MANAGEMENT DIABETES IN RAMADHAN

DR HARMY MOHAMED YUSOFF DEPARTMENT OF FAMILY MEDICINE USM

DO THEY NEED TO FAST?

ARE THEY SAFE TO FAST?

EXEMPTION FROM FASTING

Puasa yang diwajibkan itu) beberapa hari tertentu. Sesiapa antara kamu sakit atau musafir (haruslah berbuka) dan wajib digantikannya pada hari-hari yang lain. . Orang yang tidak berdaya berpuasa , wajib membayar fidyah, iaitu memberi makan kepada orang miskin. Sesiapa yang bersukarela melakukan kebajikan (membayar fidyah lebih daripada yang ditentukan) maka itu lebih baik baginya , dan jika kamu berpuasa adalah lebih baik bagi kamu jika kamu mengetahui.
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EXEMPTIONS
1. TRAVELLERS 2. SICK PERSON 3. PEOPLE WHO ARE TOO WEAK
Elderly who are too weak, terminally ill patient

4. PREGNANT WOMEN 5. BREAST FEEDING MOTHER

DEFINITION OF ILL
1. Sickness which cause extreme troublesome
Increase complication Getting worst Delay healing

( Dr Wahbah Al Zuhaily)

DIABETES PATIENTS

PHYSICIAN

ISLAMIC TEACHING

Epidemiology Of Diabetic And Ramadhan (EDPIDIAR) Study

13 countries 12 243 people with DM
i. Type 2 DM-11 173 patients (86.5 %) Mean age -4 years Duration of illness 7.6 years ii. Type 1 DM-1070 patients (8.3%) Mean age 31 year Duration 10 years iii. DM unclassified 671 patients (5.2%)
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43 % Type 1 and 79 % Type 2 DM fasting more than 15 days

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ISSUES?
REALITY-Many diabetic patient are insisting on fasting EPIDIAR (Fasting more than 15 days) - 43 % of type 1 -79 % type 2 What are the potential risks? What sort of modification? Limited Information No Guidelines No big/good study on this issue
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CHO METABOLISME

ENERGY STORAGE

Low Blood Glucose

Pancreas

Muscle

glucagon

Glycogen

Proteins Broken Down

Adipose Cells

Glucose released

Glycerol, fatty acids released

COMPLICATIONS OF DIABETES
Lack of insulin HYPOGLICEMIA

Excessive gluconeogenesis

HYPERGLYCEMIA
impaired

lipolysis DEHYDRATION

Hyperglycemia ketosis

THROMBOSIS

POSSIBLE COMPLICATIONS
1. Hypoglycemia (4.7 fold in Type 1 and 7.4 fold in type 2)
1. Decreased meal 2. Changes of life style/medication 3. Same amount of insulin secretion

2. Hyperglycemia ( 3 fold in Type 1 and 5 fold in Type 2) 3. Diabetic ketoacidosis

1. Grossly hyperglycemia before ramadhan

4. Dehydration and thrombosis

1. 2. 3. 4. Hot and humid climate Hyperglycemia Hypercoagulable state Increase retinal vein occlusion among fasted patient during Ramadhan (Saudi) (EPIDIAR study)

COMPLICATIONS
Severe Hyperglycemia (hospitalization) Type 2- 5X increase Type 1- 3X increase Reasons? Excessive reduction of medication/poor compliance Poor base-line glycemic control
15 Type 1 DM 3-14 events /100/month ( 4.5 X) Type 2 DM 0.4-3 events/100 person/month (7X)

Pre Ramadhan Assessment and Structured Education

1-2 months prior to Ramadhan Medical assessment
Overall patient condition Disease control, drug modification, concomitant illness etc Specific education Changes in regime should be done while patients in relatively good control start with puasa sunat.

Pre Ramadhan Assessment and Structured Education

Educational counselling
Self-care
Sign and sympmtoms of hyper/hypoglycemia, diet, physical activities, HBGM, hydration, dealing with acute complication etc

RISK STARTIFICATION
LOW RISK 1. Well-controlled patients treated with lifestlye therapy alone, metformin, or a thiazolidinedione and /ot incretin based who are otherwise healthy(Hb A1c < 8.0)

RISK STARTIFICATION
MODERATE RISK Well-controlled patients treated with shortacting insulin secretagogues such as repaglinide or nateglinide

RISK STARTIFICATION
HIGH RISK 1. Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mg/dl, A1C 7.59.0%) 2. Patients with renal insufficiency 3. Patients with advanced macrovascular complications 4. People living alone that are treated with insulin or sulfonylureas 5. Patients with comorbid conditions that present additional risk factors 6. Old age with ill health 7. Drugs that may affect mentation

RISK STARTIFICATION
VERY HIGH RISK 1. Severe hypoglycemia within the last 3 months prior to Ramadan 2. Patient with a history of recurrent hypoglycemia 3. Patients with hypoglycemia unawareness 4. Patients with sustained poor glycemic control 5. Ketoacidosis within the last 3 months prior to Ramadan 6. Type 1 diabetes 7. Hyperosmolar hyperglycemic coma within the previous 3 months 8. Acute illness 9. Pregnancy 10. Patients who perform intense physical labor 11. Patients on chronic dialysis

RAMADHAN 3D TRIANGLE
DRUG REGIME

DIET
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PHYSICAL ACTIVITY

GENERAL MANAGEMENT
1. Individualization
Care must be highly individualized Baseline control Compliance Concomitant illness Type 1 Type 2 on insulin Healthy and balanced diet Increase complex CHO No weight reduction diet

2. Frequent monitoring of glycemia 3. Nutrition

GENERAL MANAGEMENT
Exercise Maintain normal levels of exercise Avoid excessive physical activity in a day Tarawaih is part of the exercise- 200kcal

COMPLEX CHO

FOOD THAT ALWAYS BEEN SERVED

RAMADHAN BUFFET

FOODS OF CHOICE

DM TYPE 2
Pt with diet alone
Adequate fluid intake Risk of hypoglycemia is very low Post-prandial hyperglycemia Delay the exercise approximately 2 H before sunset

DM TYPE 2
Metformin
Generally is safe Modify timing Two third of daily requirement taken immediately before sunset meal (during ifftar) One third before predawn Metformin SR taken as usual but switch morning to evening dose if morning dose is higher Metformin XL no changes

DM TYPE 2
Sulfonylurea
Increased risk of hypoglycemia Individualized Gliazide MR/Glimeperide more effective and less hypoglycemia Short acting insulin secretagogues (Repaglinide/Metaglinide) Less hypoglycemia , bd dosing

Glibencalmide?
No study looking on the safety

Before Ramadan Patients on diet and exercise control Patients on oral hypoglycemic agents

During Ramadan No change needed (modify time and intensity of exercise), ensure adequate fluid intake Ensure adequate fluid intake

Biguanide, metformin 500 mg three times a day, or sustained release metformin (glucophage R) Divided 2/3 dose during ifftar and 1/3 during sahur TZDs, pioglitazone or rosiglitazone once daily

Metformin, 1,000 mg at the sunset meal (Iftar), 500 mg at the predawn meal (Suhur)

No change needed

Sulfonylureas once a day, e.g., glimepiride 4 mg daily, gliclazide MR 60 mg daily

Dose should be given before the sunset meal (Iftar); adjust the dose based on the glycemic control and the risk of hypoglycemia

Sulfonylureas twice a day, e.g., glibenclamide 5 mg or gliclazide 80 mg, twice a day (morning and evening)

Use half the usual morning dose at the predawn meal (Suhur) and the full dose at the sunset meal (Iftar), e.g., glibenclamide 2.5 mg or gliclazide 40 mg in the morning, glibenclamide 5 mg or gliclazide 80 mg in evening

DM TYPE 2
Pre mixed Insulin Humalog 25 (25% lispro: 75 % intermediate neutral lispro) Humalin 30 (30% soluble insulin: 70% isophane)
Morning dose------iftar Evening dose-------sahur

In good control patient reduction of 20-30% morning dose) If poor post prandial, change to Humalog 50.

Before Ramadan
Patients on insulin

During Ramadan
Ensure adequate fluid intake

70/30 premixed insulin twice daily, e.g., 30 units in morning and 20 units in evening

Use the usual morning dose at the sunset meal (Iftar) and half the usual evening dose at predawn (Suhur), e.g., 70/30 premixed insulin, 30 units in evening and 10 units in morning; a lso consider changing to glargine or detemir plus lispro or aspart (rapid acting) Combination of pre mix 50;50

Long acting analogue (Glargine , determir) Use ultra rapid as a basal plus lispro or aspart

Reduce basal insulin 20%

OTHER CONSIDERATION
INSULIN Maintain necessary level of basal insulin Judicious Use intermediate/long acting/peakless Insulin glargine single dose or NPH, lente or detemir bd before meal sunset/predawn Short acting before meal Skipp midday dose

Risk of hypoglycemia, chronic insulin use and elderly

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Approach to oral treatment of type 2 diabetes for patient planning to fast

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BREAKING THE FAST

Avoid fasting on the sick day/poor appetite All patients must always and immediately end their fast if
Hypoglycemia (BG < 3.5 mmol/l) Blood Glucose reaches < 3.9 mmol/l in the first few hours after starting fasting esp pat on SU, Meglinitide and insulin taking at pre-dawn RBS more than 16 mmol/l

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GESTATIONAL DIABETES
Generally pregnant women are exempted Fasting expected to carry a high risk morbidity and mortality to mother and infant Establish DM (Type1 or Type 2) pregnant and wanted to fast considered as high risk require intensive care.
Pre pregnancy control Counseling on complication Frequent monitoring
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CONCLUSIONS
1. 2. 3. 4. The Quran exempt people with DM from fasting Ramadan as fasting may increase risk of complications. Many people with DM fast Ramadan despite medical risks A patients decision to fast should be made after through discussion with healthcare professionals concerning the risks involved Patients who insist on fasting should undergo proper pre-Ramadan assessment and receive structured education related to physical activity, meal planning, glucose monitoring, and dosage and timing of medications Insulin &/or OHG dose adjustment preferably should be applied 1-2 months pre-Ramadan Newer OHA and Insulin are relatively low in cause hypoglycemia. GDM discourage for fasting

5. 6. 7.
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