1. Medical Management of Diabetes During Ramadan Jennifer Hamilton, MD August, 2007 CE Rajab, 1428 AH

2. Ramadan Holy month in Islam From sunrise to sunset: No food No drinking No smoking

3. Ramadan Holy month in Islam From sunrise to sunset: No food No drinking No smoking And no oral medications Specific exemption in the Qur'an if fasting would be harmful

5. Eating During Ramadan Usually two meals 65% of calories at post-sunset meal! Some studies suggest that calories, carbohydrates drop Increased fried foods

6. Medications during Ramadan Ear, eye drops Transdermals, creams, ointments Suppositories Injections (except IV feeding) Oxygen Sublingual nitroglycerin

7. Warning: limited data Ramadan is never the same Studies may not be generalizable

8. Ramadan: a lunar month 2007: September 13 – October 12 2008: September 1 – September 30 2009: August 21 – September 19 2010: August 11 – September 9 2015: June 18 – July 17

9. Diabetes, Fasting, and Ramadan 2001/1422 Epidemiology of Diabetes and Ramadan (EPIDAR) study in 13 countries 79% of Type II DM fast 43% of Type I DM fast Estimate 40-50 million people with DM observe the Ramadan fast

10. During fasting Glucose, insulin levels fall Glucagon  gluconeogenesis from glycogen Free fatty acids  ketones

11. Risks during fasting Hypoglycemia: hospitalizations increased 4.7 times for Type I (3/100 to 14/100) Increased 7.5 times for Type II (0.4/100 to 3/100) Hyperglycemia No consistent study finding EPIDAR: increase in hospitalization in both types of DM

12. Risks during fasting DKA Dehydration Orthostatic hypotension  syncope, falls Electrolyte abnormalities Thrombosis?

13. M. al-Arouj et al, “Recommendations for management of diabetes during Ramadan,” Diabetes Care, 28(2005), 2305- 2311. Risks during fasting “Most often, the recommendation will be to not undertake fasting. However, patients who insist on fasting need to be aware of the associated risks and be ready to adhere to the recommendations of their health care providers to achieve a safer fasting experience.”

14. Very High Risk Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Acute illness Pregnancy Patients on chronic dialysis Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Hyperosmolar hyperglycemic coma within the previous 3 months Patients who perform intense physical labor

15. High Risk Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mg/dl, A1C 7.5–9.0%) Patients with renal insufficiency Patients living alone Drugs that may affect mentation Patients with advanced macrovascular complications People living alone that are treated with insulin or sulfonylureas Patients with comorbid conditions that present additional risk factors Old age with ill health

16. Better candidates Moderate risk Well-controlled patients treated with short-acting insulin secretagogues such as repaglinide or nateglinide Low risk Well-controlled patients treated with diet alone, metformin, or a thiazolidinedione who are otherwise healthy

17. Type II DM Diet-Controlled Change timing and intensity of exercise to reduce risk of hypoglycemia Eat two or 3 times a night Metformin Low risk of hypoglycemia Change dosing schedule to after sunset meal (2/3) and before dawn meal (1/3)

18. Type II DM Insulin sensitizers/glitazones Low risk of hypoglycemia May not need to change dose Sulfonylureas High risk of hypoglycemia Short-acting insulin secretagogues Reschedule doses

19. Type II and insulin Much higher risk of trouble! Studies are limited! Shorter-acting insulins may be better Lispro at each meal? (Less hypoglycemia than human insulin) Intermediate-acting insulin at sunset meal?

20. Type I Diabetes Just don't do it.

21. Type I Diabetes Just don't do it. Frequent monitoring Break the fast if hypoglycemia or hyperglycemia develop

22. Other concerns Hypertension Drug scheduling & interactions Change to longer-acting medications? (naproxyn vs. ibuprofen) Change to other forms of medication? “empty-stomach” medications Food interactions

23. Before Ramadan Talk with your patients Do they want to attempt the fast? Share concerns

24. Way Before Ramadan Consider talking with an imam at a local mosque How is Ramadan approached by the local congregation?

25. Sources N Aadil, IE Houti, and S Moussamih, “Drug Intake During Ramadan,” BMJ, 329(7469), 2 October 2004, 778-782. M. al-Arouj et al, “Recommendations for management of diabetes during Ramadan,” Diabetes Care, 28(2005), 2305-2311. B.Benaji et al, “Diabetes and Ramadan: Review of the literature,” Diabetes Research and Clinical Practice 73(2006), 117-125.