Transcript Slide 1

Recommendations for Management of
Diabetes During Ramadan
Diabetes Care, volume 28, NUMBER 9, September 2005
‫بسم هللا 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 هللا بكم‬
‫اليسر وال يريد بكم العسر ولتكملوا العدة ولتكبروا هللا على ما هداكم ولعلكم تشكرون‬
‫سورة ألبقرة ‪ -‬آية ‪۱۸٥‬‬
MONIRA AL-AROUJ, MD
OUSSAMA KHATIB, MD, PHD
RADHIA BOUGERRA, MD
SOUHAIL KISHAWI, MD
JOHN BUSE, MD, PHD
ABDULRAZZAQ ALMADANI, MD
SHERIF HAFEZ, MD, FACP
ALY A. MISHAL, MD, FACP
MOHAMED HASSANEIN, FRCP
MASOUD AL-MASKARI, MD, PHD
MAHMOUD ASHRAF IBRAHIM, MD
ABDALLA BE NAKHI, MD
FARAMARZ ISMAIL-BEIGI, MD, PHD
KHALED AL-RUBEAN, MD
IMAD EL-KEBBI, MD
Diabetes Care, volume 28, NUMBER 9, September 2005
I.
Risks associated with FASTING in
patients with diabetes
II.
Management
III. 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
1. Hypoglycemia
2. Hyperglycemia
3. Diabetic ketoacidosis
4. 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
I.
Risks associated with FASTING in
patients with diabetes
II.
Management
III. 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
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
Diabetes Care, volume 28, NUMBER 9, September 2005
MANAGEMENT
I- General Considerations
c. 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
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
Diabetes Care, volume 28, NUMBER 9, September 2005
MANAGEMENT
I- 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
•
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
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
Diabetes Care, volume 28, NUMBER 9, September 2005
MANAGEMENT
II- Pre-RAMADAN medical assessment & educational
counseling
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
Diabetes Care, volume 28, NUMBER 9, September 2005
MANAGEMENT
II- Pre-RAMADAN medical assessment & educational
counseling
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
Diabetes Care, volume 28, NUMBER 9, September 2005
MANAGEMENT
II- Pre-RAMADAN medical assessment & educational
counseling
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
Diabetes Care, volume 28, NUMBER 9, September 2005
MANAGEMENT
II- Pre-RAMADAN medical assessment & educational
counseling
b. 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
a. 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
b. Close monitoring and frequent insulin dose
adjustments are essential to achieve optimal
glycemic control and avoid hypo- hyperglycemia
c. 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
d. 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 shortacting 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
e. There is an increased risk of hypoglycemia
around midday due to peaking of the early
morning insulin dose
f. 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
g. Other options:
•
Glargine once daily or
•
Detemir twice daily
•
Along with premeal rapid-acting insulin
analogs
h. 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
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
MANAGEMENT
IV- Management of patients with type 2 diabetes
Patients treated with oral agents
a. 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
MANAGEMENT
IV- Management of patients with type 2 diabetes
Patients treated with oral agents
b. 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
MANAGEMENT
IV- Management of patients with type 2 diabetes
Patients treated with oral agents
c. Sulfonylureas:
 Use should be individualized and utilized
with caution
 Chlorpropamide is absolutely contraindicated 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
c. 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
MANAGEMENT
IV- Management of patients with type 2 diabetes
Patients treated with oral agents
d. 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 nearphysiologic levels during the fasting period.
Diabetes Care, volume 28, NUMBER 9, September 2005
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
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
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
I.
Risks associated with FASTING in
patients with diabetes
II.
Management
III. 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 preRamadan 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