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

2. 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

3. 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

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

5. 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

6. Risks associated with FASTING in patients with diabetes
Hypoglycemia
Hyperglycemia
Diabetic ketoacidosis
Dehydration and thrombosis
Diabetes Care, volume 28, NUMBER 9, September 2005

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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

53. 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

54. 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

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

56. 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

57. 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

58. 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