospital)
• Ages: 9-18 yr
• Poorly controlled, recurrent DKA and not willing to do HBGM
were excluded.
• 2 groups (MDI basal bolus regimen vs conventional twice daily
(premix at Iftar and short acting at Suhur)
• Mild Hypo (need to break the fast)
• Severe hypo (need glucagon or hospital admission)
• Hyperglycemia (> 15mmol) and DKA
• No of fasting days
AlKhawari etal 2010; Pediatr Diabetes
AlKhawari etal 2010; Pediatr Diabetes
AlKhawari etal 2010; Pediatr Diabetes
AlKhawari etal 2010; Pediatr Diabetes
AlKhawari etal 2010; Pediatr Diabetes
• Conclusions and recommendations:
• Adolescents on basal-Bolus regimen can fast if they wish to
• They should receive sufficient education prior to fasting
• Increase HBGM
• CHO count
• Reduce basal by 10-20%, more if had hypoglycemia
• If blood Glucose 15  correction given
• Break fast if:
• Develop ketones
• BG < 4mmol
• Avoid skipping pre-dawn meal
Fasting in T1DM on MDI
• A study with insulin glargine suggest the relative safety and
efficacy in relatively well controlled patients who fasted for
18 hours, with minimal decline in mean BG, and only 2
episodes of mild hypoglycemia.
Mucha GT etal, Diabetes Care, 2004
• A study in patients with type 1 diabetes using insulin Lispro or
Aspart instead of regular insulin in combination with
intermediate-acting insulin injected twice a day  improved
PP glycemia + fewer hypoglycemia
Kadiri et al. Diabetes Metab 2001
Fasting in T1DM on MDI
• Insulin Lispro, as a short acting instead of regular insulin , in
combination with neutral protamine insulin in a basal bolus
regimen  lower 2-h post-prandial glucose level after sunset
meal (p = 0.026) with less hypoglycemia (p < 0.01) in an open
–label crossover study ( n=64).
• 3 slides
Kadiri et al 2010
Can a patient monitor blood
sugar while fasting?
• Patients should monitor their blood glucose during fast to
recognize subclinical hypo and hyperglycemia
• Islam allows diabetics to have regular blood tests while fasing
• If blood glucose drops below 4 mmol/L (some recommend 3.5)
the fats must be broken
• If blood glucose goes above 16.5 mmol/L, ketones should be
checked, and medical advice sought
Case 3
• 13 yrs old teenager girl
• Type 1 diabetes since the age of 8 yrs
• Was on MDI of glargine and Aspart for 3 years.
• On insulin pump since 2 years, and CGM since 8 months.
• Testing his blood glucose at home 2-3 times per day (more if feeling
funny!!!)
• Mean HbA1c this year is 6.9 (was 7.2% last year)
• He came to you in Shaaban asking about fasting this year for the
first time since diagnosed.
What will you do?
Your recommendations:
• No fasting for patients with type 1 diabetes.
• But:
• On CSII
• On CGMS
• Excellent glycemic control
• I may allow her to fast
What does the literature say?
• 63 patients, aged 22+/-7 yrs, had diabetes for 9.8+/-5.6 yrs
• On Medtronic MiniMed 722 for 20+/- 10 months
• Outcome measures:
• Days fasting
• Hypoglycemia
• Hyperglycemia
• Emergency visits to the ER
Benbaraka et al 2010; Diabetes Technol Ther 12(4)
• Results:
• Days fasting:
•
•
•
•
61.2% fasted the whole month with no problems
18.4% fasted 27-28 days
16.3% fasted 24-25%
4.1% fasted 23 days
• 50% decreased their basal by 5-50%
• 27% had hypoglycemia  break the fast
• Fasting was broken in 3.8% of potential fasting days
• No severe hypoglycemia
• Unusual hyperglycemia in 18.4%, one needed hospital visit
• 12 had pre and after Ramadan fructosamine level: 4+/-0.6 mmol vs
3.6+/-0.6 mmol/L, p =0.007
Benbaraka et al 2010; Diabetes Technol Ther 12(4)
• Conclusions:
• Fasting Ramadan is feasible in patients with
T1DM on SCII with adequate counselling and
support
Benbaraka et al 2010; Diabetes Technol Ther 12(4)
What does the literature say?
(2)
• 21 patients, median age 26 yr, adjusted their insulin in the
routine way. All were on CGMS.
• Outcome measures:
• Body weight
• HbA1c
• Blood glucose
• Total insulin dose
• Overriding tendencies
• Suspend time during fast
• Hypoglycemia
Khalil et al 2012; Diabetes Technol Ther 14(9)
• Results:
• Days fasting:
• Median days 29
• Basal insulin was decreased by 5-20%, no overall sig.
• Redistribution of insulin based on daily lifestyle and eating times
• No major hypoglycemia
• Mild hypoglycemia in 8.4%, managed by basal adjustment or
suspension of pump
Khalil et al 2012; Diabetes Technol Ther 14(9)
• Conclusions:
• The use of
CGMS add advantage on CSII in type 1
diabetic patients choosing to fast in Ramadan
Khalil et al 2012; Diabetes Technol Ther 14(9)
Conclusions & Recommendations
(1)
• Patients with T1DM are excepted from fasting during Ramadan
• Those who insist on fasting need to be aware of the
associated risks
• They should adhere to the recommendation of of the
healthcare providers to achieve a safe fast.
Conclusions & Recommendations
(2)
• Patients should maintain their strict diabetes routines, as social
functions during Ramadan are frequent and food is plenty
• All patients should have a pre-Ramadan “fasting consultation”. Even
those who choose not to fast need dose adjustment.
• Reviewing symptoms and management of hypoglycemia; ensure the
availability of glucagon
• Doses of insulin should not be omitted, may be reduced based on
CHO counting and amount of food
Conclusions & Recommendations
(3)
• Gentle physical activity should be encouraged
• Over-eating after breaking the fast is to be avoided, specially
sweat drinks
• If hypoglycemia ( <4 mmol if the first few hrs of fasting or
<3.3 after that time  breaking fast is mandatory
• If Hyperglycemia (> 15 mmol) or ketosis develop, breaking
fast is mandatory. Temptation to preserve fasting till the end
is to be discouraged.
Conclusions & Recommendations
(4)
• Blood glucose testing during the day (noon), before and 2- hrs
after Iftar , before Sohur is the minimum in T1DM.
• Reviewing the achievements and problems to the healthcare
givers and receiving feedback is very important at the end of
Ramadan