2014 6-6 PSEM Weekend Course CDO - DM in Ramadan

Managing Diabetes During Ramadan and Fasting During

Lent

Alan Chang, MD, FPCP, FPSEMJeremy Robles, MD, FPCP, FPSEM

Objectives• To understand the Religious Principles of

Ramadan and its significance to Islam

• To discuss the impact of Ramadan on individuals

• Psychological, Physiological & Biochemical Changes

• To describe dose adjustments and revisions in medications during prolonged fasting

Five Pillars of Islam• Shahadah - The declaration of Faith

• Salah - Five compulsory daily prayers

• Zakat - Annual Alms Tax to the poor and needy

• Sawm - Fasting during the month of Ramadan

• Hajj - Pilgrimage to Mecca

Ramadan• Islamic Calendar is 354 days

• Ramadan occurs in the 9th month (Hijra)

• Fasting last from dawn to dusk

• Variable time depending on geographical location & season

• Duration of fasting 28-30 days

• Dawn “Sahur” - Dusk “Iftar”

Ramadan• Fasting should be practiced by all healthy &

responsible Muslims

• Islamically Exempted from Fasting:

The Frail & Elderly

Children

Chronic Health Condition

Severe mental problems

Temporarily Exempted:

Travellers

Acutely Unwell

Pregnant & Breast feeding women

Epidemiology of Diabetes & Ramadan

(EPIDIAR) study • 12,243 subjects in 13 countries ( 9% Type 1 DM - 91% Type 2 DM )

• Younger patients (31 - 54 yo) with short duration of DM (<10y)

• Mean BMI 24 kg/m2 in type 1 DM and 27 kg/m2 in type 2 DM

• Fasting during Ramadan among Muslim diabetic patients

• 43% for type 1 DM & 79% for type 2 DM (15 days fasting)

• 50% of diabetic population (type 1 & 2) did not change lifestyle

• 1/4 changed OAD dose while 1/3 changed insulin dose Diabetes Care 27:2306 –2311, 2004

Epidemiology of Diabetes & Ramadan

(EPIDIAR) study • Overall incidence of hypoglycemic events was low

• unawareness of symptoms

• limited use of intensive therapies

• insufficient monitoring

• restriction of the definition to hospitalization

• Severe hypoglycemia more frequent during Ramadan associated with changes in treatment & activity

Diabetes Care 27:2306 –2311, 2004

Ramadan impact on Individuals

• Psychological Changes

• Practice in self sacrifice & self appreciation

• Period of reflection, character improvement and removal of fault - Spiritual Peace

• Increased prayer participation and Quarantic Recitation

NHS Gilani A. Ramadan and your Diabetic patient: A resource pack for Healthcare Professional 2011


• Physiological Changes

• Fasting > 8 hours

• Reduced Glucose levels & Insulin Secretion

• Glycogenolysis & Gluconeogenesis occurs

• Increased counter regulatory hormones (Glucagon & Cathecolamine)

• Increased fatty acid production & ketones



• Physiological Changes

• Fed > Fasting state

• Postabsorptive phase, 6–24 h after beginning fasting

• Gluconeogenic phase, from 2–10 days of fasting

• Protein conservation phase, beyond 10 days of fasting


Ramadan impact on Individuals• Biochemical Changes

JAFES vol 28, No. 1:21–25, 2013

Parameters Expected Changes

HbA1c, plasma insulin, insulin

resistance

No significant change expected. Decreased levels of fasting plasma insulin and

decreased insulin resistance in newer studies.

Lipid MetabolismNo significant change expected.

Increased total cholesterol & decreased TGL in new studies.

Micro & Macro Complications

Variable and individualised

Case• Abdul is a 56 year old Muslim diagnosed to have

diabetes on April 2014.

• His sugar is poorly controlled with an HbA1c of 9.4% & FBS of 293 mg/dL.

• He is hypertensive on an ARB+ CCB combination.

• You started him on premixed insulin BID & metformin + DPP4 combination.

• You also started him on enteric coated aspirin & a statin

Case

• On his follow-up this first week of June, his blood sugar is now better controlled at an HbA1c of 7.4% and FBS of 120 mg/dL.

• He now tells you that anticipating Ramadan, he would like to ask if your advice about the changes in his medications as he will likely fast.

Case Q1• As a devout follower of Islam, he would like to

fast during Ramadan. What do you think?

A. Yes, he should because it is absolutely necessary in their faith that he should follow

B. Yes, but he can modify the fasting

C. Yes, only for a few days

D. No, he is diabetic and is therefore is exempted

Pre-Ramadan Assessment &

Counselling• 1 - 2 months before the onset of Ramadan

• Individualized life-style, diet & drug plan

• Full annual review & detection of complications

• Counselling should focus on patient / family

• awareness of symptoms , planning of meals

• management of acute complications

Hassan Chamsi-Pasha and Khalid S. Aljabri. Avicenna J Med. 2014 Apr-Jun; 4(2): 29–33.


Counselling• Monitor blood glucose levels multiple times daily

• Most problems arise from inappropriate diet or as a consequence of overeating and insufficient sleep

• Excessive physical activity - higher risk of hypoglycaemia

• End their fast if hypoglycaemia / hyperglycaemia


Case Q2

• Before starting Ramadan, Abdul should undergo rigorous physical assessment

A. True

B. False


Counselling• Physical well being assessment;

• Assessment of metabolic control;

• Adjustment of the diet protocol for Ramadan fasting;

• Adjustment of the drug regimen

• Encouragement of continued proper physical activity;

• Recognition of warning symptoms of dehydration, hypoglycemia & other possible complications.

Case Q3

• What are the physiologic challenges that can occur to a patient during Ramadan?

A. No changes, just the same as a regular overnight fast

B. Abdul may lose up to 4 kg while fasting

Changes in Lifestyle, Weight & meds during Ramadan (EPIDIAR)

StudyEPIDIAR

Physical Activity Same

Sleep Duration Same

Food Intake Same

Fluid Intake Same

Sugar Intake Same

Weight Changes No Change

Insulin Dose Maintained

OAD Dose Maintained

Diet & Exercise during Ramadan

• Healthy balanced diet with complex carbohydrates

• Fiber rich food with mono saturated fats

• Light to moderate exercises are considered safe

• Taraweeh (night prayer ) is considered to be part of an individual exercise regime

• Ample fluid intake; Avoid caffeineNHS Gilani A. Ramadan and your Diabetic patient: A resource pack for Healthcare Professional 2011

Knowledge, Attitudes & Practices of muslims with diabetes Mellitus during Ramadan Fasting in the

Philippines(Pala-Mohammad et. al.)

• 58.2% had Inadequate knowledge about physical activity during Ramadan fasting

• 33% fasted for at least 15 days

• 37% had hypoglycemia during Ramadan Fasting

• 95% fasted >10 days

• 77% >50 years old

• 63% had diabetes >5 years

Case Q4

• Is Abdul allowed to monitor his blood sugar? How often should he check?

A. Monitoring of blood sugar will break the fast

B. He should monitor only as symptoms occur

C.He should monitor before sahur, iftar & during the day when required

South Asian Consensus Guideline: Use of insulin in Diabetes during

Ramadan• Blood sugar monitoring

• Check 2 hours post-sahur & 30 mins post-iftaar

• to check for subclinical hypoglycaemia

• Check 2 hours post-iftar

• to check for subclinical hyperglycaemia

• Adjust insulin dose at 3 day intervalsIndian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4


Diabetes Care 27:2306 –2311, 2004

Increased Risk for Hypoglycemia

Increased Risk for Hyperglycemia

Type 1 Diabetes Mellitus

4.7 Fold 5 Fold

Type 2 Diabetes Mellitus

7.5 fold 3 Fold

Case Q5• Having decided that Abdul will fast, how will you

modify his current regimen?

A. Discontinue the insulin & replace with an SU

B. Decrease the insulin dose

C. Shift to a long acting insulin analogue

D. Shift to NPH insulin BID

Medical Management (Oral - Injectable Meds)

Medical Management (Oral Medications)

• Metformin ( low risk )

• Two-thirds of the dose is taken at iftar & one-third at suhur

• Slow release formulations taken once daily after the sunset meal

• Alpha glucosidase inhibitors ( low risk )

• Taken with the first bite of a meal

• Short acting secretagouges ( low risk )

• Short duration of action

• Taken twice daily before sunset and predawn meals


Medical Management (Oral Medications)

• Glitazones (low risk)

• Amplify the hypoglycemic effects of SU, glinides, and insulin

• Require 2-4 weeks to exert substantial antihyperglycemic effects

• No adjustment in dosage required (monotherapy)

• Sulfonylureas ( high risk )

• Inherent risk of hypoglycemia use with caution

• Change the timing of the once daily dose of SU (such as glimepiride) from the usual morning dose to the evening (at iftar)

• Long-acting oral hypoglycemic agents (OHA) must be used more caution


Medical Management (Oral & Injectable Medications)

• Incretin Based Therapy ( low risk )

• Less hypoglycemia as monotherapies & suitable for Ramadan

• Exenatide before meals to minimize appetite & promote weight loss

• Liraglutide given once a day, independent of meals, for fasting hyperglycemia

• DPP4 monotherapy do not require adjustments ( Sitagliptin & Vildagliptin )

• Insulin ( high risk )

• Newer insulin analogs more useful in managing diabetes during Ramadan

• Long-acting insulin (glargine and detemir) should be reduce by 20%

• Premix insulins - AM dose given at sunset & half of the PM dose given at dawn



Ramadan

• Assess glycemic status

• Assess complications & co-morbid conditions

• Change of diet & meal plan

• Consider dehydration and electrolyte imbalance

Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4


Ramadan


Very High Risk

• Severe hypoglycemia w/in the past 3 mos.

• Recurrent hypoglycemia

• Hypoglycemia unawareness

• Sustained poor glycemia

• DKA or HHS 3 mos. prior

• On dialysis

High Risk

• Renal insufficiency• Advanced macro

vascular complications

• Autonomic neuropathy

• Living alone and treated with multiple insulin or SU

• Old age with ill health

Moderate RiskWell controlled

patients treated with short acting insulin

secretagogues

Low RiskWell controlled

patients treated with diet, MET, TZD or otherwise healthy


Ramadan• Premix Insulin (eg. 70/30 insulin)


BeforeRamadan

DuringRamadan

Morning Dose

Pre-Breakfast Sahur Half dose of Pre-dinner

Evening Dose

Pre Dinner IftarFull Pre-

Breakfast dose


Ramadan• Basal Bolus (eg. Basal Long Acting +

Prandial)


Before Ramadan During Ramadan

Morning Dose

Full prandial

doseSahur

Half prandial

dose

Lunch Dose

Full prandial

dose-

Evening Dose

Full basal Analog

Full prandial

doseIftaar

Full basal Analog

Full prandial

dose x 2


Ramadan• Split Mix Insulin (eg.Intermediate + Short

Acting)


Before Ramadan During Ramadan

option A option B option A option B

Morning Dose

SA IA + SA Sahurhalf SA +

half IAhalf SA +

half IA

Lunch Dose

SA - -

Evening Dose

IA + SA IA + SA Iftaar SA x 2 IA + SA


Ramadan• Bi-phasic insulin (eg. Biphasic + Metformin)


Before Ramadan

During Ramadan

Option A Option B

Morning Dose

BiphasicInsulin

Sahur MetforminHalf Biphasic Dose + Met

Lunch Dose

Evening Dose

Metformin IftaarBiphasic

InsulinBiphasic

Insulin


Ramadan• Rapid Acting over Regular Human Insulin

• Faster onset with higher peak with same dose

• Better post prandial control & Meal time flexibility

• Lesser hypoglycemia

• Safe in Renal & Hepatically impaired (aspart)

• Safe in Pregnancy (Aspart, Lispro)Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4


Ramadan• Analog Premix over Human Premix

Insulins

• Rapid onset of action

• Better postprandial control & meal flexibility

• Lesser night time hypoglycemia

• Can be started once daily before iftar and uptitrated to twice daily


Post Ramadan Follow-up

• The patients therapeutic regimen should be changed back to its previous schedule.

• Patients should also be required to get an overall education about the impact of fasting on their physiology

• Degenerative complications check up

• Monthly weight, blood pressure, HbA1c and renal function evaluation every six months.

Diabetes Care. 1997; 20:1925-1926.

Summary• Fasting provides unique spiritual benefits in

the life of the believer.

• Management of the Diabetic patient during fasting is complex and requires close medical follow-up

• Structured education enables patients to manage their condition better

• Modifications in diet, exercise and medications need to be discussed by the patient & doctor

Summary

• Recognition and management of complications is essential to ensure patient well being

• Monitoring of blood sugar as well as other biochemical parameters are vital in the management

• Tailored therapy with oral and injectable medications may be used during the fasting period.

Thank you!Alan Chang, MD, FPCP, FPSEM

Jeremy Robles, MD, FPCP, FPSEM

Credits to:

Dr. Patricia Gatbonton & Dr. Alan ChangWho presented the original lecture in 2012

Dr. Aniza Pala-Mohammad for articles used in updating this slide set.

2014 6-6 PSEM Weekend Course CDO - DM in Ramadan

Healthcare

Transcript of 2014 6-6 PSEM Weekend Course CDO - DM in Ramadan