Presentation is loading. Please wait.

Presentation is loading. Please wait.

” ياأيها الذين أمنوا كتب عليكم الصيام كما كتب على الذين من قبلكم لعلكم تتقون “ “ O you who believe! Fasting has been prescribed to you as it was prescribed.

Similar presentations


Presentation on theme: "” ياأيها الذين أمنوا كتب عليكم الصيام كما كتب على الذين من قبلكم لعلكم تتقون “ “ O you who believe! Fasting has been prescribed to you as it was prescribed."— Presentation transcript:

1

2 ” ياأيها الذين أمنوا كتب عليكم الصيام كما كتب على الذين من قبلكم لعلكم تتقون “ “ O you who believe! Fasting has been prescribed to you as it was prescribed to those before you so that you attain Taqwa ”

3 Fasting is not meant to create excessive hardship on the Muslim individuals. The Quran specifically exempts the sick from the duty of fasting. Fasting is not meant to create excessive hardship on the Muslim individuals. The Quran specifically exempts the sick from the duty of fasting. The Prophet Mohammad said, “God likes his permission to be fulfilled, as he likes his will to be executed.” The Prophet Mohammad said, “God likes his permission to be fulfilled, as he likes his will to be executed.”

4 Things Happened During Ramadan During Ramadan, Muslims must fast from dawn to sunset. During Ramadan, Muslims must fast from dawn to sunset. This will involve a sudden change in the daily meals. This will involve a sudden change in the daily meals. Two meals named Iftar and Sahur. Two meals named Iftar and Sahur. Ramadan is a lunar-based month. Its timing changes with respect to seasons. Ramadan is a lunar-based month. Its timing changes with respect to seasons. Depending on the geographical location and season, the duration of the daily fast may range from a few to more than 20 h. Depending on the geographical location and season, the duration of the daily fast may range from a few to more than 20 h.

5 Uniqueness of Ramadan Fasting It is a voluntary undertaking rather than being ordered by a physician It is a voluntary undertaking rather than being ordered by a physician There is no selective food intake i.e. protein only, juice only, fruit only, water only etc There is no selective food intake i.e. protein only, juice only, fruit only, water only etc There is no total calorie malnutrition There is no total calorie malnutrition An exercise in self discipline i.e. from constant nibbling, drinking, smoking etc An exercise in self discipline i.e. from constant nibbling, drinking, smoking etc

6 Physiological Effects of Fasting: On Calorie intake On Calorie intake On fluid /water intake On fluid /water intake Effects on – Digestive System Effects on – Digestive System - Kidneys - Kidneys - Endocrine glands - Endocrine glands - Lipid Metabolism - Lipid Metabolism - Respiratory system - Respiratory system - Neurological System - Neurological System

7 Some Facts : The most important metabolic fuels are glucose and fatty acids. The most important metabolic fuels are glucose and fatty acids. In normal circumstances, glucose is the only fuel the brain uses. In normal circumstances, glucose is the only fuel the brain uses. To ensure the continuous provision of glucose to the brain and other tissues, metabolic fuels are stored. To ensure the continuous provision of glucose to the brain and other tissues, metabolic fuels are stored. Carbohydrates are stored as glycogen - the amount of available glycogen stored is not large - about 75g in the liver and little amounts in the muscles. Liver glycogen can supply glucose for no longer than 16h. Carbohydrates are stored as glycogen - the amount of available glycogen stored is not large - about 75g in the liver and little amounts in the muscles. Liver glycogen can supply glucose for no longer than 16h. To provide glucose over longer periods, the body transforms non-carbohydrate compounds into glucose (Gluconeogenesis). To provide glucose over longer periods, the body transforms non-carbohydrate compounds into glucose (Gluconeogenesis).

8 Insulin and Glucagon Main determinants of glucose metabolism

9 Glucagon Proglucagon Insulin& C-peptide Proinsulin Both cell types release their hormones simultaneously at a basal level. This is augmented in response to alterations in blood glucose levels. Blood glucose<70mg/dl Insulin& C-peptide Proinsulin --- Glucagon Proglucagon +++ Blood glucose >90mg/dl

10 Paracrine Actions of Insulin and Glucagon Insulin - glucagon Glucagon + Insulin

11 Insulin glycogenesis Protein synthesis lipogenesis Glucagon glycogenolysis gluconeogenesis from aa lipolysis So, insulin favors anabolic reactions and storing energy glucagon, catabolic reactions and release of stored energy

12 1- 6 hours: blood glucose < 60 mg/dl 2- Lowered blood glucose ++ secretion of glucagon& -- insulin 3-Glycogenolysis maintain blood glucose for hours 4- Then stimulates gluconeogenesis Fuel reserves are: Triacylglycerols & tissue proteins Alanin &lactate glycerol FFA 5- Ketone bodies +++

13 So, Effects of Fasting on Carbohydrate Metabolism 1. Slight fall in serum glucose from 9 to 11 am, but not from 11 am to 6 pm. Serum Insulin Serum glucagon Growth hormone Catecholamine Serum Insulin Serum glucagon Growth hormone Catecholamine 2-Slight decrease blood glucose in the first week then normalization by day 20 ± rise in the last week

14 Fasting and Lipid Metabolism Decrease in : Total Cholesterol,LDL and Triglycerides in first few days then rise to pre fasting levels (quality and quantity of food consumed at Iftaar and Sahur) Decrease in : Total Cholesterol,LDL and Triglycerides in first few days then rise to pre fasting levels (quality and quantity of food consumed at Iftaar and Sahur) Increase in HDL-C Increase in HDL-C

15 Endocrine functions in Fasting Fall in free T3 but rise in rT3 Fall in free T3 but rise in rT3 Slight fall in total T4 (due to fall in TBG) but normal freeT4 and TSH Slight fall in total T4 (due to fall in TBG) but normal freeT4 and TSH Serum Testosterone, LH, FSH may be normal or slightly low with change of circadian pattern Serum Testosterone, LH, FSH may be normal or slightly low with change of circadian pattern

16 -- Sexual desire during fasting hours Altered circadian patterns of cortisol and testosterone, with sharper decreases of these hormones in the morning and later rises at night

17 Decrease in appetite due to ketosis and increase in Beta- endorphins

18 Decreased and delayed melatonin peak Decreased Nocturnal sleep Decreased Nocturnal sleep Daytime alertness Daytime alertness Psychomotor performance Psychomotor performance

19 Renal Function in Fasting Urinary volume Urinary volume Osmolality Osmolality Shift of fluids intracellularly Shift of fluids intracellularly Slight increase in BUN (insignificant) Slight increase in BUN (insignificant) Increase in Uric acid (less in Ramadan fasting than in prolonged fasting) Increase in Uric acid (less in Ramadan fasting than in prolonged fasting) Dehydration

20 Other Effects of Fasting Weight loss of Kg (obese lose more weight than non obese) Weight loss of Kg (obese lose more weight than non obese) Fewer suicide in Ramadan than in other months (reported in Jordan) Fewer suicide in Ramadan than in other months (reported in Jordan)

21 Benefits of fasting: Muslims do not fast because of medical benefits but because they are ordered to. 1- Self -regulation and self-training 2- Concentration of all fluids within the tissues and plasma. 3-Lower of blood sugar 4-Lowering of LDL and elevation of HDL 5-Lowering of the systolic blood pressure. 6-Lowering of body weight 7-Psychological :sense of inner peace and tranquility (Fasting Muslims realize that anger may take away the blessings of fasting) (stress elevate blood sugar via catecolamines) (Fasting Muslims realize that anger may take away the blessings of fasting) (stress elevate blood sugar via catecolamines) Ramadan fasting would be an ideal recommendation for treatment of mild to moderate stable NIDDM, obesity and essential hypertension. Ramadan fasting would be an ideal recommendation for treatment of mild to moderate stable NIDDM, obesity and essential hypertension.

22 What will happen in diabetic patient ?????????

23 In patients with diabetes Insulin replacement Hypoglycemia Insulin replacement Hyperglycemia & Ketosis Glucagon secretion may fail to increase Glucagon secretion may fail to increase Epinephrine secretion is also defective Epinephrine secretion is also defective due to a autonomic neuropathy. due to a autonomic neuropathy. Excessive: Glycogenolysis Gluconeogenesis Ketogenesis Ketogenesis

24 EPIDIAR STUDY-T2DM: 78.2% fasted >15days Salti et al: Diabetes Care Vol 27; 10 Oct 2

25 Risks associated with fasting in diabetic patient???

26 Risks associated with fasting in patients with diabetes * Hypoglycemia: Severe hypoglycemia Type 1 diabetes Type 2 diabetes Type 1 diabetes Type 2 diabetes 3 to14 events/100 people/ m 0.4 to3 events/100 people/ m. Finch GM et al, Appetite 31:2, 1998 Ghaznawi H I. et al. "The Effect of Ramadan Fasting on Body Weight." Joumalfo the IMA, 1993 Al-Hurani HM etal, Singapore Med J Oct;48(10): Faye J et al, Dakar Med. 2005;50(3):146-51

27 * Hyperglycemia: severe hyperglycemia (requiring hospitalization) Type 1 diabetes Type 2 diabetes Type 1 diabetes Type 2 diabetes 3 fold increase 5 fold increase 3 fold increase 5 fold increase ± Ketoacidosis ± Ketoacidosis due to excessive reduction in dosages of medications due to excessive reduction in dosages of medications to prevent hypoglycemia to prevent hypoglycemia

28 * Dehydration and thrombosis : if prolonged fasting if prolonged fasting In hot and humid climates In hot and humid climates Among individuals who perform hard physical labor Among individuals who perform hard physical labor Hyperglycemia Hyperglycemia Might lead hypovolemia and orthostatic hypotension, however, hospitalizations due to coronary events or stroke were not increased Might lead hypovolemia and orthostatic hypotension, however, hospitalizations due to coronary events or stroke were not increased

29 Taking the decision The decision to fast is usually taken by three people: the patient, the physician and a religious advisor. The decision to fast is usually taken by three people: the patient, the physician and a religious advisor. Ibrahim M. A. ; Managing diabetes during Ramadan; Diabetes Voice; June 2007 | Volume 52 | Issue 2

30 Thank You

31 Insulin Glargine during Ramadan Insulin Glargine during Ramadan Eman Rushdy

32 32 12,243 people with diabetes from 13 Islamic countries about 43% of patients with type 1 diabetes and 78% of patients with type 2 diabetes fast during Ramadan. Epidemiology of Diabetes and Ramadan 1422/2001 : (EPIDIAR) study Diabetes Care2004 : 27:2306–2311

33 During Ramadan about 60% of patients change their antidiabetic drug intake. During Ramadan about 60% of patients change their antidiabetic drug intake. 35% stop treatment 35% stop treatment 8% change the dosage 8% change the dosage Importantly, this is done at the patients’ own initiative without medical supervision. Importantly, this is done at the patients’ own initiative without medical supervision. Salti I, Benard E, Detournay B et al. A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries. Diabetes Care 2004; 27: 2306–11. Aslam M, Healey MA. Compliance and drug therapy in Moslem patients. J Clin Hosp Pharm 1986; 11: 321–5. Aslam M, Assad A. Drug regimens and fasting during Ramadan: a survey in Kuwait. Public Health 1986; 100: 49–53.

34 Results in

35 Sequelae of hypoglycaemia Mild”: Adrenergic (BG<70) Mild”: Adrenergic (BG<70) –No direct serious clinical effects –With a rapid decline in blood glucose : tachycardia, tachypnea, vomiting, and diaphoresis –May impair subsequent hypoglycaemia awareness Severe Neuroglycopenic (BG<50) Severe Neuroglycopenic (BG<50) Usually associated with slower or prolonged hypoglycemia, Usually associated with slower or prolonged hypoglycemia, –Stroke and transient ischaemic attacks –Memory loss/cognitive impairment –Myocardial infarction –Convulsions –Death

36 ACCORD: N Engl J Med 2008; 358(24): ADVANCE: N Engl J Med 2008; 358 (24): VADT: J Diabetes Complications 2003; 17 (6): Recent Clinical Trial Findings: Intensive glucose control in type 2 diabetes: Was associated with increased mortality in patients with longstanding DM and known CVD (ACCORD) Was associated with increased mortality in patients with longstanding DM and known CVD (ACCORD) Increases risk of severe hypoglycemia (ADVANCE, ACCORD and VADT) Increases risk of severe hypoglycemia (ADVANCE, ACCORD and VADT)

37 Hypoglycaemia and CV Disease Desouza C et al Diabetes Care 26: , 2003

38 Haematologic Responses To Hypoglycaemia Hypoglycaemia and CV Disease Wright R et al Diabetes/ Metabolism Research and Reviews, 2008 Increased RBCs Leading To Increased Blood Viscosity Enhanced Platelet Aggregation Increased Platelet Factor 4 Increased Thromboglobulin Increased Coagulation Factor VIII Increased Von Willebrand Factor Increased Thrombin Generation

39 Inflammatory Responses To Hypoglycaemia Hypoglycaemia and CV Disease *p < 0.04 vs. Baseline CRP (mg/L) Baseline 4 Hours 24 Hours Diabetes * Control 0.32 ND 0.96* Galloway P et al Diabetes Care 23: , 2000

40 Hypoglycaemia and CV Disease Wright R et al Diabetes/ Metabolism Research and Reviews, 2008 Hemodynamic Thrombotic Inflammatory Hypoglycaemia Ischaemia

41 Hypoglycemia Unawareness Type 1 DM DURATION Autonomic neuropathy Recurrent hypoglycemia

42 MIMICKING NATURE WITH INSULIN THERAPY All persons need both basal and mealtime insulin to control glucose 6- 19

43 The normal human pancreas has a basal insulin secretory rate of 1-2 U per hr, with post prandial rates increasing to 4-6 U / hr. in two phases (early & Late phase). Insulin secreted into portal circulation where 50% of it extracted by liver without reaching systemic circulation.Insulin secreted into portal circulation where 50% of it extracted by liver without reaching systemic circulation. Insulin catabolized by insulinase in Liver, Kidney, & placenta.

44 Regulation of Basal insulin secretion Na + K+K+ K+K+ K+K+ K+K+ GLUT2 Ca 2+ Voltage-gated Ca 2+ channel KIR Pancreatic ß cell Pacemaker ß cells Signal Insulin granules Ca 2+ VmVm Mature insulin granules contracts by exposure to high intracellular Ca.

45 Post prandial insulin secretion Glucokinase Glucose K Ca

46 Physiologic Insulin Secretion: Basal/Prandial Concept Breakfast Lunch Supper Insulin (µU/mL) Glucose (mg/dL) Basal Glucose A.M.P.M. Time of Day Basal Insulin Nutritional Glucose Nutritional (Prandial) Insulin Basal Insulin *Suppresses Glucose Production Between Meals & Overnight *Nearly constant levels % of daily needs Prandial Insulin *Limits hyperglycemia after meals *Immediate rise and sharp peak *10% to 20% of total daily insulin requirement at each meal

47 Good 70/30 premixed insulin twice daily, ….Use the usual morning dose at the sunset meal (Iftar) and half the usual evening dose at predawn (Suhur), 70/30 premixed insulin twice daily, ….Use the usual morning dose at the sunset meal (Iftar) and half the usual evening dose at predawn (Suhur), e.g., 30 units in morning and 20 units in evening…e.g., 70/30 premixed insulin, 30 units in Iftar and 10 units in Suhur. e.g., 30 units in morning and 20 units in evening…e.g., 70/30 premixed insulin, 30 units in Iftar and 10 units in Suhur.

48 The best: Consider changing premixed insulin preparations to Glargine or Dtemir plus Lispro, Glulisine or Aspart. Consider changing premixed insulin preparations to Glargine or Dtemir plus Lispro, Glulisine or Aspart. 48 Diabetes Care September 2005, pages

49 49 Types of basal insulin Intermediate- Acting (e.g. NPH, lente) Long-Acting Analogues (glargine, detemir) Onset1-3 hr(s)1.5-3 hrs Peak5-8 hrs No peak with glargine, dose- dependent peak with detemir DurationUp to 18 hrs 9-24 hrs (detemir); hrs (glargine) Rossetti P, et al. Arch Physiol Biochem 2008;114(1): 3 – 10.

50 Ideal Basal Insulin: Safe Safe Effective Effective Less glucose excurtions Less glucose excurtions

51 Why Glargine

52 52 Insulin Glargine has less intra-patient variation & has a relatively constant, longer action profile with no pronounced peak in contrast to the peak and intermediate activity of NPH insulin Glucose utilization rate mg/kg/min Insulin Glargine NPH Time Insulin Glargine Peakless with 24hour Release

53 Janka HU, et al. Diabetes Care 2005;28(2):254–259 LAPTOP: lower incidence of hypoglycaemia with Insulin Glargine versus premix

54 54 Less hypoglycemia with glargine vs NPH Adapted from Mullins P, et al. Clin Ther 2007;29: p=0.021 NPH insulin Insulin glargine Rate of Hypoglycemia (Events/100 Patient-Years) HbA 1c (%) Meta-Regression Analysis 11 randomized controlled trials; n=3,083

55 Insulin glargine consistently achieves HbA 1C ≤ 7% 1. Riddle M, et al. Diabetes Care 2003;26:3080–6. 2. Gerstein HC, et al. Diabetes Med 2006;23:736– Bretzel RG, et al. Lancet 2008;371:1073– Yki-Järvinen H, et al. Diabetes Care 2007;30:1364–9. 5. Schreiber SA, et al. Diabetes Obes Metab 2007;9:31–8. Baseline Study end T-T-T 1 (n = 367) INSIGHT 2 (n = 206) APOLLO 3 (n = 174) INITIATE 4 (n = 58) Schreiber 5 (n = 12,216) HbA 1C (%)

56 56 Janka HU, et al. Diabetes Care 2005;28(2):254–259 LAPTOP: once-daily Insulin Glargine + oral antidiabetic drug therapy is better than two premixes when initiating insulin in Type 2 diabetes Randomized study in 371 insulin-naïve subjects with T2DM, who received Insulin Glargine or premix (70% NPH/30% regular) insulin for 24 weeks Insulin Glargine + OADs is more efficient in lowering HbA1c, with less hypoglycaemia

57 57 Porcellati F, et al. Diabetes Care 2007;30(10):2447–2452 PK/PD: Insulin Glargine has a longer duration of action than detemir Randomized study comparing the pharmacokinetics and pharmacodynamics of Insulin Glargine with that of detemir in 24 subjects with T1DM who were naïve to Insulin Glargine and detemir

58 58 –FBG at or close to target (90–130 mg/dl) but HbA1c ≥7%1 –FBG controlled but PPBG consistently high –Basal insulin dose > 0.5U/Kg The need for prandial insulin despite optimal titration of basal insulin is indicated by:

59 Fasting and Insulin Glargine in Individuals With Type 1 Diabetes

60

61 Fasting during Ramadan in T2DM patients with insulin Glargine

62

63 Breaking the fast Diabetic patients must end their fast immediately in the following cases: Diabetic patients must end their fast immediately in the following cases: if blood glucose levels drop dramatically to 60 mg/dl or lower if blood glucose levels drop dramatically to 60 mg/dl or lower if blood glucose reaches 70 mg/dl in the first few hours after the start of the fast, especially if insulin, sulfonylureas, or meglitinides are taken at the pre-dawn meal if blood glucose reaches 70 mg/dl in the first few hours after the start of the fast, especially if insulin, sulfonylureas, or meglitinides are taken at the pre-dawn meal if blood glucose levels rise excessively to 300 mg/dl. if blood glucose levels rise excessively to 300 mg/dl. Ibrahim M. A. ; Managing diabetes during Ramadan; Diabetes Voice; June 2007 | Volume 52 | Issue 2

64

65 THANK YOU

66 People with type 1 diabetes In general, people with type 1 diabetes are at very high risk of developing severe complications, and should be strongly advised to not fast during Ramadan. In general, people with type 1 diabetes are at very high risk of developing severe complications, and should be strongly advised to not fast during Ramadan. Management: Ibrahim M. A. ; Managing diabetes during Ramadan; Diabetes Voice; June 2007 | Volume 52 | Issue 2

67 Management: To be Discussed later in the following sessions To be Discussed later in the following sessions

68

69 Two daily injections of NPH intermediate-acting insulin in combination with a short-acting insulin Two daily injections of NPH intermediate-acting insulin in combination with a short-acting insulin administered the usual dose before Iftar and half the dose before Sahour, However, there is an increased risk of hypoglycaemia around midday administered the usual dose before Iftar and half the dose before Sahour, However, there is an increased risk of hypoglycaemia around midday Another option : use one daily injection of the long-acting insulin analogue, glargine; or detemir along with pre-meal rapid-acting insulin analogues. Another option : use one daily injection of the long-acting insulin analogue, glargine; or detemir along with pre-meal rapid-acting insulin analogues.

70 Management People with type 2 diabetes Lifestyle and nutrition In people who manage their diabetes with diet and physical activity, the risks associated with fasting are quite low. In people who manage their diabetes with diet and physical activity, the risks associated with fasting are quite low. However, if people eat excessively, a potential risk of post-meal hyperglycaemia. However, if people eat excessively, a potential risk of post-meal hyperglycaemia. Distributing energy intake over two to three smaller meals during the non- fasting interval may help. Distributing energy intake over two to three smaller meals during the non- fasting interval may help. A person’s regular daily exercise programme should be modified in its intensity and timing to avoid episodes of hypoglycaemia. A person’s regular daily exercise programme should be modified in its intensity and timing to avoid episodes of hypoglycaemia. Ibrahim M. A. ; Managing diabetes during Ramadan; Diabetes Voice; June 2007 | Volume 52 | Issue 2

71 Glucose absorption Hepatic glucose overproduction Beta-cell dysfunction Insulin resistance Major Targeted Sites of Oral Drug Classes DPP-4=dipeptidyl peptidase-4; TZDs=thiazolidinediones. DeFronzo RA. Ann Intern Med. 1999;131:281–303. Buse JB et al. In: Williams Textbook of Endocrinology. 10th ed. Philadelphia: WB Saunders; 2003:1427–1483. Pancreas ↓Glucose level Muscle and fat Liver Biguanides TZDsBiguanides Sulfonylureas Meglitinides TZDs Alpha- glucosidase inhibitors Gut The glucose-dependent mechanism of DPP-4 inhibitors targets 2 key defects: insulin release and unsuppressed hepatic glucose production. DPP-4 inhibitors GLP-1 DPP-4 inhibitors Biguanides

72 Source of hyperglycemia during fasting hours: Source of hyperglycemia during fasting hours: 1- Dietary 2- Insulin deficiency 3- Hepatic glucose output 4- Non of the above.

73 An Ideal Oral Agent Should You Select during fasting..? Achieve A1c Target Achieve A1c Target Has lower hypoglycemic events Has lower hypoglycemic events Promotes weight loss Promotes weight loss In general, medications that act by increasing insulin sensitivity are associated with a significantly lower risk of hypoglycaemia than insulin secretagogues

74 Glucose absorption Hepatic glucose overproduction Beta-cell dysfunction Insulin resistance Major Targeted Sites of Oral Drug Classes DPP-4=dipeptidyl peptidase-4; TZDs=thiazolidinediones. DeFronzo RA. Ann Intern Med. 1999;131:281–303. Buse JB et al. In: Williams Textbook of Endocrinology. 10th ed. Philadelphia: WB Saunders; 2003:1427–1483. Pancreas ↓Glucose level Muscle and fat Liver Biguanides TZDsBiguanides Sulfonylureas Meglitinides TZDs Alpha- glucosidase inhibitors Gut The glucose-dependent mechanism of DPP-4 inhibitors targets 2 key defects: insulin release and unsuppressed hepatic glucose production. DPP-4 inhibitors GLP-1 DPP-4 inhibitors Biguanides

75 Management Oral medications Metformine: two thirds of the total daily dose to be taken after the sunset meal, with the other third taken after the pre-dawn meal. Metformine: two thirds of the total daily dose to be taken after the sunset meal, with the other third taken after the pre-dawn meal. Rosiglitazone and Pioglitazone: have a low risk of hypoglycemia. Usually no change in dose is required. Rosiglitazone and Pioglitazone: have a low risk of hypoglycemia. Usually no change in dose is required. Ibrahim M. A. ; Managing diabetes during Ramadan; Diabetes Voice; June 2007 | Volume 52 | Issue 2

76 Sulfonylureas are believed to be unsuitable for use during fasting because of the inherent risk of hypoglycemia; they should be used with caution and select the safest SU (glimipride). Sulfonylureas are believed to be unsuitable for use during fasting because of the inherent risk of hypoglycemia; they should be used with caution and select the safest SU (glimipride). Meglitinides are superior to SU as long as they could control hyperglycemia. Meglitinides are superior to SU as long as they could control hyperglycemia. Chlorpropamide is absolutely contraindicated during Ramadan because of the high possibility of prolonged and unpredictable hypoglycemia. Chlorpropamide is absolutely contraindicated during Ramadan because of the high possibility of prolonged and unpredictable hypoglycemia. Ibrahim M. A. ; Managing diabetes during Ramadan; Diabetes Voice; June 2007 | Volume 52 | Issue 2

77 Insulin The aim should be to maintain necessary levels of basal insulin to suppress output of glucose from the liver to near-normal levels during fasting. The aim should be to maintain necessary levels of basal insulin to suppress output of glucose from the liver to near-normal levels during fasting. Careful use of intermediate or long-acting insulins plus a short- acting insulin administered before meals would be an effective strategy. Careful use of intermediate or long-acting insulins plus a short- acting insulin administered before meals would be an effective strategy. Ibrahim M. A. ; Managing diabetes during Ramadan; Diabetes Voice; June 2007 | Volume 52 | Issue 2

78 Recommended changes to treatment regimen in patients with type 2 diabetes who fast during Ramad an (MONIRA AL-AROUJ, MD. RADHIA BOUGUERRA, 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. OUSSAMA KHATIB, MD, PHD. SUHAIL KISHAWI, MD. ABDULRAZZAQ AL-MADANI, MD. ALY A. MISHAL, MD, FACP. MASOUD AL-MASKARI, MD, PHD. ABDALLA BEN NAKHI, MD. KHALED AL-RUBEAN, MD) Recommendations for Management of Diabetes During Ramadan; Reviews / Commentaries / ADA Statements ADA WORK GROUP REPORT; DIABETES CARE, VOLUME 28, NUMBER 9: , SEPTEMBER 2005

79 47 years old male, accountant 47 years old male, accountant Sedentary lifestyle Sedentary lifestyle BMI 32 BMI 32 Diabetic 5 years on Glimipride 4 mg /day and metformin 500 mg 3 times daily Diabetic 5 years on Glimipride 4 mg /day and metformin 500 mg 3 times daily Case #1 Glimipride adjusted dose (2 or 3 mg) before Iftar and metformin 1000 mg after Iftar and 500mg after Sahour

80 51 year old male 51 year old male Type 2 diabetes currently treated with Metformin 1500 mg Type 2 diabetes currently treated with Metformin 1500 mg Serum creatinin 1.9 mg/dl Serum creatinin 1.9 mg/dl Case #2 Not to fast Shift to Insulin Sensitizers

81 48 years old male 48 years old male BMI 28 BMI 28 Diabetic 11 years controlled on mixed Insulin 60 U breakfast &40 U dinner and metformin 850mg after lunch Diabetic 11 years controlled on mixed Insulin 60 U breakfast &40 U dinner and metformin 850mg after lunch Case #1 Basal Insulin 40 U & Short acing (better ultra short analogues) 30 U Iftar & 10 U Sahour 60 U Iftar and 20 U Sahour

82 Patient Care and Management !!! Frequent monitoring This is especially critical in people who require insulin This is especially critical in people who require insulin Medical assessment This should take place one to two months before Ramadan. This should take place one to two months before Ramadan. Specific attention should be paid to people’s overall well-being and to the control of their blood glucose levels, blood pressure, and lipids. Specific attention should be paid to people’s overall well-being and to the control of their blood glucose levels, blood pressure, and lipids. Ibrahim M. A. ; Managing diabetes during Ramadan; Diabetes Voice; June 2007 | Volume 52 | Issue 2

83 Nutrition People should maintain a healthy and balanced diet during Ramadan. People should maintain a healthy and balanced diet during Ramadan. The common practice of ingesting large amounts of foods that are high in fat and carbohydrates, should be avoided The common practice of ingesting large amounts of foods that are high in fat and carbohydrates, should be avoided It is recommended that non-caloric fluid intake be increased during the non-fasting hours. It is recommended that non-caloric fluid intake be increased during the non-fasting hours. The Sahour meal should be taken as late as possible before the start of the daily fast. The Sahour meal should be taken as late as possible before the start of the daily fast. Ibrahim M. A. ; Managing diabetes during Ramadan; Diabetes Voice; June 2007 | Volume 52 | Issue 2 x

84 Physical activity Normal levels of physical activity can be maintained. Normal levels of physical activity can be maintained. However, excessive physical activity may lead to higher risk of hypoglycaemia and should be avoided. However, excessive physical activity may lead to higher risk of hypoglycaemia and should be avoided. x If Tarawih prayers (multiple prayers after the sunset meal) are performed, they should be considered a part of a person’s daily physical activity programme. If Tarawih prayers (multiple prayers after the sunset meal) are performed, they should be considered a part of a person’s daily physical activity programme. Ibrahim M. A. ; Managing diabetes during Ramadan; Diabetes Voice; June 2007 | Volume 52 | Issue 2

85 Diabetics should not fast if : Uncontrolled (no defined figure) Uncontrolled (no defined figure) Recurrent hypoglycemic attacks Recurrent hypoglycemic attacks Hypoglycemia unawareness. Hypoglycemia unawareness. A history of Diabetic Ketoacidosis · A history of Diabetic Ketoacidosis · Recent infections Recent infections Kidney disease Kidney disease Unstable ischemic heart disease. Unstable ischemic heart disease.


Download ppt "” ياأيها الذين أمنوا كتب عليكم الصيام كما كتب على الذين من قبلكم لعلكم تتقون “ “ O you who believe! Fasting has been prescribed to you as it was prescribed."

Similar presentations


Ads by Google