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

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

Mohamed Hassanein, FRCP 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 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 Diabetes Care, volume 28, NUMBER 9, September 2005

Risks associated with FASTING in patients with diabetes Management Conclusions Diabetes Care, volume 28, NUMBER 9, September 2005

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 Hypoglycemia Hyperglycemia Diabetic ketoacidosis Dehydration and thrombosis Diabetes Care, volume 28, NUMBER 9, September 2005

Risks associated with FASTING in patients with diabetes -hypoglycemia 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 Diabetes Care, volume 28, NUMBER 9, September 2005

Risks associated with FASTING in patients with diabetes -hypoglycemia 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 Diabetes Care, volume 28, NUMBER 9, September 2005

Risks associated with FASTING in patients with diabetes -hyperglycemia 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 Diabetes Care, volume 28, NUMBER 9, September 2005

Risks associated with FASTING in patients with diabetes -hyperglycemia 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 Diabetes Care, volume 28, NUMBER 9, September 2005

Risks associated with FASTING in patients with diabetes -hyperglycemia 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 Diabetes Care, volume 28, NUMBER 9, September 2005

Risks associated with FASTING in patients with diabetes –Diabetic Ketoacidosis 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) Diabetes Care, volume 28, NUMBER 9, September 2005

Risks associated with FASTING in patients with diabetes –Dehydration & Thrombosis 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 Diabetes Care, volume 28, NUMBER 9, September 2005

Risks associated with FASTING in patients with diabetes –Dehydration & Thrombosis 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 Diabetes Care, volume 28, NUMBER 9, September 2005

Risks associated with FASTING in patients with diabetes Management Conclusions Diabetes Care, volume 28, NUMBER 9, September 2005

MANAGEMENT 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. Diabetes Care, volume 28, NUMBER 9, September 2005

MANAGEMENT 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 Diabetes Care, volume 28, NUMBER 9, September 2005

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

MANAGEMENT I- General Considerations Individualization 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 I- General Considerations 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) Diabetes Care, volume 28, NUMBER 9, September 2005

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

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

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

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

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

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

MANAGEMENT III- Management of patients with type 1 diabetes 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. Diabetes Care, volume 28, NUMBER 9, September 2005

MANAGEMENT III- Management of patients with type 1 diabetes There is an increased risk of hypoglycemia around midday due to peaking of the early morning insulin dose 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. Diabetes Care, volume 28, NUMBER 9, September 2005

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

MANAGEMENT IV- Management of patients with type 2 diabetes 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 Diabetes Care, volume 28, NUMBER 9, September 2005

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

Metformin alone: safer because of the minimal risk of hypoglycemia MANAGEMENT IV- Management of patients with type 2 diabetes Patients treated with oral agents 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 Diabetes Care, volume 28, NUMBER 9, September 2005

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

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

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

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

MANAGEMENT IV- Management of patients with type 2 diabetes Patients treated with insulin 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. Diabetes Care, volume 28, NUMBER 9, September 2005

Special risk of hypoglycemia MANAGEMENT IV- Management of patients with type 2 diabetes Patients treated with insulin 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 Diabetes Care, volume 28, NUMBER 9, September 2005

As long as the dose/injection is properly individualized MANAGEMENT IV- Management of patients with type 2 diabetes Patients treated with insulin 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 Diabetes Care, volume 28, NUMBER 9, September 2005

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

Many will need additional dose of short-acting insulin at predawn MANAGEMENT IV- Management of patients with type 2 diabetes Patients treated with insulin 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 Diabetes Care, volume 28, NUMBER 9, September 2005

MANAGEMENT IV- Management of patients with type 2 diabetes Patients treated with insulin 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 Diabetes Care, volume 28, NUMBER 9, September 2005

MANAGEMENT IV- Pregnancy and fasting during RAMADAN Pregnancy is a state of increased insulin resistance and insulin secretion and of reduced hepatic insulin extraction Elevated BG & HbA1c 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) Diabetes Care, volume 28, NUMBER 9, September 2005

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

MANAGEMENT IV- Pregnancy and fasting during RAMADAN 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 Diabetes Care, volume 28, NUMBER 9, September 2005

MANAGEMENT IV- Pregnancy and fasting during RAMADAN 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 Diabetes Care, volume 28, NUMBER 9, September 2005

MANAGEMENT V- Hypertension and dyslipidemia 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 Diabetes Care, volume 28, NUMBER 9, September 2005

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

Risks associated with FASTING in patients with diabetes Management Conclusions Diabetes Care, volume 28, NUMBER 9, September 2005

Conclusion(s) 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 Diabetes Care, volume 28, NUMBER 9, September 2005

Conclusion(s) 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 Diabetes Care, volume 28, NUMBER 9, September 2005

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