Transcript here - Medication Management during Ramadan

Medication Management During
Ramadan
Cultural Sensitivity Training for
Pharmacists
Outline
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What is Ramadan?
Physiological/Psychological Impact
Medication management
Pharmacist Opportunities
Patient Cases
Cultural Sensitivity
Cultural Sensitivity
What is Ramadan?
• A month of total abstention food, fluid,
smoking, sexual activity from sunrise to sunset
What is Ramadan?
• Occurs in the 9th month of the lunar Islamic
calendar, for 28-30 days
• Islamic calendar is 354 days, thus it precedes
every year by 10-11 days
Why do Muslims Fast?
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Self-discipline
Self-restraint
Exert control of the mind
Understand the plight of
the less privileged and
appreciate what one has
• Increase good deeds, God-consciousness and purify the
body and soul
• Feelings of anger nullify the benefit of fasting
• Attain spiritual peace
Upon reaching puberty, all healthy
Muslims are required to partake in
the fast
Exemptions
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Children
Elderly
Chronically ill
Traveling*
Acutely ill*
Pregnant*
Breast-feeding*
Menstruating*
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*temporarily exempt and can be made up at a later date
Many Muslims who are
eligible for exemption
choose to fast
nonetheless
Physiological Impact
• No consistent data on the effect on lipid
profiles
• No significant changes in blood pressure or
heart rate
• Possible reduction in oxidative stress
• Possible increase in gastric acidity
• Weight gain/loss is largely dependent on
night-time diet
Psychological Impact
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Decrease in alertness
Increase in lethargy and irritability
Cognitive function decline
Alterations in normal circadian rhythms, with
individuals becoming more active through the
evening and at night, and sleep deprivation
• Effects of tobacco, caffeine and energy and
fluid intake
Medication Management
Life Adjustment
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First meal (large) at sunset (Iftar)
Second (lighter) meal before dawn (Suhur)
2013: July 9th – August 7th
9:00 PM – 4:00 AM
~ 7 hours of eating time/day
Single daily dose – morning or evening
2 or more doses
Medication Management
• Individualize therapy
• Pay attention to drugs with a narrow
therapeutic index
• Switch to long-acting medications
• Pay attention to Drug-Drug Interactions and
Drug-Food interactions
• Encourage extra monitoring
• PLAN AHEAD!
Pre-Ramadan Medical Assessment
• 1-2 months before Ramadan
• Order blood work, examine glycemic control,
blood pressure and lipids
• Offer specific medical advice
• Changes in diet or medication can be made
early, so the patient can initiate fasting on a
stable and effective program
Pharmacist Opportunities
Pharmacist Role
• Encourage maintenance of a healthy diet
• Encourage weaning off of caffeine and
nicotine to avoid withdrawal symptoms
• Opportunities! Quit smoking?
• Discourage fasting during chronic illness,
pregnancy and lactation
Dietary Advice
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Continue to choose healthy foods
Don’t reward yourself! Eat healthy!
Remain hydrated during evening hours
Don’t skip suhur (morning meal)
Consume slow digesting foods (complex
carbohydrates) and high protein foods
• Don’t overeat. Don’t overindulge.
For more information…
Ramadanmanagement.weebly.com
Patient Cases
Real-Life Case
Patient #1
• Type II Diabetes, controlled, A1c = 7.5
• Hypertension
• Hyperlipidemia
Current Medication
• Lantus (Glargine) long acting insulin 33 units ~ 6 pm daily
• Metformin 2 500 mg tabs bid
• Trandalapril 4 mg
• Rosuvastatin 20 mg
• Lifestyle: Moderate physical activity, bike-riding and jogging 3-4x
per week
• How would you change his insulin?
Patient #1
New Regimen:
• Morning (before dawn) take 2 metformin 500 mg
• Evening (break-fast) 9 pm, take all other oral
medications, 2 metformin
• Reduce long-acting insulin to 16 units at sunset meal
• Add 8 units of Novo-rapid (Aspart) at sunset meal
• Continue exercise – start light, increase workout later
• Rationale: Would rather be on higher end than lower.
• “By the time I master it, Ramadan is over”
Diabetes
• EPIDIAR study is the largest collection of data on
type I and type II diabetic patients that fast
• 43% of patients with Type I Diabetes and 78%
with Type II fasted for at least 15 days
• Overall, the number of severe hypoglycemic
episodes per month per patient were significantly
higher during Ramadan compared to the
preceding year (4.7 fold, 7.5 fold increased risk)
• Increased risk of hyperglycemia associated with a
change in diet
Insulin Management
Type II: Maintain basal insulin to prevent fasting
hyperglycemia.
Use intermediate- or long-acting insulin
preparations plus a short-acting insulin
administered before meals
Type I: Once or twice daily injections of
intermediate or long-acting insulin along with
premeal rapid-acting insulin
Patient #2
• 32 year old female patient
• Gabapentin 300 mg TID for epilepsy partial
seizures
• Acetaminophen for headaches
You advise Patient #2 not to partake in fasting.
While she appreciates your advice, she says her
religion is more important and she’s going to do
it anyways. What do you do?
Patient #2
• Be respectful
• Outline the risks clearly
• Offer other alternatives (donating meals,
charity, prayer)
• Recommend she speaks with her religious
guide (Imam)
Seizure frequency
• Gomceli et al studied seizure frequency in
Ramadan
• Out of 114 patients, 38 had seizures and one
of these developed status epilepticus
• Statistically significant increase in frequency
compared to months prior to Ramadan
• Even patients on monotherapy, who did not
change drug regimens, had an increase in
seizure frequency
Offer Respect
• Some patients may refuse your advice and
continue fasting against medical wishes
• Present the risks respectfully and understand that
their spiritual reasoning may be different from
yours
• Fasting is a spiritual issue for which patients make
their own decision after receiving advice from
religious teachings and from health care
providers
• Our role is to provide information and let them
decide
Opportunity to build patient care
Questions?
References
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Leiper JB, Molla AM, Molla AM. Effects on health of fluid restriction during fasting in Ramadan.
Eu J Clin Nutrition 2003 57 31-38
Aslam M, Healy MA. Compliance and drug therapy in fasting Moslem patients. J Clin Hosp Pharm
1986;11:321-5.
Aadil B, Houti IE, Moussamih S. Drug intake during Ramadan. BMJ Volume 329. 2004. 778-782.
Trepanowski JF, Canale RE, Marshall KE et al. Impact of caloric and dietary restriction regimens
on markers of health and longevity in humans and animals: a summary of available findings.
Nutrition Journal 2011, 10: 107
Recommendations for Management of Diabetes During Ramadan. Diabetes Care. 2010 33(8):
1895-1902
Etemadyfar M. Effect of Ramadan on frequency of seizures. Abstract book, Congress on Health
and Ramadan, October 2001. Tehran: Iranian Journal of Endocrinology and Metabolism, 2001: 32.
Mafauzy M, Mohammed WB, Anum MY et al. A study of the fasting diabetic patients during the
month of Ramdan. Med J Malaysia 1990; 45: 14-7.
Dikensoy E, Balat O, Cebesoy B et al. The effect of Ramadan fasting on maternal serum lipids,
cortisol levels and fetal development. Arch Gynecol Obset 2009; 279: 119-23.
Salti I, Benard E, Detournay B, et al. EPIDIAR study group. A population-based Study of Diabetes
and its characteristics during the fasting month of Ramadan in 13 countries: results of the
epidemiology of diabetes and Ramadan 1422/2001(EPIDIAR) study. Diabetes Care 2004;27:230611.