1. Managing T2DM during Ramadan Dr. Asrar Said Hashem Specialist in Internal Medicine (Al-Amiri Hospital) Fellow of KIMS Endocrine, Diabetes and Metabolism Program

2. Case-1 59 years old gentleman T2DM for 4 years On – Metformin 2 gm/ day – Sitagliptin 100 mg/ day – Gliclazide MR 60 mg/ day A1c 7.2% To fast or not to fast?

3. Case-1 Pre-Ramadan Medical Assessment – Individual risk stratification – Medication changes – Ramadan-focused diabetic education

4. Diabetes and fasting Ramadan: summary of recommendations of the organization of the Islamic Conference Category 1: very high-risk group severe hypoglycaemia within the last 3 months prior to Ramadan Patients with a history of recurrent hypoglycaemia Patients with lack of hypoglycaemia awareness Patients with sustained poor glycaemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycaemic coma within the previous 3 months Patients who perform intense physical labour Pregnancy Patients on chronic dialysis Category 2: high-risk group Patients with moderate hyperglycaemia blood glucose levels of 10.0–16.5 mmol/L (180–300 mg/dL) or high HbA1C (> 10%) Patients with renal insufficiency Patients with advanced macrovascular complications People living alone who are treated with insulin or sulphonylureas Patients living alone with comorbid conditions that present additional risk factors old age with ill healt Drugs that may affect cognitive state Hassanein M, et al. Diabetologia 2009;52:367-8 Category 3: moderate risk Well-controlled patients treated with short-acting insulin secretagogues such as repaglinide or nateglinide Category 4: low risk Well-controlled patients treated with diet alone, metformin, or a thiazolidinedione, who are otherwise healthy

5. Case-1 Low risk Good glycemic control Rx – Sitagliptin: no change, given at Iftar – Metformin: 1000 mg at Iftar, 500 mg at Suhur – Gliclazide MR: reduce to 30 mg at Iftar

6. Case-1 Ramadan-focused diabetic education – Standard diabetic education – Monitoring CBG – When to break the fast – Diet – Exercise

7. READ Study Ramadan Education and Awareness in Diabetes Program for Muslims with T2DM who fast during Ramadan Determine impact of Ramadan-focused education on weight and hypoglycemic episodes – T2DM taking oral glucose lowering agents Prospective Analysis – Group A (n=57) attended 2-hr structured education program – Group B (n=54) Did not Results – Group A Mean wt loss of 0.7 kg Decrease in total no. of hypoglycemic attacks (9 → 5) – Group B Mean wt gain of 0.6 kg Increase in total hypoglycemic attacks (9 → 36) Diabet. Med. 27, 327-331 (2010).

8. QUESTIONS?

9. Case-2 77 years old lady T2DM for 14 years Complicated by – Preproliferative Retinopathy – Peripheral Neuropathy – Stage 2 CKD Hypertension Dyslipidemia CAD (PCI and stent to LAD in 2011)

10. Case-2 On – Insulin glargine 42 units/ day – Actrapid insulin 10 – 14 – 8 units pre-meals – Metformin 2 gm/ day – Valsartan 160 mg/ day – Atrovastatin 40 mg/ day – Aspirin 81 mg/ day – Isosorbide mononitrates 30 mg/ day A1c 10.6% To fast or not to fast?

11. Case-2 Pre-Ramadan Medical Assessment – Individual risk stratification – Medication changes – Ramadan-focused diabetic education

12. Diabetes and fasting Ramadan: summary of recommendations of the organization of the Islamic Conference Category 1: very high-risk group severe hypoglycaemia within the last 3 months prior to Ramadan Patients with a history of recurrent hypoglycaemia Patients with lack of hypoglycaemia awareness Patients with sustained poor glycaemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycaemic coma within the previous 3 months Patients who perform intense physical labour Pregnancy Patients on chronic dialysis Category 2: high-risk group Patients with moderate hyperglycaemia blood glucose levels of 10.0–16.5 mmol/L (180–300 mg/dL) or high HbA1C (> 10%) Patients with renal insufficiency Patients with advanced macrovascular complications People living alone who are treated with insulin or sulphonylureas Patients living alone with comorbid conditions that present additional risk factors old age with ill healt Drugs that may affect cognitive state Hassanein M, et al. Diabetologia 2009;52:367-8 Category 3: moderate risk Well-controlled patients treated with short-acting insulin secretagogues such as repaglinide or nateglinide Category 4: low risk Well-controlled patients treated with diet alone, metformin, or a thiazolidinedione, who are otherwise healthy

13. Case-2 High risk Poor glycemic control Patient should be prohibited from fasting

14. Case-2 Patient insists on fasting! – Clearly explain the risks of fasting – Possible complications – Ramadan-focused diabetic education Standard diabetic education Monitoring CBG When to break the fast Diet

15. Major risks associated with fasting in patients with diabetes Hypoglycemia Hyperglycemia Diabetic ketoacidosis Dehydration and thrombosis

16. Hypoglycemia Risk of severe hypoglycemia in EPIDIAR study Ramadan fasting 2001 5-fold increase in T1DM 7.5-fold increase in T2DM salti I, Benard e, Detournay B et al. Diabetes Care 2004; 27:2306-11.

17. Hyperglycemia and DKA Severe hyperglycemia requiring hospitalization 5-fold increased in T2DM 3-fold higher in T1DM – With or without ketoacidosis salti I, Benard e, Detournay B et al. Diabetes Care 2004; 27:2306-11.

18. Dehydration and Thrombosis Dehydration → Hard physical labor ↑ risk of Thrombosis among diabetics ↓ endogenous anticoagulants Impaired fibrinolysis ↑ clotting factors

19. Case-2 Medication Adjustments – Insulin glargine: Dose reduction by 20% Given at Iftar – Actrapid Insulin Launch dose at Iftar Reduced Dinner dose at Suhur – Metformin 1000 mg at Iftar, 500 mg at Suhur

20. QUESTIONS?

21. Case-3 65 years old lady T2DM for 16 years Complicated by – Proliferative Retinopathy – Peripheral Neuropathy – Stage 3 CKD Hypertension Dyslipidemia Admitted to the hospital 3 weeks ago with hyperosmolar hyperglycemic state (HHS) secondary to urosepsis

22. Case-3 On – Insulin glargine 46 units/ day – Actrapid insulin 12 – 16 – 10 units pre- meals – Lisinopril 20 mg/ day – Amlodipine 10 mg/ day – Atorovastatin 40 mg/ day A1c 11.4% To fast or not to fast?

23. Case-3 Pre-Ramadan Medical Assessment – Individual risk stratification – Medication changes – Ramadan-focused diabetic education

24. Diabetes and fasting Ramadan: summary of recommendations of the organization of the Islamic Conference Category 1: very high-risk group severe hypoglycaemia within the last 3 months prior to Ramadan Patients with a history of recurrent hypoglycaemia Patients with lack of hypoglycaemia awareness Patients with sustained poor glycaemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycaemic coma within the previous 3 months Patients who perform intense physical labour Pregnancy Patients on chronic dialysis Category 2: high-risk group Patients with moderate hyperglycaemia blood glucose levels of 10.0–16.5 mmol/L (180–300 mg/dL) or high HbA1C (> 10%) Patients with renal insufficiency Patients with advanced macrovascular complications People living alone who are treated with insulin or sulphonylureas Patients living alone with comorbid conditions that present additional risk factors old age with ill healt Drugs that may affect cognitive state Hassanein M, et al. Diabetologia 2009;52:367-8 Category 3: moderate risk Well-controlled patients treated with short-acting insulin secretagogues such as repaglinide or nateglinide Category 4: low risk Well-controlled patients treated with diet alone, metformin, or a thiazolidinedione, who are otherwise healthy

25. Case-3 Very High risk Patient should be prohibited from fasting

26. Case-3 Patient insists on fasting! – Strongly insist against fasting – Clearly explain the risks of fasting – Possible complications

27. Case-3 Patient insists on fasting !!! – Ramadan-focused diabetic education Standard diabetic education Monitoring CBG When to break the fast Diet – Medication Adjustments Insulin glargine: – Same Dose – Given at Iftar Actrapid Insulin – Launch dose at Iftar – Reduced Dinner dose at Suhur

28. QUESTIONS?

29. Key Points Pre-Ramadan Medical Assessment (2-3 months ahead) – The passion to fast should be directed to improve diabetes-related targets and reduce the possible complications Individual risk stratification – The risk category for many people could be higher or lower depending on many changes such as an acute illness, pregnancy, a change in type of treatment Review of medication and plan for changes

30. Key Points Ramadan-focused diabetic education – Monitoring CBG – When to break the fast – Diet – Exercise Aim for a safe fasting of your diabetic patient

31. Thank you