Transcript Management of DM in Ramadan Fasting Month

Management of Diabetes Mellitus
in Ramadan Fasting Month
Pradana Soewondo
Division of Endocrine and
Metabolism, Department of Internal
Medicine, Medical Faculty, University
of Indonesia
Surah Al-Baqarah: 183-184
• …..Observing As-Saum (the fasting) is
prescribed for you as it was prescribed
for those before you, ….
• ….., but if any of you is ill or on a
journey, …… And as for those who can
fast with difficulty, (e.g. elderly,
etc),…….
PHYLOSOPHY OF FASTING
• During Ramadan, Muslims must fast
from dawn to sunset.
• Food and fluids may be consumed
freely during the night, but forbidden
during day time, including oral and
parenteral medication.
• This will involve a sudden and major
change in the daily meals.
• This include meal timing, total calories,
food type and consistency.
• Prior to the month of Ramadan, people
usually take 3 major meals (breakfast,
lunch, dinner/supper)
• This will change to only two meal
named Iftar and Sahur. Iftar will be
around 6:00 pm and Sahur will be
around 3:00 am.
Things Happened During Ramadan
• Eating habits change in many ways, not only
do mealtimes change, but patterns of meals,
the short of food eaten and caloric intake all
change in a stereotyped way.
• Increased in post prandial physical activity
during the nighttimes associated with Tarawih.
• Psychological changes due to the general
spiritual atmosphere during Ramadan, which
create a feeling of inner well-being
Physiological State of Healthy Individuals
During Ramadan (Kuwait study) (1)
• Body weight decrease transiently during the
first half of Ramadan, but recovered by the
end.
• Respiratory and cardiovascular parameters
during exercise were perturbed.
• Plasma osmolarity and protein concentration
were increased during Ramadan, maybe an
indication of dehydration.
Physiological State of Healthy Individuals
During Ramadan (2)
• Increases in acid and pepsin secretion
were noted with no changes in plasma
gastrin, mucogastrin, or the duodenogastric reflex. (Moroccan study)
• Decrease in fasting plasma glucose
and insulin. Increase in plasma
proteins. Lipid parameters were not
altered. (Tunisian study)
Impact of Fasting in Diabetics During
Ramadan
• Blood glucose levels  triggered homeostatic
mechanism to prevent hypoglycemia. But in
diabetics, this mechanism can be disrupted, and
also perturbed by medication.
• Risk of hypoglycemia during daytime and
hyperglycemia following Iftar are 6 % and 3 %
respectively.
• Changes in timing medication are important.
Impact of Fasting in Diabetics During
Ramadan
• If a proper medication regimen is
followed, stable and uncomplicated
patients on OHA should be able to fast
without problems.
• Patients taking single dose insulin or
combination therapy may be able to fast
but needs to be evaluated on an
individual basis.
Impact of Fasting in Diabetics During
Ramadan
• In the fasting state, individual depends
totally on endogenous substrates for
energy.
• Fasting subject is considered in a state of
catabolism since his source of energy are
all decreasing.
• The liver supplies glucose by
glycogenolysis.
Impact of Fasting in Diabetics During
Ramadan
• Glucose oxidation in liver and muscles
is spared as soon as increased
quantities of FFA becomes available.
• A balance is reached at a plasma
glucose level sufficient to ensure
adequate brain function and at insulin
and glucagon levels sufficient to prevent
excessive depletion of previously stored
nutrients.
Effect on Diabetic Controlled During
Ramadan Fasting
• Observational study
• N=60 (30 males and 30 females)
• Well controlled type 2 diabetics treated with
OHA (PPG < 200 mg%)
• Mean body weight
0,75 Kg
• Mean Post Prandial Glucose
9,32 mg%
• No correlation from both parameters.
Askandar T etal, Kopapdi V,1978.
Effect of Ramadan Fasting on Well
Controlled Diabetic Patients
• Observational study
• Well controlled diabetics with out severe
complication
• N=55; 49 on diet and 6 on diet +OHA
• No Changes in BW, BG and lipid profile
• There is no negative effects of fasting during
Ramadan, as long as they followed the
instructions.
Manaf A. etal, Kopapdi V, 1981
Blood Glucose Responses Of Diabetics
During the Fasting Month Ramadan
•
•
•
•
Observational study
N=22; controlled diabetic
Diet and medication were maintain
Blood glucose levels from 8 to 11 am at the
first and last week of fasting month, but not
from 11 am to 6 pm.
• Hypoglycemia should be anticipated when
good controlled diabetics are going to fast.
Soegondo S etal, AOCE
• Observational study
• N=41 type 2 diabetics (9 on diet, 12 on single OHA,
and 20 on combined OHA)
• Number of symptomatic hypoglycemic periods,
which were not biochemically verified, increased in
eight of patients (19,5%) during Ramadan. None of
the patients, however, experienced severe
hypoglycemia or neuroglycopenic symptoms
Ali Riza etal, Univ of Ankara
In conclusion:
• type 2 diabetic is not a contraindication to fasting
in Ramadan
• Patients on single or combination OHA could
observe Ramadan fasting with appropriate
instruction about meals and OHA use.
• However some patients may still experience an
increased number of hypoglycemic episodes
Ali Riza etal, Univ of Ankara
Treatment regimen and HbA1C level in 8 type 2
Diabetics, whose Hypoglycemic Events Were More
Frequent During Ramadan Fasting
Hypoglycemic events
Patient
number
before during
1
2
3
4
5
6
7
8
1
1
1
1
1
1
1
1
Treatment
regimen
2
4
4
3
3
9
3
8
AC=acarbose; MF=metformin
Diet only
Gliclazide
Gliclazide
Glybornuride
Gliclazide, MF
Glybori,MF
Glyburi,MF,AC
Glipizide, MF,AC
HbA1c level (%)
before
after
after
3 weeks 8 weeks
6.6
7.5
7.6
7.6
5.6
7.5
8.2
9.5
6.7
7.3
7.2
7.3
5.8
7.6
8.6
9.6
6.6
7.2
7.4
7.3
5.9
7.5
8.7
9.2
An Observational Survey of the Impact of
Ramadan fasting on Diabetes
• N=22; carried out in Malaysia.
• No evidence of hypoglycemia was obtained.
• Total caloric and carbohydrate intake both
during Ramadan compared with Shaban,
although the proportion of simple
carbohydrate consumed from 8,4% to 14%
• No changes in FBG or cholesterol level.
• But fructosamine level from 6.6 to 4.3 mM.
Mafauzy et al., 1990
Muslims with NIDDM Fasting During Ramadan:
Treatment with Glibenclamide
• Setting of study university hospital, private
hospital, private clinic in Casablanca and
Rabat, Morocco
• n = 591 diabetic patients (198 men, 391
women and two unspecified) with similar
duration of illness, length and amount of
glibenclamide treatment.
• To compare the efficacy of two glibenclamide
regimen in NIDDM who were fasting and
regular dose in non fasting group.
Belkhadir et al., 1993
• Non randomized non fasting control
group >< two groups of patients who
fasted randomized equally two one of
two regimen
• Take their usual morning dose of
glibenclamide in the evening and their
usual evening dose before dawn; or to
follow this pattern but to reduce the total
dose by a quarter.
Characteristics of Patients on Admission to
Study, Value are Means (standard deviations)
unless Stated Otherwise
Groups of patients*
Full dose
Reduced dose
Control of glibenclamideof glibenclamide
(n = 199)
(n = 198)
(n = 194)
p Value
56
No of men
137
No of women
Age (years)†
57.2 (9.0)
Weight (kg)‡
64.9 (11.3)
2
Body mass index (kg/m ) ‡
25.9 (3.9)
Duration of diabetes (years)§
8.53 (6.2)
Usual daily dose of glibenclamide
11.7 (3.5)
(mg)ll
383 (84)
Serum concentration of
fructosamine (mol)§
14.2 (3.3)
Glycated hemoglobin (%)§
75
123
54.9 (9.3)
68.6 (10.3)
26.7 (3.8)
7.03 (5.5)
10.7 (3.1)
366 (85)
67
131
54.8 (9.7)
67.9 (11.4)
26.7 (4.2)
7.05 (5.35)
10.7 (3.5)
352 (82)
NS
0.18
0.02
0.01
0.06
0.02
0.02
0.01
13.7 (3.4)
13.2 (3.6)
0.01
Data missing for † 10 cases, ‡ 4 cases, § 13 cases, and II 30 cases
Characteristics of the 542 Who Completed the
Study at The End of Ramadan. Figures are
Means (standard deviations)
Groups of patients*
Full dose
Reduced dose
of
of
Control glibenclamide glibenclamide
(n = 183)
(n = 177)
(n = 182)
Fructosamine concentration
(µmol/l):
At start of Ramadan
At end of Ramadan
Glycated hemoglobin (%):
At start of Ramadan
At end of Ramadan
Body weight (kg)
At start of Ramadan
At end of Ramadan
396 (91)
400 (102)
367 (80)
381 (96)
359 (82)
376 (98)
14.3 (3.6)
14.7 (3.2)
13.6 (3.5)
14.0 (2.9)
13.2 (3.6)
13.6 (3.2)
65.2 (11.4)
65.7 (11.4)
68.2 (10.0)
69.2 (10.0)
68.2 (82)
68.7 (10.8)
Number of Hypoglycemia Events (number of
affected patients) Reported During Study
Groups of patients*
During
run in
Control
16 (15)
11 (9)
8 (6)
35 (30)
Full dose of glibenclamide
19 (13)
14 (10)
16 (12)
49 (35)
Reduced dose of
18 (15)
10 (9)
8 (6)
36 (30)
glibenclamide
During
During
Ramadan follow up
Total
Result
At the end of Ramadan there were no
significant differences between the groups in
fructosamine concentration, HbA1c and
number of hypoglycemic event.
Conclusion
Glibenclamide is effective and safe for patients
with non-insulin dependent diabetes who fast
during Ramadan. The easiest regimen is
taking the normal morning dose at sunset and
any evening dose before dawn
HYPOGLYCAEMIC EVENT AMONG TYPE 2 DIABETICS ON
GLIMEPIRIDE AND OTHER SULFONILUREAS DURING RAMADHAN
OBJECTIVE
•To observe the occurrence of hypoglycaemic event on type 2
Diabetics on glimipiride and other sulfonilureas during fasting
month
•To describe the nutrition intake and metabolic changes on type 2
diabetic who were fasting during Ramadhan month
METHOD
•Hospital based, observational study, enrolliring controlled type 2
diabetics who want to fast Ramadhan
•23 controlled type 2 diabetics who was treated with single
dose sulfonilurea were enrolled
Soewondo P et al. RSCM, Jakarta 1999.
RESULTS
23 type 2 DM
2 drop out
21 completed the study
12 on glimepiride
9 other Sulfonilurea
(glibenclamide, glicazide,
gliquidone, glipizide)
mg/dl
Average Blood Glucose Level before dawn in Type 2
Diabetic Patients During Ramadan Fasting Month
138
134
130
126
122
118
114
110
106
102
98
94
90
132
128
125
126
126
119
111
105
I
III
II
IV
Week
Glimepirid
other Sulfonilurea
Average Blood Glucose Level before break
In Type 2 Diabetic Patients During Ramadan Fasting Month
110
106
104
105
104
mg/dl
100
100
98
100
96
96
95
90
I
II
III
Week
IV
Glimepirid
Other Sulfonilurea
Average Energy Intake in Type 2 Diabetic patients
during Ramadan Fasting Month
1700,00
1600,00
Energy(cal)
1500,00
1400,00
1300,00
1200,00
1100,00
1000,00
1
2
3
Visit
4
5
6
Subject Characteristics
Victim Group
Glimepiride
(n=12)
Other Sulfonilureas
(n=9)
P
Men
2
4
Women
10
5
0.331
Old (year)
49.8 (+ 13.4)
58.1 (+ 8.4)
0.121
Lama DM (month)
33.9 (+ 34.2)
74.2 (+ 45.0)
0.048
Fasting Glucose (mg/dl) 124.0 (+ 30.7)
129.8 (+ 21.9)
0.637
Post Prandial
185.8 (+ 68.9)
183.0 (+ 45.4)
0.644
HbA1c (%)
7.4 (+1.3)
7.8 (+1.3)
0.470
IMT (kg/m2)
23.3
23.6
Dose (mg)
2.6 (+1.3)
Glibenklamid 4 (+1.4)
Gliklazide
80
Glipisid
5
Glikuidon
22.5 (+ 10.6)
Body Mass Index and HbA1c Level in Type 2 Diabetic Patient
Before and After Ramadan Fasting Month
Group
Glimepiride
Other Sulfonilurea
BMI (kg/m2)
Before
After
HbA1c (%)
Before
After
23.3
23.2
23.6
23.2
7.4 (+1.3)
7.2 (+1.2)
7.8 (+1.3)
7.3 (+1.7)
Lipid profile and kidney function in Type 2 Diabetic
Patient Before and After Ramadan Fasting Month
Parameter \ Group
Total cholesterol (mg/dl)
Before
After
HDL Cholesterol (mg/dl)
Before
After
LDL Cholesterol (mg/dl)
Before
After
Triglycerida (mg/dl)
Before
After
Ureum (mg/dl)
Before
After
Creatinine (mg/dl)
Before
After
Glimepiride
Other Sulfonilurea
214 (+36)
218 (+38)
230 (+70)
225 (+53)
56 (+6)
56 (+6)
48 (+8)
51 (+8)
115 (+61)
133 (+37)
141 (+50)
141 (+46)
213 (+24)
146 (+45)
205 (+14)
166 (+49)
32 (+4)
52 (+66)
37 (+10)
41 (+24)
0.9 (+0.2)
0.8 (+0.2)
1.1 (+0.5)
1.3 (+1.1)
CONCLUSION
 There was no hypoglycemic event were
reported in both groups in this study
 Changes in caloric and nutrient intake
were noted and should be considered for
diet consultation as well as treatment
adjustment
Recommendations on The Management
of Diabetes During Ramadan
• Put forward at a Consensus Meeting held in
Casablanca, Morocco in 1995
• These covered:
– criteria allowing for or exempting from fasting and
recommendations for monitoring.
– Other topic covered included community
education programmers, treatment regimens
– methodology and content for the future research
programs
CURRENT RECOMENDATIONS
• Permitted to fasting :
NIDDM patients treated with biguanides or
sulphonyureas, who are stable and do not
have any complicating progressive co morbid
pathology.
• Exempted from fasting :
IDDM, unstable disease, co-morbid
degenerative disease, pregnancy, elderly.
CURRENT RECOMENDATIONS
• Monitoring was recommended before,
during and after Ramadan, include diabetic
symptoms and glucose control, psychological state and co morbidity.
• Education programs directed at patients and
their families. should focus on condition in
which fasting is contraindicated, modifying
the regimen, dietary considerations, and the
importance of monitoring.
HOW TO IMPROVE THE MANAGEMENT
1. Guidelines
The existence of clear guidelines on the
management of diabetes during Ramadan
are indispensable in ensuring safe and
rewarding fasting in patients treated in
primary care away from specialist clinic.
2. Education Programs
3. Research
Contraindications
•
•
•
•
Four contraindications in which patient
should be exempted from fasting :
Patients treated with insulin (NIDDM or
IDDM)
Brittle and decompensated diabetes
(history of episodes of DKA or NKHO)
Pregnancy
Patients with potentially life-threatening
acute complications
Lifestyle
• Ramadan provides and excellent
opportunity to initiate healthy lifestyle
changes.
• Motivation for self improvement is high at
this time of year, the switch in eating
pattern breaks previous habits, and weight
lose goals
• Meals time should be fixed, with the
principal meal in the evening, and the
lesser meal before sunrise.
Lifestyle
• Patient should be encouraged to eat a
proper.
• Eating snacks between two meals
should be avoided
• Ensure that an appropriate level of
physical activity is maintained, whether
formal exercise programs or associated
with fulfilling religious obligations.
MEDICATION
• In principle, any efficacious medication
upon which patients is stabilized can be
used during Ramadan.
• An abrupt change in the nature of
medication given should be avoided.
• Medications regimen during Ramadan
need to be modified in timing and
possibly dose, and should be tailored for
each individual patient.
Monitoring
• Important to be done to ensure
adequate blood sugar control in spite of
changes in eating habits and treatment
protocols.