Sahih Internation

al[Fasting for] a limited number of days. So whoever among you is ill or on a journey [during them] - then an equal number of days [are to be made up]. And upon those who are able [to fast, but with hardship] - a ransom [as substitute] of feeding a poor person [each day]. And whoever volunteers excess - it is better for him. But to fast is best for you, if you only knew.

ADA GUIDELINES FOR MANAGEMENT OF DIABETES IN RAMADAN

ADA 2010 UPDATE

Major Updates

★ Addresses voluntary 1-2 days fast per week

★Discusses effect of prolonged fasting

★ Effect of structured education and support for safe fasting

Major Updates

★New medications with less risk of hypoglycemia

★Safety and limitations of existing medications

★Addresses growing global scope of challenges of diabetes and fasting in ramadan

Major Risks

★Hypoglycemia

★Hyperglycemia

★Diabetic ketoacidosis

★Dehydration and thrombosis

Management

❏ Individualization.❏Frequent monitoring of glycemia.❏Nutrition.❏Exercise.❏Breaking the fast.

Management

➢ Individualisation

Managment

➢ Frequent monitoring

Management

Nutrition

Management

➢ Exercise

Management

Break fast !➢ less than 60➢ more than 300

Pre-Ramadan Medical Assessment

★Should take place 1–2 months before★Specific attention to overall wellbeing★Lab work up★Specific advice and potential risks★Changes in diet and medication

Ramadan Focussed Structured Education

❖An awareness campaign

❖RFSE for healthcare professionals

❖RFSE for diabetic patients

Type I DM Management

High risk ➔Poorly controlled DM➔Poor compliance to monitoring➔Unstable glycemic control➔Recurrent hospitalizations

Type I DM Management

Require intensive glycemic control❖Multiple daily injections(3+)❖ Insulin infusion pumps❖ Frequent monitoring and dose adjustment❖ Basal bolus is preferred protocol

Type II DM Management

Diet controlled patients

● 2-3 smaller meals

● Modified exercise

Oral Hypoglycemic Agents

➢Chose insulin sensitisers➢Metformin-safe with modified dosage➢Glitazones cannot be substituted ➢1st generation sulfonylureas are

unsuitable➢2nd generation sulfonylureas use with

caution

Short-acting Insulin Secretagogues.

➢Short duration of action.➢Twice daily before sunset & predawn

meals.➢Nateglinide has lowest risk of

hypoglycemia

Incretin-based Therapy.➢Not associated with hypoglycemia,➢Exenatide can be used before meals➢Liraglutide OD controls fasting glycemia➢GLP-1 require titration & cause nausea➢DPP-4 do not require titration

alfa-Glucosidase Inhibitors.

➢Less risk of hypoglycemia

➢Used in combination

➢ Increase flatulence

Type II DM on Insulin.

➢Less incidence of hypoglycemia

➢Long/intermediate acting with short acting before meals

➢Rapid acting better than short acting

Insulin Pumps

➢Frequent glucose monitoring

➢Hypo/Hyperglycemia can be precisely controlled

➢Need education and training

Treatment Changes in Type II DM

➢ Diet & exercise control

➢ Patients on OHA➢ Metformin 500 TID

➢ TZDs/ AGIs/ incretin

➢ Modified exercise with more fluids

➢ Adequate fluids➢ 1000 iftar -500

@sohar➢ No change

Treatment Changes in Type II DM

➢ Sulfonylureas OD

➢ Sulfonylureas BID

➢ Adjusted dose before sunset meal

➢ Half dose for predawn meal

Type II DM on Insulin

➢ Patients on insulin

➢ BID Premixed/ intermediate-acting

➢ Adequate fluids

➢ Change to long/intermediate with short acting half dose at predawn & usual dose at sunset

Pregnancy & fasting in Ramadan

➢High risk of morbidity & mortality to fetus & mother

➢Requires intensive care and education➢ Idealy managed in high risk clinic➢ Intensive diet and insulin therapy

Hypertension & Dyslipidemia

➢Prone for dehydration & hypotension➢Need dose adjustment➢Diuretics inappropriate➢Avoid carbohydrate rich & saturated

fat diet

Conclusions➢ Type I DM carry very high risk of life threatening

complications➢ Limited Type II DM carry high risk of

hypoglycemia➢ Pre-ramadan structured education➢ Newer agents have advantage in ramadan ➢ Insulin pumps provide greater safety in ramadan

➢Need more research