practical guide to diabetes management in ramadhan

Practical Guide to

Diabetes Management in Ramadan

MINISTRY OF HEALTH MALAYSIA

MALAYSIA ENDOCRINE& METABOLIC SOCIETY

Practical Guide to diabetes ManaGeMent in raMadan

table of contents

FOREWORD..................................................................................................................................... i

PREFACE......................................................................................................................................... ii

OBJECTIVES.................................................................................................................................... iii

WORKING.COMMITTEE................................................................................................................. iv

EXTERNAL.REVIEWERS................................................................................................................... v

SUMMARY.OF.TREATMENT.ALGORITHM...................................................................................... vi

section 1 BACKGROUND..............................................................................................................1

section 2 PATHOPHYSIOLOGY.OF.FASTING.DURING.RAMADAN..................................................3

section 3 MEDICAL.BENEFITS.OF.FASTING.DURING.RAMADAN..................................................7

section 4 RISKS.OF.FASTING.IN.DIABETES.DURING.RAMADAN....................................................9

section 5 PATIENTS.WHO.ARE.AT.RISK.OF.DEVELOPING.COMPLICATIONSDURING.FASTING......................................................................................................11

section 6 PREPARATION.PRIOR.TO.RAMADAN...........................................................................15

section 7 SELF-MONITORING.OF.BLOOD.GLUCOSE.DURING.RAMADAN...................................19

section 8 LIFESTYLE.AND.DIET.MANAGEMENT.DURING.RAMADAN..........................................23

section 9 ORAL.ANTI-DIABETIC.THERAPY.DURING.RAMADAN..................................................27

section 10 INSULIN.THERAPY.DURING.RAMADAN....................................................................31

GLOSSARY.OF.TERMS...................................................................................................................35

ACKNOWLEDGEMENTS............................................................................................................... .35

SOURCES.OF.FUNDING.................................................................................................................35

iForeWord bY

tHe director General oF HealtH oF MalaYsia

Many.people.around.the.world.observe.fasting.as.an.important.religious.ritual..Healthy.Muslims.are. obligated. to. fast. during. the. Holy.Month. of. Ramadan,.while. those. suffering. from. poorly.controlled.diabetes.or.with.major.diabetes-related.complications.are.exempted.from.doing.so..However.due.to.strong.personal.beliefs,.many.of.them.still.fast.during.Ramadan..Malaysia.is.one.of.the.countries.with.a.high.prevalence.of.diabetes.with.an.estimated.1.2.million.Malaysians.who.have.high.blood.sugars..Patients.with.diabetes.who.fast.during.Ramadan.will.require.additional.attention. by. their. healthcare. providers.. There. are. international. and. local. clinical. practice.guidelines. on. overall. diabetes. management. available. but. practical. guidelines. on. managing.diabetes.particularly.during.Ramadan.are.limited.

In. line.with. this,. several.endocrinologists. from.the.Ministry.of.Health. (MOH).and.Ministry.of.Education. (MOE). have. come. together. to. form. a. working. committee,. dedicating. their. time.working. together. diligently. to. develop. a. practical. guide. to. diabetes. management. during.Ramadan.that.will.be.relevant.for.Malaysian.healthcare.providers..I.would.like.to.acknowledge.the.efforts.taken.by.the.working.committee.and.to.congratulate.them.on.the.development.of.this.practical.guide.which.will.assist.healthcare.providers.particularly.primary.care.physicians.in.ensuring.safe.and.optimal.management.of.patients.with.diabetes.during.periods.of.fasting.particularly.during.Ramadan.

This. practical. guide. is. an. addition. to. the. collaborative. milestones. between. MOH. and. the.Malaysian.Endocrine.&.Metabolic.Society.(MEMS)..With. it. in.place,. I.believe.our.patients.will.benefit. from. optimised. treatment. and.management. of. their. diabetes.when. they. are. fasting.during.Ramadan..Hence.I.would.like.to.urge.all.healthcare.providers.to.fully.utilise.this.practical.guide.to.further.improve.the.quality.of.diabetes.care.in.Malaysia.during.Ramadan.period.for.the.lasting.benefit.of.our.patients.

datuk dr. noor Hisham abdullahDirector.General.of.Health.Malaysia

ii

PreFace

In.Malaysia,.an.estimated.61%.of.the.population.practice.Islam.as.their.religion..One.of.the.five.pillars.of.Islam.is.to.fulfill.the.annual.fasting.during.the.holy.month.of.Ramadan..In.those.with.illness,. fasting. is.exempted.but.the.majority.of.Muslims.with.diabetes.will.eagerly. fast.during.Ramadan..Muslims.may.also.practice.the.non-obligatory. fast.during.the.non-Ramadan.period.and.some.non-Muslims.may.also.practice.fasting.for.either.religious.or.health.reasons.

There.is.a.concern.that.fasting.among.those.with.diabetes.may.increase.risk.of.acute.diabetes-.related.complications.such.as.hypoglycaemia,.hyperglycaemia.and.dehydration.. It. is.generally.observed.that.there.are.higher.rates.of.emergency.department.admissions.and.hospitalisation.for.diabetes.emergencies.among.those.with.diabetes.who.fast.during.Ramadan.

Therefore. it. is. important. for. clinicians. and. health. care. providers. to. recognise. and. provide.appropriate. advice. to. those.with. diabetes. having. high. risks. for. complications. during. fasting..With.structured.patient.education.and.individualised.adjustments.of. lifestyle.and.medications.performed. well. in. advance,. most. Muslims. with. diabetes. can. achieve. acceptable. metabolic.control.while.fasting,.having.better.confidence.in.self-management.and.thus,.avoiding.the.known.serious.complications.previously.described.

This.practical.guide.has.been.developed.to.provide.a.clear.and.concise.approach.to.all.health.care.providers.regarding.the.management.of.diabetes.during.fasting,.particularly.in.Ramadan..I.hope.it.will.help.to.ensure.that.those.with.diabetes.may.practice.fasting.safely,.free.from.adversity.and.be.able.to.experience.the.many.potential.health.benefits.of.fasting.in.addition.to.the.spiritual.fulfillment.gained.

Finally,. I.would. like. to.express.my.gratitude. to.everyone. involved. in. the.development.of. this.practical.guide.and.especially.to.the.members.of.the.Working.Committee.for.their.support.and.contribution.

dr. Zanariah HusseinChairpersonWorking.Committee

iii

obJectiVes

The.aim.of.the.practical.guide.is.to.assist.health.care.providers,.particularly.primary. care. physicians. in. ensuring. safe. and. optimal. management. of.patients.with.diabetes.during.periods.of.fasting.as.in.Ramadan.

clinical QuestionsThis.practical.guide.aims.to.address.the.following.clinical.questions:

1. What.are.the.benefits.and.risks.of.fasting?

2. Who.are.at.risk.to.fast?

3. How.to.screen.and.educate.patients.with.diabetes.priorto.Ramadan?

4. What.are.the.glycaemic.targets.during.Ramadan?

5. How.to.monitor.glycaemia.in.patients.during.Ramadan?

6. How.to.optimise.lifestyle.and.anti-diabetic.therapy?

target PopulationThis.practical.guide.is.applicable.to.adults.with.diabetes.intending.to.fast.as.in.Ramadan.

target GroupThis.practical.guide.is.meant.for.all.health.care.professionals.involved.in.the.management.of.patients.with.diabetes.mellitus,.both.in.primary.care.and.hospital.care.

iv

cHairPerson

dr. Zanariah bt Hussein Consultant.Endocrinologist,.Hospital.Putrajaya,Putrajaya

MeMbers (Alphabetical.Order)

dr. ijaz bt Hallaj rahmatullah Consultant.Endocrinologist,.Hospital.Raja.Permaisuri.Bainun,.Perak

dr. nor azizah aziz Consultant.Endocrinologist,.Hospital.Pulau.Pinang,.Pulau.Pinang

dr. norhaliza Mohd ali Consultant.Endocrinologist,.Hospital.Sultanah.Aminah,.Johor.Bahru

dr. nurain Mohd noor Consultant.Endocrinologist,.Hospital.Putrajaya,.Putrajaya

Prof. Madya dr. norasyikin bt a. Wahab Consultant.Endocrinologist,.Pusat.Perubatan.Universiti.Kebangsaan.Malaysia,.Kuala.Lumpur

adVisor

Prof. dato Paduka dr. Wan Mohamad Wan bebakar Senior.Consultant.Endocrinologist,.Hospital.Universiti.Sains.Malaysia,.Kelantan

dr. Masni Mohamad Consultant.Endocrinologist,.Hospital.Putrajaya,.Putrajaya

dr. nor shaffinaz bt Yusoff azmi Merican Consultant.Endocrinologist,.Hospital.Sultanah.Bahiyah,.Alor.Setar

dr. norhayati bt Yahaya Consultant.Endocrinologist,.Hospital.Raja.Perempuan.Zainab.II,.Kelantan

dr. Wan Mohd izani Wan Mohamed Consultant.Endocrinologist,.Hospital.Universiti.Sains.Malaysia,.Kelantan

WorKinG coMMittee

veXternal reVieWers

Y. bhg. datin dr. rugayah bakri Head,.Malaysian.Health.Technology.Assessment.Section.(MaHTAS).&.Deputy.Director,.Medical.Development.Division.Ministry.of.Health,.Malaysia

Prof. dato dr. Mafauzy Mohamed Director.of.Campus./.Professor.of.Medicine,.Senior.Consultant.Endocrinologist,.Hospital.Universiti.Sains.Malaysia,.Kelantan

Prof. dr. nor azmi Kamaruddin President,.Malaysian.Endocrine.and.Metabolic.Society.(MEMS),.Senior.Consultant.Endocrinologist,.Pusat.Perubatan.Universiti.Kebangsaan.Malaysia,.Kuala.Lumpur

dr. Feisul idzwan Mustapha Public.Health.Physician,.Disease.Control.Division,.Department.of.Public.Health,.Ministry.of.Health.Malaysia,.Putrajaya

dr. G. r. letchuman Senior.Consultant.Physician,.Hospital.Raja.Permaisuri.Bainun,.Perak

dr. Mastura Hj. ismail Consultant.Family.Medicine.Specialist,.Klinik.Kesihatan.Seremban.2,.Negeri.Sembilan

(The following external reviewers provided feedback on the draft.)

vi

suMMarY oF treatMent alGoritHM

Pre-ramadan medical review.Performed.12.months.before.Ramadan.Approach.should.be.individualised.Assessment.of.glycaemic.control,.blood.pressure,.and.lipids

Follow-up is essential after ramadan.HbA1c,.blood.pressure,.lipids.Readjustment.of.medications.where.appropriate.Revert.back.to.pre-Ramadan.treatment.regimen

evaluate risk of developing complications during ramadan

.Moderate.risk.Low.risk

structured ramadan-focused patient education.Meal.planning.and.dietary.advice.with.a.dietitian.Appropriate.timing.and.intensity.of.exercise.Blood.glucose.monitoring.Knowing.when.to.end.the.fast.Recognising.and.managing.acute.complications

treatment adjustmentsChanges.to.diabetes.medication.regimens:.Treatment.choice.Timing.and.frequency.of.dosing.Dosage.adjustments

.Very.high.risk.High.risk

advised to abstain from fasting

1section 1bacKGround

2A.few.religions.worldwide.practice.the.fasting.ritual..Ramadan.fasting.is.observed.by.Muslims.worldwide. as. fasting. from. dawn. until. dusk. daily. for. 29. . 30. days.. Non-Ramadan. fasting. is.undertaken.by.Muslims.and.people.of.other.faith.as.either.a.single.day.or.a.few.consecutive.days.of.fasting..Due.to.Malaysias. location.near.the.Equator,.annual.Ramadan.fasting.in.Malaysia. is.between.12..14.hours.daily.

Among.the.benefits.of.fasting.apart.from.heeding.the.Creators.order.is.to.teach.self-restraint.and.discipline.as.well.as.resting.and.cleansing.the.alimentary.tract..The.call.to.fast.during.Ramadan.for.a.healthy.Muslim.is.stated.in.the.holy.Quran,.where.there.is.also.a.clear.guide.on.individuals.who.are.exempted. from. fasting.which. includes. those.with. chronic.diseases. such.as.diabetes.mellitus..(Surah.Al.Baqarah.Verse.184-185)

Fasting. in.certain. individuals.with.diabetes.may.be.associated.with.adverse.outcomes;.hence.they.are.not.obliged.to.fast.1.However,.many.diabetic.patients.choose.to.fast.as.shown.in.the.Epidemiology. of. Diabetes. and. Ramadan. (EPIDIAR). study.1. Managing. a. Muslim. patient. with.diabetes.during.Ramadan.continues.to.be.a.challenge.for.healthcare.professionals.2

The.adverse.outcomes.during.fasting.include.dehydration,.hypoglycaemia.and.hyperglycaemia.2,3.In.a.Malaysian.study,.diabetic.patients.with.tight.glycaemic.control.as.well.as.the.elderly.were.found.to.have.a.higher.risk.of.developing.hypoglycaemia.4

As. a. diabetic. patient. undertakes. fasting,. pre-fasting. education. and.planning. is. of. paramount.importance.to.lower.the.incidence.of.adverse.outcomes.associated.with.fasting.

references1. Salti.I,.Bnard.E,.Detournay.B,.et.al..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(10):.2306-2311.

2. Al-Arouj.M,.Assaad-Khalil.S,.Buse.J,.et.al..Recommendations.for.management.of.diabetes.during.Ramadan:.update.2010..Diabetes Care. 2010;.33(8):.1895-902.

3. Karamat.MA,.Syed.A,.Hanif.W..Review.of.diabetes.management.and.guidelines.during.Ramadan..J R Soc Med. 2010;.103(4):.139-147.

4. Loke.SC,.Rahim.KF,.Kanesvaran.R,.et.al..A.prospective.cohort.study.on.the.effect.of.various.risk.factors.on.hypoglycaemia.in.diabetics.who.fast.during.Ramadan..Med J Malaysia. 2010;.65(1):.3-6.

section 1 bacKGround

3section 2PatHoPHYsioloGY oF FastinG durinG raMadan

4section 2 PatHoPHYsioloGY oF FastinG durinG raMadan

An. appreciation. of. the. physiology. of. fasting. is. essential. to. the. understanding. of. therapeutic.interventions.and.the.effect.of.food.deprivation.in.Ramadan..Muslims.intentionally.abstain.from.eating,.drinking,.and.smoking.from.predawn.to.sunset..The.changes.that.occur.in.the.body.in.response.to.fasting.depend.on.the.length.of.the.continuous.fast..The.body.enters.into.a.fasting.state.eight.hours.or.so.after.the.last.meal,.when.the.gut.finishes.absorption.of.nutrients.from.the.food.

in the transition from a fed to fasted state (Figure 1):1

i.. In.the.normal.fed.state,.glycogen.is.the.bodys.main.source.of.energy.

ii.. .Secretion. of. insulin. is. reduced. while. counter-regulatory. hormones. glucagon. and.catecholamines.are.increased.

iii.. .During.a.fast,.these.glycogen.stores.are.utilised.first.to.produce.energy..The.liver.glycogen.is.depleted.in.the.first.18.to.24.hours.via.glycogenolysis.

iv.. .Later.in.the.fasting.state,.once.glycogen.stores.are.depleted,.fat.becomes.the.next.source.of.energy.for.the.body..Fats.are.mobilised. in.the.form.of.triglycerides.which.further.undergo.lipolysis.into.free.fatty.acids.and.glycerol..

v.. .With.prolonged.periods.of.fasting.(days.to.weeks),.protein.becomes.the.source.of.energy.and.will.be.released.from.the.catabolism.of.muscle.

Figure.1..Pathophysiology.of.fasting.in.diabetes.1

Gluconeogenesis & ketogenesis increased glucose uptake

Insulin secretion decreased or absent

Glycogen storesdepletion excessive

breakdown

LIVER

PANCREAS

PERIPHERALTISSUES

(MUSCLE)

GLUCOSE

5As.the.Ramadan.fast.only.extends.from.dawn.till.dusk,.there.is.ample.opportunity.to.replenish.energy.stores.at.pre-dawn.and.dusk.meals..This.provides.a.gradual.transition.from.using.glucose.to.fat.as.the.main.source.of.energy,.and.prevents.the.breakdown.of.muscle.for.protein.1

After.a. few.days.of. fast,.circulating.endorphin. levels. increase,.resulting. in. improved.alertness.and.general.well-being.2.Balanced.food.and.fluid. intake. is. important.between.fasts..The.renal.homeostasis.mechanism.maintains.the.bodys.water.and.salts,.such.as.sodium.and.potassium..A.balanced.diet.with.adequate.quantities.of.nutrients,.salts.and.water.is.vital.1

Type.1.diabetes1

In. patients.with. Type. 1. diabetes,. glucose. homeostasis. is. affected. by. underlying. disease. and.by. insulin. therapy.. Glucagon. secretion. may. fail. to. increase. appropriately. in. response. to.hypoglycaemia,.and.in.patients.with.severe.insulin.deficiency,.a.prolonged.fast.in.the.absence.of.adequate.basal.insulin.can.lead.to.excessive.glycogen.breakdown.and.increased.gluconeogenesis.and.ketogenesis.leading.to.hyperglycaemia.and.eventual.ketoacidosis.

Type.2.diabetes1

Patients. with. Type. 2. diabetes. may. suffer. similar. consequences,. however. ketoacidosis.is.uncommon.

There. can. be. varying. changes. in. body. weight. among. diabetics. fasting. in. Ramadan.. The.Epidemiology. of. Diabetes. and. Ramadan. (EPIDIAR). study. showed. that. majority. of. patients.had.unchanged.weight.3.Many.patients. show.no. significant. change. in. their.glycaemic.control.although.blood.lipid.levels.have.been.shown.to.be.reduced.4-7

6references1. Karamat.MA,.Syed.A,.Hanif.W..Review.of.diabetes.management.and.guidelines.during.Ramadan..J R Soc Med. 2010;.

103(4):.139-147.2. Lahdimawan.A,.Handono.K,. Indra.MR.et.al..Effect.of.Ramadan.Fasting.on.Endorphin.and.Endocannabinoid. level. in.

Serum,.PBMC.and.Macrophage..International Journal of Pharmaceutical Science Invention. 2013;.2(3):.46-54.3. Salti.I,.Bnard.E,.Detournay.B,.et.al..A.population-based.study.of.diabetes.and.its.characteristics.during.the.fasting.


4. Akanji.AO,.Mojiminiyi.OA,.Abdella.N..Beneficial.changes. in.serum.apo.A-1.and. its.ratio.to.apo.B.and.HDL. in.stable.hyperlipidaemic.subjects.after.Ramadan.fasting.in.Kuwait..Eur J Clin Nutr. 2000;.54(6):.508-513.

5. Mafauzy.M,.Mohammed.WB,.Anum.MY,.et.al..A.study.of.the.fasting.diabetic.patients.during.the.month.of.Ramadan..Med.J.Malaysia..1990;.45(1):.14-17.

6. Uysal.AR,.Erdoan.MF,.Sahin.G,.et.al..Clinical.and.metabolic.effects.of. fasting. in.41.type.2.diabetic.patients.during.Ramadan..Diabetes Care. 1998;.21(11):.2033-2034.

7. Yarahmadi.Sh,.Larijani.B,.Bastanhagh.MH,.et.al..Metabolic.and.clinical.effects.of.Ramadan.fasting.in.patients.with.type.II.diabetes..J Coll Physicians Surg Pak. 2003;.13(6):.329-332.

7section 3Medical beneFits oF FastinG durinG raMadan

8section 3 Medical beneFits oF FastinG durinG raMadan

Many.people.observe.fasting.as.a.religious.obligation.and.should.be.aware.of.the.health.benefits..The.possible.benefits.of.fasting.may.include:

.Decrease.in.body.weight.

. ..The.reduction.in.body.mass.index.(BMI).may.be.due.to.a.decrease.in.the.number.of.meals.(two.meals.instead.of.three).that.significantly.contributes.to.the.reduction.of.calorie.intake.1

..Increase. in.high-density. lipoprotein. (HDL). cholesterol,.with.or.without.any. changes. in. total.cholesterol.and.triglycerides.levels.2

.Improvement.in.glycaemic.control.in.diabetics.3

.Decrease.in.daytime.average.systolic.and.diastolic.blood.pressures.in.hypertensive.patients.4,5

..Improvement.in.immunity.by.elimination.of.toxins;.reducing.insulin-like.growth.factor.1.(IGF-1).which.allows.the.regeneration.of.stem.cells.in.the.bone.marrow.6

..Reduce.cardiovascular.disease.markers.such.as.high.sensitive.C-reactive.protein.(hs-CRP).and.plasminogen.activator.inhibitor.type-1.(PAI-1).7

references1. Mafauzy.M,.Mohammed.WB,.Anum.MY,.et.al..A.study.of.the.fasting.diabetic.patients.during.the.month.of.Ramadan..

Med J Malaysia. 1990;.45(1):.14-17.2. Benaji.B,.Mounib.N,.Roky.R,.et.al..Diabetes.and.Ramadan:.review.of.the.literature..Diabetes Res Clin Pract. 2006;.73(2):.

117-125.3. Chamakhi.S,.Ftouhi.B,.Rahmoune.NB,.et.al.. Influence.of.the.fast.of.Ramadan.on.the.balance.glycemic.to.diabetics..

Medicographia. 1991;.13:.27-29.4. Perk. G,. Ghanem. J,. Aamar. S,. et. al.. The. effect. of. the. fast. of. Ramadan. on. ambulatory. blood. pressure. in. treated.

hypertensives..J Hum Hypertens. 2001;.15(10):.723-725.5. Akturk.IF,.Biyik.I,.Kocas.C,.et.al..PP-014.The.effect.of.Ramadan.fasting.on.blood.pressure.levels.of.hypertensive.patients.

with.combination.therapy..Int J Cardiol. 2012;.155(Suppl.1):.S103.6. Cheng.CW,.Adams.GB,.Perin.L,.et.al..Prolonged.fasting.reduces.IGF-1/PKA.to.promote.hematopoietic-stem-cell-based.

regeneration.and.reverse.immunosuppression..Cell Stem Cell. 2014;.14(6):.810-823.7. .Ibrahim. O,. Kamaruddin. N,. Wahab. N,. et. al.. Ramadan. fasting. and. cardiac. biomarkers. in. patients. with. multiple.

cardiovascular.disease.risk.factors..The Internet Journal of Cardiovascular Research. 2010;.7(2).

9section 4risKs oF FastinG in diabetes durinG raMadan

10

section 4 risKs oF FastinG in diabetes durinG raMadan

Fasting. in. diabetes. during. Ramadan. may. be. associated. with. adverse. outcomes. in. certain.individuals.which.include.hypoglycaemia,.hyperglycaemia./.ketoacidosis.and.dehydration.

1. HypoglycaemiaThe.effect.of.fasting.during.Ramadan.on.the.rates.of.hypoglycaemia.in.patients.with.diabetes.is.not.known.with.certainty...However,.the.Epidemiology.of.Diabetes.and.Ramadan.(EPIDIAR).study.showed.a.4.7.fold.increase.in.hospitalisation.due.to.severe.hypoglycaemia.in.Type.1.diabetes.and.7.5.fold.in.Type.2.diabetes..Severe.hypoglycaemia.was.also.more.frequent.in.patients.who.made.inappropriate.changes.to.their.medications.dosages.and.lifestyle.1

A.prospective.study.done.locally.showed.that.the.rate.of.hypoglycaemia.was.1.6.times.higher.during. fasting. compared. to. non-fasting. periods.2.Diabetics.with.HbA1c. less. than. 8%.and. the.elderly.have.more.than.twice.the.risk.of.developing.hypoglycaemia.during.the.fasting.month.

2. Hyperglycaemia / ketoacidosisIn.EPIDIAR.study,.there.was.a.five.times.increase.in.severe.hyperglycaemia.requiring.hospitalisation.in.Type.2.diabetes..In.Type.1.diabetes,.there.were.three.times.increase.in.the.incidence.of.severe.hyperglycaemia,.with.or.without.ketosis.1

Hyperglycaemia. may. be. due. to. excessive. reduction. of. medication. dosages. to. prevent.hypoglycaemia..Patients.who.reported.an.increase.in.their.food.and/or.sugar.intake.during.non-fasting.hours.also.had.significantly.higher.rates.of.severe.hyperglycaemia.

Patients.who.are.poorly.controlled.before.Ramadan.are.at.an.increased.risk.of.diabetic.ketoacidosis.(DKA).when.they.fast..Excessive.reduction.of.insulin.dosage.is.also.a.contributing.factor.

3. dehydrationDehydration.happens.as.a.result.of.limitation.in.fluid.intake,.especially.if.the.fasting.is.prolonged.and.in.those.who.perform.hard.physical.labour..Osmotic.diuresis.as.a.result.of.hyperglycaemia.further.contributes.to.water.and.electrolyte.depletion.

Orthostatic.hypotension.may.occur. leading.to.syncope,.falls,. injuries.and.fractures..Hypercoa-gulable.states.in.diabetes.might.be.exacerbated,.enhancing.the.risk.of.thrombosis.and.stroke.

references1. Salti. I,.Bnard.E,.Detournay.B,.et.al.A.population-based.study.of.diabetes.and. its.characteristics.during.the.fasting.


2. Loke.SC,.Rahim.KF,.Kanesvaran.R,.et.al..A.prospective.cohort.study.on.the.effect.of.various.risk.factors.on.hypoglycaemia.in.diabetics.who.fast.during.Ramadan..Med J Malaysia. 2010;.65(1):.3-6.

11

section 5Patients WHo are at risK oF deVeloPinG

coMPlications durinG FastinG

12

section 5 Patients WHo are at risK oF deVeloPinG coMPlications

durinG FastinG

For.diabetic.patients,. fasting. represents.an. important.personal.decision. that. should.be.made.based. on. religious. recommendation. with. careful. considerations. of. the. associated. risks. and.possible. detrimental. effects. of. fasting.. Therefore,. diabetic. patients. should. consult. their.healthcare.providers.prior.to.fasting..Table.1.categorises.a.diabetic.patients.risk.of.fasting.

Table.1..Categories.of.risk.in.patients.with.Type.1.or.Type...2.diabetes.mellitus.who.fast.during.Ramadan.1

Very high risk

History.of.severe.diabetes.complications.within.3.months.prior.to.fasting

.Severe.hypoglycaemia.Ketoacidosis.Hyperosmolar.hyperglycaemic.coma.Recurrent.hypoglycaemia

Hypoglycaemia.unawareness

Acute.illness

Sustained.poor.glycaemic.control.(HbA1c.>9%)

Pregnancy

Advanced.renal.failure./.chronic.dialysis

13

High risk

Moderate.hyperglycaemia.(HbA1c.7.59.0%)

Moderate.renal.failure

Advanced.macrovascular.complications

Living.alone.and.treated.with.insulin.or.sulfonylureas

Patients.with.co.morbid.conditions.that.present.additional.risk.factors

Old.age.with.ill.health

Treatment.with.drugs.that.may.affect.mentation

Moderate risk

Well-controlled.diabetes.treated.with.short-acting.insulin.secretagogues

low risk

Well-controlled.diabetes.treated.with.lifestyle.therapy,.metformin,.acarbose,.thiazolidinediones,.and/or.incretin-based.therapies.in.otherwise.healthy.patients

Note:.This.classification.is.based.largely.on.expert.opinion.and.not.on.scientific.data.derived.from.clinical.studies.

Those.who.fall.in.the.very.high.and.high.risk.group.are.advised.to.abstain.from.fasting.

This.table.is.a.modification.of.Table.2.from.Recommendations.for.management.of.diabetes.during.Ramadan:.update.2010.by.Al-Arouj.et.al..(2010).

14

Fasting in special Populations with diabetes1. Pregnant women

In.general,.women.with.diabetes. should.be.strongly.advised.against. fasting.during.Ramadan..However,. if.they.insist.on.fasting,.then.special.attention.should.be.given.to.their.care.. Ideally,.patients. should. be. managed. in. high-risk. clinics. staffed. by. an. obstetrician,. diabetologist,. a.nutritionist,. and. diabetes. nurse. educators.. The. management. of. pregnant. patients. during.Ramadan.is.based.on.an.appropriate.diet.and.intensive.insulin.therapy.1

2. children and adolescents

Children.and.adolescents.with.good.glycaemic.control.who.do.regular.self-monitoring.can.fast.safely.during.Ramadan.provided.that.a.well.structured.program.of.education.for.both.children.and.their.families.is.completed.prior.to.Ramadan,.and.that.they.receive.close.follow-up.during.the.month.of.Ramadan.2

3. dialysis patients

Most.stable.patients.on.haemodialysis.and.peritoneal.dialysis.can.fast,.provided.that.they.strictly.adhere.to.their.medications.and.dialysis. therapy. in.addition.to.the.dietary.restrictions..These.patients.should.be.followed-up.closely.to.detect.any.complications.and.to.ensure.that.adequate.fluid.and.electrolyte.balance.are.maintained.3,4

4. elderly patients

Elderly. patients. are. exempted. from. fasting..Many.may.wish. to. observe. the. fast.. Those.with.diabetes. having. any. degree. of. cognitive. dysfunction,. dehydration,. or. an. increased. risk. of.thrombosis.are.advised.against.fasting.5

references1. Al-Arouj.M,.Assaad-Khalil.S,.Buse.J,.et.al..Recommendations.for.management.of.diabetes.during.Ramadan:.update.

2010..Diabetes Care. 2010;.33(8):.1895-902.2. Azad.K,.Mohsin.F,.Zargar.AH,.et.al..Fasting.guidelines.for.diabetic.children.and.adolescents..Indian J Endocrinol Metab.

2012;.16(4):.516-518.3. Al.Wakeel. J,.Mitwalli.AH,.Alsuwaida.A,. et. al.. Recommendations. for. fasting. in.Ramadan. for.patients.on.peritoneal.

dialysis..Perit Dial Int. 2013;.33(1):.86-91.4. Al.Wakeel. JS.. Kidney. function. and. metabolic. profile. of. chronic. kidney. disease. and. hemodialysis. patients. during.

Ramadan.fasting..Iran J Kidney Dis. 2014;.8(4):.321-8.5. Beshyah.S,.Benbarka.M,.Sherif.I..Practical.management.of.diabetes.during.Ramadan.fast..Libyan J Med. 2007;.2(4):.

185-189.

15

section 6PreParation Prior to raMadan

16

section 6 PreParation Prior to raMadan

a. Preramadan medical reviewAssessment.of.the.following.should.be.performed.1..2.months.before.Ramadan:1

.Overall.wellbeing

.Glycaemic.control

.Blood.pressure.control

.Lipid.control

.Diabetes-related.complications

.Diabetes-unrelated.comorbidities

Following.the.assessment,.changes.in.diet.and.medication.regimen.may.need.to.be.made,.so.as.to.establish.a.safe.and.effective.anti-diabetic.regimen.and.provide.stable.glycaemic.control.prior.to.the.start.of.Ramadan.fast..The.Pre-Ramadan.consultation.provides.an.opportunity.to.reinforce.healthy.living.advice.and.encourage.patients.to.stop.smoking.2,3

Patients. need. to. be. informed. regarding. the. potential. risk. of. fasting.. Risk. stratification. of.diabetic.patients.who.are.planning.to.fast.is.recommended.based.on.the.presence.of.various.risk.factors.

Dose.and.timing.of.anti-hypertensive.medications.may.need.to.be.adjusted. to.prevent.hypotension.. Diuretics. should. be. used. with. caution. to. avoid. volume. depletion.. Lipid..lowering.medications.should.be.continued.without.the.need.for.dose.adjustment,.as.it.is.common.practice.to.have.higher.intake.of.foods.rich.in.carbohydrates.and.saturated.fats.during.Ramadan.4

It. is.useful. for. those.with.diabetes.who. intend. to. fast. to. start.practising. fasting. in. the.months. prior. to. Ramadan.. This. is. in. accordance. with. Islamic. teaching. and. allows. for.appropriate.dose.adjustments.of.anti-diabetic.therapies.

17

b. Patient educationStructured. patient. education. is. important. to. impart. the. essential. elements. necessary. to.render.fasting.safer.so.as.to.prevent.and.reduce.risks.and.complications.during.fasting..The.Ramadan.period.presents.a.golden.opportunity.to.empower.people.with.diabetes.for.better.management.of.their.diabetes,.not.only.in.Ramadan.but.also.throughout.the.year.1,2,5

Educational.sessions.should.be.provided.by.healthcare.professionals.to.people.with.diabetes.who.are.intending.to.fast.for.Ramadan,.preferably.several.weeks.before.Ramadan.to.provide.adequate.time.for.patients,.their.families.and.caregivers.to.prepare.for.the.fasting.month.1,2

Patients.and.care-givers./.family.members.should.receive.education.concerning.self-care.such.as.the.following:1,2,6

.Risks.of.fasting

. .Hypoglycaemia..symptoms.and.signs

. .Hyperglycaemia..symptoms.and.signs

. .Dehydration

.Blood.glucose.monitoring..during.fasting.and.non-fasting.hours

.When.to.stop.the.fast

.Hydration

.Meal.planning.and.food.choices

.Physical.activity..timing.and.intensity

.Medication.administration..timing.and.dosing

.Management.of.Acute.complications

Patient.education.programme.may.be.delivered.to.people.with.diabetes.either.individually.or.in.a.group.session.at.diabetes.resource.centres.and.primary.health.care.centres.

18

references1. Bashir.MI,.Pathan.MF,.Raza.SA,.et.al..Role.of.oral.hypoglycemic.agents.in.the.management.of.type.2.diabetes.mellitus.

during.Ramadan..Indian J Endocrinol Metab. 2012;.16(4):.503-507.2. Benaji.B,.Mounib.N,.Roky.R,.et.al..Diabetes.and.Ramadan:.review.of.the.literature..Diabetes Res Clin Pract. 2006;.73(2):.

117-125.3. Karamat.MA,.Syed.A,.Hanif.W..Review.of.diabetes.management.and.guidelines.during.Ramadan..J R Soc Med. 2010;.

103(4):.139-147.4. Al-Arouj.M,.Assaad-Khalil.S,.Buse.J,.et.al..Recommendations.for.management.of.diabetes.during.Ramadan:.update.

2010..Diabetes Care. 2010;.33(8):.1895-902.5. Hui.E,.Devendra.D..Diabetes.and.fasting.during.Ramadan..Diabetes Metab Res Rev. 2010;.26(8):.606-610.6. Bravis.V,.Hui.E,.Salih.S,.et.al..Ramadan.Education.and.Awareness.in.Diabetes.(READ).programme.for.Muslims.with.Type.

2.diabetes.who.fast.during.Ramadan..Diabet Med. 2010;.27(3):.327-331.

19

section 7selF-MonitorinG oF blood Glucose durinG raMadan

20

section 7 selF-MonitorinG oF blood Glucose durinG raMadan

Patients.with.diabetes.intending.to.fast.especially.those.who.are.on.insulin.should.monitor.their.blood. glucose. levels. regularly. to. detect. hypoglycaemia. or. hyperglycaemia.. They. should. also.conduct.self-monitoring.of.blood.glucose.(SMBG).if.they.are.not.feeling.well.1.Finger.prick.for.SMBG.or.insulin.injection.does.not.constitute.breaking.of.fast.2

When to end a fastWhen.fasting.adversely.affect.health,.patients.must.always.and.immediately.end.their.fast..These.conditions.are:

.Blood.glucose.

21

Table.2..Timing.of.SMBG.could.reflect.adequacy.of.insulin.dose.

time of glucose monitoring insulin timing and type

Mid-day Pre-sahurPremixed./.bolus./.basal.insulin

Pre-iftar Pre-sahurPremixed.or.basal.insulin

2-hour post iftar or bedtime Pre-iftarPremixed.or.bolus.insulin

Pre-sahur Pre-iftar / Pre-bedPremixed.or.basal.insulin

2 hour post sahur Pre-sahurPremixed.or.bolus.insulin

22


2010..Diabetes Care. 2010;.33(8):.1895-902.2. Pathan.MF,.Sahay.RK,.Zargar.AH,.South.Asian.Consensus.Guideline:.Use.of.insulin.in.diabetes.during.Ramadan..Indian

J Endocrinol Metab. 2012;.16(4):.499-502.3. Bravis.V,.Hui.E,.Salih.S,.et.al..Ramadan.Education.and.Awareness.in.Diabetes.(READ).programme.for.Muslims.with.Type.

2.diabetes.who.fast.during.Ramadan..Diabet Med. 2010;.27(3):.327-331.4. Ibrahim.MA..Managing.diabetes.during.Ramadan..Diabetes voice. 2007;.52(2):.19-22.5. Hui.E,.Bravis.V,.Hassanein.M,.et.al..Management.of.people.with.diabetes.wanting.to.fast.during.Ramadan..BMJ. 2010;.

340:c3053.

23

section 8liFestYle and diet ManaGeMent durinG raMadan

24

section 8 liFestYle and diet ManaGeMent durinG raMadan

Meal planning and dietary adviceAppropriate.meal.planning.is.important.to.avoid.postprandial.hyperglycaemia.

The.diet.during.Ramadan. should.not.differ. from.a.healthy.balanced.diet.. It. is.encouraged. to.consume.slow.energy-release.food.(such.as.wheat,.beans.and.rice).and.to.distribute.calories.over.two.to.three.smaller.meals.during.the.non-fasting.interval.

adjustment of the diet protocol for ramadan fasting1

..Never. skip. sahur (dawn. meal).. Sahur should. consist. of. balanced. meal. with. adequate.carbohydrate. taken. as. late. as. possible. just. before Imsak to. avoid. unnecessary. prolonged.fasting.

..Do.not.delay.berbuka.i.e..the.breaking.of.the.fast.at.sunset,.also.known.as.iftar..Limit.intake.of.high-sugary.foods.e.g..kuih..However,.1-2.kurma (dates).at.start.of.iftar according.to.Sunnah may. be. taken. as. part. of. carbohydrate. exchange.. Main. meal. is. encouraged. after. Maghrib prayers.

.Supper.after.Tarawih can.be.taken.as.replacement.of.pre-bed.snack.

..Include.fruits.and.vegetables.at.both.sahur and.iftar..High.fibre.carbohydrates.are.encouraged.at.all.meals.

.Limit.fried.or.fatty.foods.

.Limit.intake.of.highly.salted.foods.to.reduce.risk.of.dehydration.

..Sufficient.fluid.must.be.taken.to.replenish.fluid. loss.during.the.day..Aim.for.8.glasses.a.day..Choose.sugar-free.drinks..Drink.adequately.at.sahur..

..Dietary. indiscretion. during. the. non-fasting. period.with. excessive. binging,. or. compensatory.consumption.of.carbohydrates.especially.sweetened.and.fatty.foods.contributes.to.the.risk.of.hyperglycaemia.and.weight.gain.

25

Figure 2. an illustration of a good buka puasa meal vs. one that intake should be limited

during buka puasa .

Physical activityAppropriate.modification. in. intensity. and. timing. of. physical. activity. is. important. to.maintain.optimal.glycaemic.control.and.optimal.weight.

Physical. activities. and. exercise. needs. to. be. adjusted. during. Ramadan.. The. following. are.recommended:2,3

.Light.and.moderate.intensity.exercise.on.a.regular.basis.

.Avoid.rigorous.exercise.during.fasting.time.because.of.risk.of.hypoglycaemia.

.The.timing.of.exercise.is.preferably.1-2.hours.after.the.break.of.fast.

.Performance.of.Tarawih night.prayers.helps.to.maintain.physical.activity.

Management of hypoglycaemia during ramadan1. Patients.need.to.end.their. fast. if. they.experience.symptoms.of.hypoglycaemia.or.have. low.

blood.glucose.values.(Section.7).

2. Take.simple.carbohydrates.

a

a

b

b

26

references1. Persatuan.Dietitian.Malaysia..Medical.nutrition.therapy.guidelines.for.type.2.diabetes.mellitus..2013..Second.Edition.2. Bravis.V,.Hui.E,.Salih.S,.et.al..Ramadan.Education.and.Awareness.in.Diabetes.(READ).programme.for.Muslims.with.Type.

2.diabetes.who.fast.during.Ramadan..Diabet Med. 2010;.27(3):.327-331.3. Karamat.MA,.Syed.A,.Hanif.W..Review.of.diabetes.management.and.guidelines.during.Ramadan..J R Soc Med. 2010;.

103(4):.139-147.

27

section 9oral anti-diabetic tHeraPY durinG raMadan

28

section 9 oral anti-diabetic tHeraPY durinG raMadan

The.choice.of.oral.anti-diabetic.(OAD).therapies.should.be.individualised.during.fasting.1.Generally,.the.insulin.secretagogues.have.higher.risk.of.hypoglycaemia.than.the.insulin.sensitizers.2.There.is.also.probably.a.need.to.change.the.dose.and.timing.of.OAD.during.Ramadan.

In.general,.OAD.therapies.that.act.by.increasing.peripheral.insulin.sensitivity.may.be.preferred.due. to. a. low. risk. of. hypoglycaemia.. The. newer. sulphonylureas. can. be. safely. used. during.Ramadan.3. Dipeptidyl. peptidase-4. inhibitors. which. facilitates. insulin. secretion. in. a. glucose.dependent.manner.are. safe.and.have. important. role. in. the.management.of. Type.2.diabetes.mellitus.during.Ramadan.fasting.in.future.4,5

Non-insulin. injectables.such.as.glucagon-like.peptide-1. receptor.agonists.do.not. require.dose.adjustments.during.Ramadan..However,.injections.may.preferably.be.administered.at.iftar.

29

Table.3..Adjustments.of.oral.anti-diabetic.agents.in.patients.with.Type.2.diabetes.who.are.fasting.during.Ramadan.6

regimen sunset meal (iftar) Pre-dawn meal (sahur)

-glucosidase.inhibitors No.changes No.changes

Biguanides.(Metformin)

Immediate-release

Twice.daily

Thrice.daily

No.changes

Two.third.of.dose

No.changes

One.third.of.dose

Extended-release

Full.dose None

Dipeptidyl.peptidase-4.inhibitors

No.changes No.changes

Meglitinides No.changes No.changes

Sulphonylureas Glibenclamide,.Gliclazide

No.changes Reduce/omit

Gliclazide.MR,..Glimepiride

No.changes Switch.dosing.to.sunset.meal

Sodium.glucose.co-transporter.2.inhibitors*

No.changes Switch.dosing.to.sunset.meal

Thiazolidinediones No.changes None

Modified.from.Pharmacological.approaches.to.the.management.of.type.2.diabetes.in.fasting.adults.during.Ramadan.by.AlMaatouq.(2012).

MR:.Modified-release

*Based.on.expert.opinion.

30


2010;.Diabetes Care. 2010;.33(8):.1895-902.2. Mafauzy.M..Repaglinide.versus.glibenclamide.treatment.of.Type.2.diabetes.during.Ramadan.fasting..Diabetes Res Clin

Pract. 2002;.58(1):.45-53.3. Glimepiride. in.Ramadan.(GLIRA).Study.Group..The.efficacy.and.safety.of.glimepiride. in.the.management.of.type.2.

diabetes.in.Muslim.patients.during.Ramadan..Diabetes Care. 2005;.28(2):.421-422.4. Al-Arouj.M,.Hassoun.AA,.Medlej.R,.et.al..The.effect.of.vildagliptin.relative.to.sulphonylureas.in.Muslim.patients.with.

type.2.diabetes.fasting.during.Ramadan:.the.VIRTUE.study..Int J Clin Pract. 2013;.67(10):.957-963.5. Al.Sifri.S,.Basiounny.A,.Echtay.A,.et.al..The.incidence.of.hypoglycaemia.in.Muslim.patients.with.type.2.diabetes.treated.

with.sitagliptin.or.a.sulphonylurea.during.Ramadan:.a.randomised.trial..Int J Clin Pract. 2011;.65(11):.1132-1140.6. Almaatouq.MA..Pharmacological.approaches.to.the.management.of.type.2.diabetes.in.fasting.adults.during.Ramadan..

Diabetes Metab Syndr Obes. 2012;.5:.109-119.

31

section 10insulin tHeraPY durinG raMadan

32

section 10 insulin tHeraPY durinG raMadan

In.the.Epidemiology.of.Diabetes.and.Ramadan.(EPIDIAR).study,.both.Type.1.and.Type.2.diabetics.on. insulin.had.an. increased. complication. rate.of. severe.hypoglycaemia.and.hyperglycaemia.1.Few.small.studies.have.been.conducted.among.Type.1.diabetics.to.assess.the.safety.and.efficacy.of.various.insulin.type.and.regimens.2-6.For.patients.with.Type.1.diabetes.mellitus.who.wish.to.fast.during.Ramadan,.basal.bolus.insulin.therapy.is.the.preferred.regime.

Insulin. analogues.were. shown. to. be. safe.with. fewer. episodes. of. hypoglycaemia. and. smaller.post.prandial.glucose.rise.after.sunset.meal.(iftar).7.The.conventional.regular.short.acting.human.insulin.and.Neutral.Protamine.Hagedorn.(NPH).insulin.are.more.widely.used..Insulin.glargine.can.be.given.once.daily.any.time.after.iftar..Insulin.levemir.and.NPH.insulin.can.be.given.either.once.daily.at.bedtime.or.divided.into.twice.daily.during.pre-dawn.meal.(sahur) and.iftar.

Individualised.adjustments.of.insulin.dose.and.timing.will.need.to.be.implemented.when.fasting.during.Ramadan.(Table.4)..Self-monitoring.of.blood.glucose.(SMBG).will.aid.in.determining.the.appropriate.insulin.dose.(Section.7;.Table.2)..Based.on.the.evaluation.of.Muslim.T2DM.patient.observing.Ramadan14,.the.switch.from.human.premix.to.mid.mix.analog.insulin.at.iftar.resulted.in.improvement.in.glycaemic.control.without.an.increase.in.hypoglycaemia.

Table.4..Insulin.adjustments.during.Ramadan.7-13

insulin regimen type 1 diabetes mellitus type 2 diabetes mellitus

basal insulin only

Not.applicable. Basal.Insulin.to.be.taken.at.bedtime.or.after.iftar meals..May.need.dose.reduction.if.there.is.risk.of.daytime.hypoglycaemia.

Premixed insulin once daily

Not.applicable. Inject.usual.dose.at.iftar meals.

Premixed insulin twice daily

Reverse.doses..Morning.dose.given.at.iftar and.evening.doseat.sahur.

Reverse.doses..Morning.dose.given.at.iftar and.evening.dose.at.sahur.

Insulin.dose.at.sahur reduced.by.20..50%.to.prevent.daytime.hypoglycaemia.

Insulin.dose.at.sahur reduced.by.20..50%.to.prevent.daytime.hypoglycaemia.

Or

Change.to.short./.rapid.acting.**Late.afternoon.hypoglycaemia.may.occur.

33

insulin regimen type 1 diabetes mellitus type 2 diabetes mellitus

basal bolus insulin

.Basal.insulin Taken.at.bedtime.or.any.time.after.iftar meals..May.require.dose.reduction.if.there.is.day.time.hypoglycaemia.

..Bolus/Prandial.insulin

Sahur .Usual.pre-Ramadan.breakfast.or.lunch.dose..May.require.dose.reduction.to.avoid.daytime.hypoglycaemia.Lunch..Omit.Iftar .Usual.pre-Ramadan.dinner.dose..May.require.dose.increment.*.Total.insulin.requirement.for.Type.1.diabetics.who.are.on.basal.bolus.insulin.regimen.while.fasting.during.Ramadan.may.require.dose.reduction.by.1530%.of.their.pre-Ramadan.dose.requirements.

insulin pump Basal.insulin.rate:.Unchanged.or.may.require.reduction.of.up.to.25%.

Prandial.bolus:.According.to.individualised.insulin.to.carbohydrate.ratio.(ICR).

34

references1. Salti.I,.Bnard.E,.Detournay.B,.et.al.A.population-based.study.of.diabetes.and.its.characteristics.during.the.fasting.


2. Kobeissy.A,.Zantout.MS,.Azar.ST..Suggested.insulin.regimens.for.patients.with.type.1.diabetes.mellitus.who.wish.to.fast.during.the.month.of.Ramadan..Clin Ther. 2008;.30(8):.1408-1415.

3. Kassem.HS,.Zantout.MS,.Azar.ST..Insulin.therapy.during.Ramadan.fast.for.Type.1.diabetes.patients..J Endocrinol Invest. 2005;.28(9):.802-805.

4. Kadiri.A,.Al-Nakhi.A,.El-Ghazali.S,.et.al..Treatment.of.type.1.diabetes.with.insulin.lispro.during.Ramadan..Diabetes Metab. 2001;.27(4.Pt.1):.482-486.

5. Reiter.J,.Wexler.ID,.Shehadeh.N,.et.al..Type.1.diabetes.and.prolonged.fasting..Diabet Med. 2007;.24(4):.436-439.6. Mucha.GT,.Merkel.S,.Thomas.W,.et.al..Fasting.and.insulin.glargine.in.individuals.with.type.1.diabetes..Diabetes Care.

2004;.27(5):.1209-1210.7. Al-Arouj.M,.Assaad-Khalil.S,.Buse.J,.et.al..Recommendations.for.management.of.diabetes.during.Ramadan:.update.

2010..Diabetes Care. 2010;.33(8):.1895-902.8. Ministry.of.Health.Malaysia..Practical.guide.to.insulin.therapy.in.type.2.diabetes.mellitus..2010.9. Pathan.MF,.Sahay.RK,.Zargar.AH,.South.Asian.Consensus.Guideline:.Use.of.insulin.in.diabetes.during.Ramadan..Indian

J Endocrinol Metab. 2012;.16(4):.499-502.10. Hui.E,.Devendra.D..Diabetes.and.fasting.during.Ramadan..Diabetes Metab Res Rev. 2010;.26(8):.606-610.11. Bin-Abbas.BS..Insulin.pump.therapy.during.Ramadan.fasting.in.type.1.diabetic.adolescents..Ann Saudi Med. 2008;.

28(4):.305-306.12. Hawli.YM,.Zantout.MS,.Azar.ST..Adjusting.the.basal.insulin.regimen.of.patients.with.type.1.diabetes.mellitus.receiving.

insulin.pump.therapy.during.the.Ramadan.fast:.A.case.series.in.adolescents.and.adults..Curr Ther Res Clin Exp. 2009;.70(1):.29-34.

13. Benbarka.MM,.Khalil.AB,.Beshyah.SA,.et.al..Insulin.pump.therapy.in.Moslem.patients.with.type.1.diabetes.during.Ramadan.fasting:.an.observational.report..Diabetes Technol Ther. 2010;.12(4):.287-290.

14. Hui.E,.Bravis.V,.Salih.S,.et.al..Comparison.of.Humalog.Mix.50.with.human.insulin.Mix.30.in.type.2.diabetes.patients.during.Ramadan..Int J Clin Pract. 2010; 64(8):.10951099.

35

GlossarY oF terMs

. BMI. Body.mass.index

. DKA. Diabetic.ketoacidosis

. EPIDIAR. Epidemiology.of.Diabetes.and.Ramadan

. HDL. High-density.lipoprotein

. hs-CRP. High-sensitivity.C-reactive.protein

. ICR. Insulin.to.carbohydrate.ratio

. IGF-1. Insulin-like.growth.factor.1

. OAD. Oral.anti-diabetic

. MR.. Modified-release

. PAI-1. Plasminogen.activator.inhibitor.type-1

. SMBG. Self-monitoring.of.blood.glucose

acKnoWledGeMentsThe.members.of.the.working.committee.of.this.guide.would.like.to.express.their.gratitude.and.appreciation.to.the.following.for.their.contributions:

.Panel.of.external.reviewers.who.reviewed.the.draft.

.All.those.who.have.contributed.directly.or.indirectly.to.the.development.of.this.guide.

sources oF FundinGThe.development.of.this.guide.was.supported.by.an.educational.grant.from:

practical guide to diabetes management in ramadhan

Documents

diabetes management