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Recommendations for Management of Diabetes During Ramadan Diabetes Care, volume 28, NUMBER 9, September 2005.

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Presentation on theme: "Recommendations for Management of Diabetes During Ramadan Diabetes Care, volume 28, NUMBER 9, September 2005."— Presentation transcript:

1 Recommendations for Management of Diabetes During Ramadan Diabetes Care, volume 28, NUMBER 9, September 2005

2 بسم الله 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 الله بكم اليسر ولا يريد بكم العسر ولتكملوا العدة ولتكبروا الله على ما هداكم ولعلكم تشكرون آية - ألبقرة سورة ۱۸٥

3 MONIRA AL-AROUJ, MD RADHIA BOUGERRA, MD JOHN BUSE, MD, PHD SHERIF HAFEZ, MD, FACP MOHAMED HASSANEIN, FRCP MAHMOUD ASHRAF IBRAHIM, MD FARAMARZ ISMAIL-BEIGI, MD, PHD IMAD EL-KEBBI, MD Diabetes Care, volume 28, NUMBER 9, September 2005 OUSSAMA KHATIB, MD, PHD SOUHAIL KISHAWI, MD ABDULRAZZAQ ALMADANI, MD ALY A. MISHAL, MD, FACP MASOUD AL-MASKARI, MD, PHD ABDALLA BE NAKHI, MD KHALED AL-RUBEAN, MD

4 Diabetes Care, volume 28, NUMBER 9, September 2005 I. Risks associated with FASTING in patients with diabetes II. Management III. Conclusions

5 Risks associated with FASTING in patients with diabetes Diabetes Care, volume 28, NUMBER 9, September 2005 EPI.DIA.R trial (EPIdemilogy DIAbetes in Ramadan)  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

6 Risks associated with FASTING in patients with diabetes Diabetes Care, volume 28, NUMBER 9, September Hypoglycemia 2. Hyperglycemia 3. Diabetic ketoacidosis 4. Dehydration and thrombosis

7 Diabetes Care, volume 28, NUMBER 9, September 2005 EPI.DIA.R  EPI.DIA.R  Fasting during Ramadan increased the risk of severe hypoglycemia (defined as hospitalization due to hypoglycemia) 4.7-fold in patients with type 1 diabetes 7.5-fold in patients with type 2 diabetes Risks associated with FASTING in patients with diabetes -hypoglycemia

8 Diabetes Care, volume 28, NUMBER 9, September 2005 EPI.DIA.R  EPI.DIA.R  Severe hypoglycemia was more frequent among patients who: Had changed the dosage of their hypoglycemic agent or insulin Reported a significant change in their lifestyle Risks associated with FASTING in patients with diabetes -hypoglycemia

9 Diabetes Care, volume 28, NUMBER 9, September 2005 Long term morbidity-mortality trials demonstrated a link between hyperglycemia, microvascular complications and possibly macrovascular complications  Long term morbidity-mortality trials demonstrated a link between hyperglycemia, microvascular complications and possibly macrovascular complications  There is no data linking short term hyperglycemia and diabetes related complications Risks associated with FASTING in patients with diabetes -hyperglycemia

10 Diabetes Care, volume 28, NUMBER 9, September 2005  EPI.DIA.R  5-fold increase in the incidence of hyperglycemia in patients with type 2 diabetes  3-fold increase in the incidence of severe hyperglycemia (with or without keto-acidosis) in patients with type 1 diabetes Risks associated with FASTING in patients with diabetes -hyperglycemia

11 Diabetes Care, volume 28, NUMBER 9, September 2005  EPI.DIA.R  Hyperglycemia may have been due to excessive reduction in dosages of medication to prevent hypoglycemia  Patients who reported an increase in food/sugar intake had significantly higher rates of severe hypoglycemia Risks associated with FASTING in patients with diabetes -hyperglycemia

12 Diabetes Care, volume 28, NUMBER 9, September 2005  EPI.DIA.R  Patients with diabetes (especially type 1) who fast during RAMADAN are: At increased risk for developing keto-acidosis Risk furthermore increased if they reduce the insulin dosages (assuming that food intake is reduced during RAMADAN) Risks associated with FASTING in patients with diabetes –Diabetic Ketoacidosis

13 Diabetes Care, volume 28, NUMBER 9, September 2005  Patients with diabetes exhibit a hypercoagulable state due to: An increase in clotting factors A decrease in endogenous anticoagulants An impaired fibrinolysis  Increased blood viscosity secondary to dehydration may enhance the risk of thrombosis Risks associated with FASTING in patients with diabetes –Dehydration & Thrombosis

14 Diabetes Care, volume 28, NUMBER 9, September 2005  A report from KSA suggested an increased incidence of retinal vein occlusion in patients who fasted during RAMADAN  Hospitalization due to coronary events or stroke was not increased during RAMADAN  No available data on the effect of fasting on mortality in patients with or without diabetes Risks associated with FASTING in patients with diabetes –Dehydration & Thrombosis

15 Diabetes Care, volume 28, NUMBER 9, September 2005 I. Risks associated with FASTING in patients with diabetes II. Management III. Conclusions

16 Diabetes Care, volume 28, NUMBER 9, September 2005  Fasting for patients with diabetes represents an important personal decision that should be made in the light of guidelines for religious exemptions and after careful considerations of the associated risks following ample discussion with the treating physician. MANAGEMENT

17 Diabetes Care, volume 28, NUMBER 9, September 2005  Most of the time: the recommendations will be not to undertake fasting  Patients who insist on fasting must be aware of the associated risks and must be ready to adhere to the recommendations of their healthcare providers MANAGEMENT

18 Diabetes Care, volume 28, NUMBER 9, September 2005  Patients may be at HIGHER or LOWER risk for fasting-related complications depending on the number and extent of their risk factors MANAGEMENT

19 Diabetes Care, volume 28, NUMBER 9, September 2005 Conditions associated with “Very High”, “High”, “Moderate” & “Low” risk for adverse events in diabetic patients deciding to fast RAMADAN

20 Diabetes Care, volume 28, NUMBER 9, September 2005 Conditions associated with “Very High”, “High”, “Moderate” & “Low” risk for adverse events in diabetic patients deciding to fast RAMADAN

21 Diabetes Care, volume 28, NUMBER 9, September 2005 Conditions associated with “Very High”, “High”, “Moderate” & “Low” risk for adverse events in diabetic patients deciding to fast RAMADAN

22 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 I- General Considerations

23 Diabetes Care, volume 28, NUMBER 9, September 2005 c. Nutrition: Healthy and balanced diet Maintain constant body mass 20-25% gain or loose weight during the RAMADAN fast Avoid ingesting large amount of carbohydrate and fat (common practice) MANAGEMENT I- General Considerations

24 Diabetes Care, volume 28, NUMBER 9, September 2005 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 I- General Considerations

25 Diabetes Care, volume 28, NUMBER 9, September 2005 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 In some poorly controlled type 1 diabetic patients: exercise could lead to extreme hyperglycemia MANAGEMENT I- General Considerations

26 Diabetes Care, volume 28, NUMBER 9, September 2005 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 I- General Considerations

27 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 II- Pre-RAMADAN medical assessment & educational counseling

28 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 II- Pre-RAMADAN medical assessment & educational counseling

29 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 II- Pre-RAMADAN medical assessment & educational counseling

30 Diabetes Care, volume 28, NUMBER 9, September 2005 b. Educational Counseling: Emphasizing on adequate nutrition and hydration Ensuring preparedness to treat hypoglycemia promptly Glucose gel Glucose containing liquids Glucose tablets Glucagon injections… MANAGEMENT II- Pre-RAMADAN medical assessment & educational counseling

31 Diabetes Care, volume 28, NUMBER 9, September 2005 a. Should be advised not to fast: Type 1 diabetic patients, especially if poorly controlled Patients unwilling/unable to monitor their BG multiple times daily MANAGEMENT III- Management of patients with type 1 diabetes

32 Diabetes Care, volume 28, NUMBER 9, September 2005 b. Close monitoring and frequent insulin dose adjustments are essential to achieve optimal glycemic control and avoid hypo- hyperglycemia c.One injection of intermediate or long acting insulin before evening meal is not likely to provide adequate insulin coverage for 24hrs MANAGEMENT III- Management of patients with type 1 diabetes

33 Diabetes Care, volume 28, NUMBER 9, September 2005 d.Typically, patients will need to use 2 daily injections of NPH as intermediate-acting insulin, administered before the predawn and the sunset meals, in combination with a short- acting insulin to cover food intake at the associated meal. MANAGEMENT III- Management of patients with type 1 diabetes

34 Diabetes Care, volume 28, NUMBER 9, September 2005 e.There is an increased risk of hypoglycemia around midday due to peaking of the early morning insulin dose f.Using the long-acting insulin ultralent is an option, with twice daily injections at 12 hrs intervals & a rapid- or short-acting insulin should be added before the 2 meals. MANAGEMENT III- Management of patients with type 1 diabetes

35 Diabetes Care, volume 28, NUMBER 9, September 2005 g.Other options: Glargine once daily or Detemir twice daily Along with premeal rapid-acting insulin analogs MANAGEMENT III- Management of patients with type 1 diabetes h.Clinical studies with other types of insulin during fasting are limited.

36 Diabetes Care, volume 28, NUMBER 9, September 2005  Low risks of complications for type 2 diabetic patients well controlled with diet alone  Potential risk of postprandial hyperglycemia after predawn and sunset meals if patients overindulge in eating  Distributing calories over 2 or 3 smaller meals may help preventing excessive hyperglycemia MANAGEMENT IV- Management of patients with type 2 diabetes

37 Diabetes Care, volume 28, NUMBER 9, September 2005 individualized The choice of oral agents should be individualized MANAGEMENT IV- Management of patients with type 2 diabetes Patients treated with oral agents

38 Diabetes Care, volume 28, NUMBER 9, September 2005 a.Metformin: Metformin alone: safer because of the minimal risk of hypoglycemia Recommendations for the dose in Ramadan: 2/3 of the total daily dose immediately before the sunset meal 1/3 before the predawm meal MANAGEMENT IV- Management of patients with type 2 diabetes Patients treated with oral agents

39 Diabetes Care, volume 28, NUMBER 9, September 2005 b.Glitazones: Glitazone monotherapy: low risk of hypoglycemia Recommendations for the dose: Usually no change in the dose is required MANAGEMENT IV- Management of patients with type 2 diabetes Patients treated with oral agents

40 Diabetes Care, volume 28, NUMBER 9, September 2005 c.Sulfonylureas: Use should be individualized and utilized with caution Chlorpropamide is absolutely contra- indicated during Ramadan (prolonged hypoglycemia) MANAGEMENT IV- Management of patients with type 2 diabetes Patients treated with oral agents

41 Diabetes Care, volume 28, NUMBER 9, September 2005 c.Sulfonylureas: New members of the SU family (e.g. Gliclazide MR) have been shown to be effective, resulting in a lower risk of hypoglycemia MANAGEMENT IV- Management of patients with type 2 diabetes Patients treated with oral agents

42 Diabetes Care, volume 28, NUMBER 9, September 2005 d.Short acting insulin secretagogues: Useful be cause of their short duration of action. Can be taken twice daily: Before sunset meal Before predawn meal MANAGEMENT IV- Management of patients with type 2 diabetes Patients treated with oral agents

43 Diabetes Care, volume 28, NUMBER 9, September 2005  Problems similar to those of the patients with type 1 diabetes but with less incidence of hypoglycemia  Aim:  To maintain necessary levels of basal insulin  To suppress Hepatic Glucose Output to near- physiologic levels during the fasting period. MANAGEMENT IV- Management of patients with type 2 diabetes Patients treated with insulin

44 Diabetes Care, volume 28, NUMBER 9, September 2005  Judicious choice of intermediate or long-acting insulin preparations + short-acting insulin before meals would be an effective strategy  Special risk of hypoglycemia Patients who had required insulin for a number of years Very elderly diabetic patients MANAGEMENT IV- Management of patients with type 2 diabetes Patients treated with insulin

45 Diabetes Care, volume 28, NUMBER 9, September 2005  May provide adequate coverage: One injection of a long-acting insulin analog or 2 injections of NPH, lente or Detemir insulin before the sunset and pre-dawn meals As long as the dose/injection is properly individualized MANAGEMENT IV- Management of patients with type 2 diabetes Patients treated with insulin

46 Diabetes Care, volume 28, NUMBER 9, September 2005  May provide acceptable glycemic control in patients with reasonable basal insulin secretion: Single injection of intermediate-acting insulin, before the sunset meal MANAGEMENT IV- Management of patients with type 2 diabetes Patients treated with insulin

47 Diabetes Care, volume 28, NUMBER 9, September 2005  Most patients will require short-acting insulin administered in combination with the intermediate- or long-acting insulin at the sunset meal (to cover for the large caloric load of Iftar)  Many will need additional dose of short-acting insulin at predawn MANAGEMENT IV- Management of patients with type 2 diabetes Patients treated with insulin

48 Diabetes Care, volume 28, NUMBER 9, September 2005  The overall dosage of medications, especially that of insulin, must be adjusted in conjunction with the weight loss or gain that may occur during Ramadan MANAGEMENT IV- Management of patients with type 2 diabetes Patients treated with insulin

49 Diabetes Care, volume 28, NUMBER 9, September 2005  Pregnancy is a state of increased insulin resistance and insulin secretion and of reduced hepatic insulin extraction  Elevated BG & HbA 1c levels in pregnancy are associated with increased risk of major congenital malformations  Fasting during pregnancy would be expected to carry a high risk of morbidity-mortality to the fetus and the mother (controversies exist) MANAGEMENT IV- Pregnancy and fasting during RAMADAN

50 Diabetes Care, volume 28, NUMBER 9, September 2005  Muslim women are exempted from fasting during RAMADAN: those who insist on fasting constitutes a high-risk group MANAGEMENT IV- Pregnancy and fasting during RAMADAN

51 Diabetes Care, volume 28, NUMBER 9, September 2005  Women with pre-gestational/gestational diabetes: Should be strongly advised to not fast Those who insist of Fasting: Special attention to their care Essential pre-Ramadan evaluation of their medical condition Pre-conception care Emphasis on achieving near-normal BG and A1c values Counseling about maternal and fetal complications associated with poor glycemic control Education on self-management skills MANAGEMENT IV- Pregnancy and fasting during RAMADAN

52 Diabetes Care, volume 28, NUMBER 9, September 2005  Ideally, patients should be managed in high risk clinics staffed by an Obstetrician, Diabetologists, a nutritionist and diabetes nurse educators  The management of pregnant patients during RAMADAN is based on appropriate diet and intensive insulin therapy MANAGEMENT IV- Pregnancy and fasting during RAMADAN

53 Diabetes Care, volume 28, NUMBER 9, September 2005  May occur in Ramadan, especially if fasting is prolonged or associated with excessive perspiration: Dehydration Volume depletion Tendency toward hypotension  Dosage of antihypertensive medications may need to be adjusted MANAGEMENT V- Hypertension and dyslipidemia

54 Diabetes Care, volume 28, NUMBER 9, September 2005  Carbohydrate & fat intake is commonly increased in Ramadan: Counseling to avoid this excessive intake Continue the lipid- cholesterol lowering agents previously prescribed MANAGEMENT V- Hypertension and dyslipidemia

55 Diabetes Care, volume 28, NUMBER 9, September 2005 I. Risks associated with FASTING in patients with diabetes II. Management III. Conclusions

56 Diabetes Care, volume 28, NUMBER 9, September 2005  Fasting carries a risk of complications for diabetic patients  Type 1 diabetic patients should be strongly advised not to fast (hypo- hyperglycemia)  Type 2 diabetic patients, who fast Ramadan, are at relatively lower risk of hypo- hyperglycemia Conclusion(s)

57 Diabetes Care, volume 28, NUMBER 9, September 2005  Patient’s decision to fast should be made after discussion with his/her physician  Patients who insist of fasting should undergo pre- Ramadan assessment & receive appropriate education/counseling  Close follow-up is essential to reduce the risk of complications Conclusion(s)

58 Recommendations for Management of Diabetes During Ramadan Diabetes Care, volume 28, NUMBER 9, September 2005 Ramadan Consensus Kindly pick-up your copy of the Ramadan Consensus before leaving the meeting room


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