Workshop : Managing DM 2 during Ramadan DR.Obaid Almutairi

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

A large number of Muslim patients with diabetes fast during Ramadan 1 The Pew Forum on Religion & Public Life. (Accessed March 2013); 2 Al-Arouj M et al. Diabetes Care 2010;33:1895–902; 3 Salti I et al. Diabetes Care 2004;27:2306–11; 4 IDF Diabetes Atlas 5 th edition. (Accessed March 2013); 5 Whiting DR et al. Diabetes Res Clin Pract 2011; 94: 311–21; 6 Beshyah SA. Ibnosina J Med Biomed Sci 2009;1:58–60http:// 3 The global prevalence of diabetes is projected to increase in emerging economies, including those with large Muslim populations 4,5 The pattern of daytime fasting and night-time meals and use of anti-diabetic treatment increases the risk of complications, including hypoglycaemia in patients with diabetes 2,3 Although the consensus from religious and medical leaders is that Muslims with diabetes are generally not obliged to fast 6 many choose to do so 2,3 1.6 billion (2010) 2.2 billion (2030) Global Muslim population 1 > 50 million people with diabetes are estimated to fast during Ramadan worldwide 2,3

Fasting is a worldwide custom practiced for religious and cultural reasons 1 4 ReligionExamples of fasting practices 2 – 5 MuslimRamadan: fasting during daylight hours for 29–30 days 2,3 JewishYom Kippur and Tish’ah B’av: single days of fasting 4 HinduismSingle days of fasting 4 ChristianityAsh Wednesday and Good Friday: single days of fasting 4 MormonFasting once a month for a single day 5 Healthy adult Muslims fasting during the month of Ramadan abstain from food, water, or use of oral medications between dawn and sunset for 29–30 days every year 2,3 1 Fasting can range from restricting certain foods to complete abstinence from all food and drink: 1 Fazel M. J R Soc Med 1998;91:260 –63; 2 Al-Arouj M et al. Diabetes Care 2010;33:1895–902; 3 Salti I et al. Diabetes Care 2004;27:2306–11; 4 Green V. Br J Nursing 2004;13:658 –62; 5 Horne BD et al. Am J Cardiol 2008; 102:814 –19.

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

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

EPIDIAR study: fasting during Ramadan increases the risk of severe hypoglycaemia and hyperglycaemia in patients with T2DM 1 Salti I, et al. Diabetes Care 2004;27:2306–11; 2 Al-Arouj M, et al. Diabetes Care 2010;33:1895–902 7 Incidence (events/100 patients/month) 7.5-fold increase* 5-fold increase P< EPIDIAR = EPIdemiology of DIAbetes and Ramadan; T2DM = type 2 diabetes mellitus 11,173 patients with T2DM; 78.7% chose to fast for at least 15 days during Ramadan 1 Higher risk of severe hypoglycaemic events † in overall population during Ramadan ‡1,2 Higher risk of severe hyperglycaemic events † in overall population during Ramadan ‡1,2 Pre-RamadanDuring Ramadan † Events requiring hospitalization in overall population with T2DM; ‡compared with previous months * There was a 7.5 fold difference of hypoglycaemia in overall population fasting during Ramadan. For patients who fasted for > 15 days difference was, 6.7 fold

Recommendations for Management of Diabetes During Ramadan Ramadan Consensus

Conditions associated with “Very High”, “High”, “Moderate” & “Low” risk for adverse events in diabetic patients deciding to fast RAMADAN

13 Female patient aged 47 years Type 2 diabetes diagnosed 4 years ago Poor compliance with diet and exercise regimen Case study 1 Current treatment Metformin, 850 mg twice daily SU once daily BMI29 kg/m 2 Weight82 kg HbA 1c 8.7% FBG9 mmol/L (162 mg/dL)

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 Pre-RAMADAN medical assessment & educational counseling

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 Pre-RAMADAN medical assessment & educational counseling

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 Pre-RAMADAN medical assessment & educational counseling

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 General Considerations

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 General Considerations

c. Nutrition: Healthy and balanced diet Maintain constant body mass Avoid ingesting large amount of carbohydrate and fat (common practice) MANAGEMENT General Considerations

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 General Considerations

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 MANAGEMENT General Considerations

Treatment before RamadanTreatment during Ramadan Oral anti-diabetic agentsEnsure adequate fluid intake BiguanidesMetformin 1 g at sunset meal and 500 mg at predawn meal TZDs, AGIs, or incretin-based therapiesNo change needed Sulphonylureas once a dayDose should be given before sunset meal. Adjust dose based on glycaemic control and hypoglycaemia risk Sulphonylureas twice a dayHalf the usual morning dose at predawn meal and usual dose at sunset meal InsulinEnsure adequate fluid intake Premixed or intermediate-acting insulin twice daily Consider change to long-acting or intermediate insulin in the evening, and short or rapid-acting insulin with meals; take usual dose at sunset meal and half usual dose at predawn meal Considerations for anti-hyperglycaemic treatment for fasting patients with T2DM Al-Arouj M et al. Diabetes Care 2010;33:1895–902 TZD = thiazolidinedione; AGI, alpha-glucosidase inhibitor;T2DM = type 2 diabetes mellitus; SU = sulphonylureas T reatment considerations: The choice of oral anti-diabetic agent should be individualized with consideration to the risk of hypoglycaemia Newer pharmacological agents have lesser hypoglycaemic potential & may have specific advantages during Ramadan Caution is advised when using old Su groups

23 Female patient aged 47 years Type 2 diabetes diagnosed 4 years ago Poor compliance with diet and exercise regimen Case study 1 Current treatment Metformin, 850 mg twice daily SU once daily BMI29 kg/m 2 Weight82 kg HbA 1c 8.7% FBG9 mmol/L (162 mg/dL)

24 Male patient aged 61 years Type 2 diabetes diagnosed 16 years ago Motivated to maintain busy lifestyle Case study 2 Current treatment Long Acting Insulin Analog 32 units/day Metformin 1 g BID BMI31 kg/m 2 Weight88 kg HbA 1c 8.0% FBG5.6 mmol/L (100 mg/dL)

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