Transcript Document

Workshop :
Managing DM 2
during Ramadan
DR.Obaid Almutairi
‫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 آية‬‫سورة ألبقرة ‪۱۸٥‬‬
A large number of Muslim patients with diabetes fast during Ramadan
Global Muslim population1
1.6 billion
2.2 billion
(2010)
(2030)
> 50 million people with diabetes are estimated to fast during
Ramadan worldwide2,3
• The global prevalence of diabetes is projected to increase in emerging economies, including those with
large Muslim populations4,5
• 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 diabetes2,3
• Although the consensus from religious and medical leaders is that Muslims with diabetes are generally
not obliged to fast6 many choose to do so2,3
1The
Pew Forum on Religion & Public Life. http://www.pewforum.org/The-Future-of-the-Global-Muslim-Population.aspx (Accessed March 2013); 2Al-Arouj M et al.
Diabetes Care 2010;33:1895–902; 3Salti I et al. Diabetes Care 2004;27:2306–11; 4IDF Diabetes Atlas 5th edition. www.idf.org/diabetesatlas/5e/the-global-burden
(Accessed March 2013); 5Whiting DR et al. Diabetes Res Clin Pract 2011; 94: 311–21; 6Beshyah SA. Ibnosina J Med Biomed Sci 2009;1:58–60
3
Fasting is a worldwide custom practiced for religious and cultural reasons1
Religion
Examples of fasting practices2–5
Muslim
Ramadan: fasting during daylight hours for 29–30 days2,3
Jewish
Yom Kippur and Tish’ah B’av: single days of fasting4
Hinduism
Single days of fasting4
Christianity
Ash Wednesday and Good Friday: single days of fasting4
Mormon
Fasting once a month for a single day5
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 year2,3
1Fasting
can range from restricting certain foods to complete abstinence from all food and drink: 1Fazel M . J R Soc Med 1998;91:260–63;
M et al. Diabetes Care 2010;33:1895–902; 3Salti I et al. Diabetes Care 2004;27:2306–11; 4Green V. Br J Nursing 2004;13:658–62; 5Horne BD et al. Am J Cardiol
2008; 102:814–19.
4
2Al-Arouj
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
EPIDIAR study: fasting during Ramadan increases the risk of severe
hypoglycaemia and hyperglycaemia in patients with T2DM
11,173 patients with T2DM;
78.7% chose to fast for at least 15 days during Ramadan1
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
Incidence
(events/100 patients/month)
P<0.0001
P<0.0001
4
6
7.5-fold increase*
3
3
5
4
2
1
3
2
0.4
1
1
0
0
Pre-Ramadan
†Events
5
5-fold increase
During Ramadan
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
EPIDIAR 7
= EPIdemiology of DIAbetes and Ramadan; T2DM = type 2 diabetes mellitus
1Salti I, et al. Diabetes Care 2004;27:2306–11; 2Al-Arouj M, et al. Diabetes Care 2010;33:1895–902
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
Case study 1
• Female patient aged 47 years
• Type 2 diabetes diagnosed 4 years ago
• Poor compliance with diet and exercise regimen
BMI
29 kg/m2
Weight
82 kg
HbA1c
8.7%
FBG
9 mmol/L (162 mg/dL)
Current treatment
Metformin, 850 mg twice daily
SU once daily
MANAGEMENT
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
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
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
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
MANAGEMENT
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
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
d. Exercise:
General Considerations
•
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
Considerations for anti-hyperglycaemic treatment for fasting
patients with T2DM
Treatment before Ramadan
Treatment during Ramadan
Oral anti-diabetic agents
Ensure adequate fluid intake
Biguanides
Metformin 1 g at sunset meal and 500 mg at predawn meal
TZDs, AGIs, or incretin-based therapies
No change needed
Sulphonylureas once a day
Dose should be given before sunset meal. Adjust dose based on glycaemic
control and hypoglycaemia risk
Sulphonylureas twice a day
Half the usual morning dose at predawn meal and usual dose at sunset
meal
Insulin
Ensure 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
Treatment 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
TZD = thiazolidinedione; AGI, alpha-glucosidase inhibitor;T2DM = type 2 diabetes mellitus; SU = sulphonylureas
Al-Arouj M et al. Diabetes Care 2010;33:1895–902
Case study 1
• Female patient aged 47 years
• Type 2 diabetes diagnosed 4 years ago
• Poor compliance with diet and exercise regimen
BMI
29 kg/m2
Weight
82 kg
HbA1c
8.7%
FBG
9 mmol/L (162 mg/dL)
Current treatment
Metformin, 850 mg twice daily
SU once daily
Case study 2
• Male patient aged 61 years
• Type 2 diabetes diagnosed 16 years ago
• Motivated to maintain busy lifestyle
BMI
31 kg/m2
Weight
88 kg
HbA1c
8.0%
FBG
5.6 mmol/L (100 mg/dL)
Current treatment
Long Acting Insulin Analog 32 units/day
Metformin 1 g BID
24
Thank
You