recommendations for management of diabetes during ramadan diabetes care, volume 28, number 9,...

Recommendations for Recommendations for

Management of Diabetes During Management of Diabetes During

RamadanRamadan

Diabetes Care, volume 28, NUMBER 9, September 2005

بسم الله الرحمن الرحيمبسم الله الرحمن الرحيم

من وبينات للناس هدى القرآن فيه انزل الذي رمضان شهر

كان ومن فليصمه الشهر منكم شهد فمن والفرقان الهدى

اليسر بكم الله يريد اخر ايام من فعدة سفر على او مريضا

ما على الله ولتكبروا العدة ولتكملوا العسر بكم يريد وال

تشكرون ولعلكم سورة ألبقرة - يةآ هداكم

۱۸٥

MONIRA AL-AROUJ, MDMONIRA AL-AROUJ, MD

RADHIA BOUGERRA, MDRADHIA BOUGERRA, MD

JOHN BUSE, MD, PHDJOHN BUSE, MD, PHD

SHERIF HAFEZ, MD, FACPSHERIF HAFEZ, MD, FACP

MOHAMED HASSANEIN, FRCPMOHAMED HASSANEIN, FRCP

MAHMOUD ASHRAF IBRAHIM, MDMAHMOUD ASHRAF IBRAHIM, MD

FARAMARZ ISMAIL-BEIGI, MD, PHDFARAMARZ ISMAIL-BEIGI, MD, PHD

IMAD EL-KEBBI, MDIMAD EL-KEBBI, MD


OUSSAMA KHATIB, MD, PHDOUSSAMA KHATIB, MD, PHD

SOUHAIL KISHAWI, MDSOUHAIL KISHAWI, MD

ABDULRAZZAQ ALMADANI, MDABDULRAZZAQ ALMADANI, MD

ALY A. MISHAL, MD, FACPALY A. MISHAL, MD, FACP

MASOUD AL-MASKARI, MD, PHDMASOUD AL-MASKARI, MD, PHD

ABDALLA BE NAKHI, MDABDALLA BE NAKHI, MD

KHALED AL-RUBEAN, MDKHALED AL-RUBEAN, MD


I.I. Risks associated with FASTING in Risks associated with FASTING in

patients with diabetespatients with diabetes

II.II. ManagementManagement

III.III. ConclusionsConclusions

Risks associated with FASTING in Risks associated with FASTING in patients with diabetespatients with diabetes


EPI.DIA.R EPI.DIA.R trial (EPIdemilogy DIAbetes in trial (EPIdemilogy DIAbetes in

Ramadan)Ramadan)

Multi-country epidemiological study (Algeria,

Bangladesh, Egypt, India, Indonesia, Jordan, Lebanon,

Malaysia, Morocco, Pakistan, Saudi Arabia, Tunisia & Turkey)

12,273 diabetic patients

Individuals who fast during Ramadan showed a

high rate of acute complications

Risks associated with FASTING Risks associated with FASTING in patients with diabetesin patients with diabetes


1. Hypoglycemia

2.2. HyperglycemiaHyperglycemia

3.3. Diabetic ketoacidosisDiabetic ketoacidosis

4.4. Dehydration and Dehydration and

thrombosisthrombosis


EPI.DIA.REPI.DIA.R

Fasting during Ramadan increased the risk of

severe hypoglycemia (defined as hospitalization

due to hypoglycemia)

4.7-fold in patients with type 1 diabetes

7.5-fold in patients with type 2 diabetes

Risks associated with FASTING in Risks associated with FASTING in patients with diabetespatients with diabetes - -

hypoglycemiahypoglycemia


EPI.DIA.REPI.DIA.R

Severe hypoglycemia was more frequent among

patients who:

Had changed the dosage of their

hypoglycemic agent or insulin

Reported a significant change in their lifestyle

Risks associated with FASTING in Risks associated with FASTING in patients with diabetes patients with diabetes --

hypoglycemiahypoglycemia


Long term morbidity-mortality trials Long term morbidity-mortality trials

demonstrated a link between hyperglycemia, demonstrated a link between hyperglycemia,

microvascular complications and possibly microvascular complications and possibly

macrovascular complicationsmacrovascular complications

There is no data linking short term

hyperglycemia and diabetes related

complications


hyperglycemiahyperglycemia


EPI.DIA.R

5-fold increase in the incidence of

hyperglycemia in patients with type 2

diabetes

3-fold increase in the incidence of severe

hyperglycemia (with or without keto-

acidosis) in patients with type 1 diabetes




EPI.DIA.R

Hyperglycemia may have been due to

excessive reduction in dosages of medication

to prevent hypoglycemia

Patients who reported an increase in

food/sugar intake had significantly higher

rates of severe hypoglycemia




EPI.DIA.R

Patients with diabetes (especially type 1)

who fast during RAMADAN are:

At increased risk for developing keto-

acidosis

Risk furthermore increased if they reduce

the insulin dosages (assuming that food

intake is reduced during RAMADAN)

Risks associated with FASTING in Risks associated with FASTING in patients with diabetes patients with diabetes –Diabetic –Diabetic

KetoacidosisKetoacidosis


Patients with diabetes exhibit a

hypercoagulable state due to:

An increase in clotting factors

A decrease in endogenous anticoagulants

An impaired fibrinolysis

Increased blood viscosity secondary to

dehydration may enhance the risk of

thrombosis

Risks associated with FASTING in Risks associated with FASTING in patients with diabetes patients with diabetes –Dehydration & –Dehydration &

ThrombosisThrombosis


A report from KSA suggested an increased

incidence of retinal vein occlusion in patients

who fasted during RAMADAN

Hospitalization due to coronary events or

stroke was not increased during RAMADAN

No available data on the effect of fasting on

mortality in patients with or without diabetes

Risks associated with FASTING in Risks associated with FASTING in patients with diabetes patients with diabetes –Dehydration & –Dehydration &

ThrombosisThrombosis


Fasting for patients with diabetes

represents an important personal

decision that should be made in the

light of guidelines for religious

exemptions and after careful

considerations of the associated risks

following ample discussion with the

treating physician.

MANAGEMENTMANAGEMENT


Most of the time: the

recommendations will be not to

undertake fasting

Patients who insist on fasting must be

aware of the associated risks and must

be ready to adhere to the

recommendations of their healthcare

providers



Patients may be at HIGHER or LOWER

risk for fasting-related complications

depending on the number and extent of

their risk factors



Conditions associated with “Conditions associated with “Very HighVery High”, ”, “High”, “Moderate” & “Low” risk for “High”, “Moderate” & “Low” risk for adverse events in diabetic patients adverse events in diabetic patients

deciding to fast RAMADANdeciding to fast RAMADAN


Conditions associated with “Very High”, Conditions associated with “Very High”, ““HighHigh”, “Moderate” & “Low” risk for ”, “Moderate” & “Low” risk for adverse events in diabetic patients adverse events in diabetic patients



Conditions associated with “Very High”, Conditions associated with “Very High”, “High”, ““High”, “ModerateModerate” & “” & “LowLow” risk for ” risk for adverse events in diabetic patients adverse events in diabetic patients



a. Individualization

b. Frequent monitoring of glycemia

• Patient must have the means to

monitor his BG multiple times daily

• Very important with patients using

insulin


I- General ConsiderationsI- General Considerations


c. Nutrition:

• Healthy and balanced diet

• Maintain constant body mass

• 20-25% gain or loose weight during the

RAMADAN fast

• Avoid ingesting large amount of

carbohydrate and fat (common

practice)




c. Nutrition:

• “Complex” carbohydrates are advisable at

the predawn meal (delay in absorption)

• Simple carbohydrates more appropriate at

the sunset meal

• Increase liquid intake during non-fasting

hours

• Delay predawn meal as much as possible




d. Exercise:

• Maintain normal level of physical activity

• Excessive physical activity: increased risk of hypoglycemia (especially before Iftar)

• Tarawih are to be considered as part of the daily exercise

• In some poorly controlled type 1 diabetic patients: exercise could lead to extreme hyperglycemia




e. Breaking the fast:

• Immediately if hypoglycemia occurs

(BG<60mg/dL, 3.3 mmol/L)

• If BG<70mg/dL, 3.9 mmol/L in the few hours after the start of the fast

• If BG exceeds 300 mg/dL, 16.7 mmol/L

• Sick days




a. Medical Assessment:

• 1-2 months before RAMADAN

• Specific attention to the: well-being of the patient Glycemia BP lipids

• Specific medical advice for those who wish to fast against medical recommendations

MANAGEMENTMANAGEMENTII- Pre-RAMADAN II- Pre-RAMADAN medical assessment medical assessment & &

educational counselingeducational counseling


a. Medical Assessment:

• During this assessment, necessary

changes in the diet or medication

regimen should be made so that the

patient initiates fasting while being on

stable and effective program

MANAGEMENTMANAGEMENTII- Pre-RAMADAN II- Pre-RAMADAN medical assessment medical assessment & &



b. Educational Counseling:

• Educate the patient and his family on: Signs & symptoms of hypoglycemia

BG monitoring

Meal planning

Physical activity

Medication administration

Management of acute complications

MANAGEMENTMANAGEMENTII- Pre-RAMADAN medical assessment & II- Pre-RAMADAN medical assessment &



b. Educational Counseling:

• Emphasizing on adequate nutrition and

hydration

• Ensuring preparedness to treat hypoglycemia

promptly

Glucose gel

Glucose containing liquids

Glucose tablets

Glucagon injections…

MANAGEMENTMANAGEMENTII- Pre-RAMADAN medical assessment & II- Pre-RAMADAN medical assessment &



a. Should be advised not to fast:

• Type 1 diabetic patients, especially if poorly

controlled

• Patients unwilling/unable to monitor their BG

multiple times daily

MANAGEMENTMANAGEMENTIII- Management of patients with III- Management of patients with type 1type 1 diabetes diabetes


b. Close monitoring and frequent insulin dose

adjustments are essential to achieve

optimal glycemic control and avoid hypo-

hyperglycemia

c. One injection of intermediate or long acting

insulin before evening meal is not likely to

provide adequate insulin coverage for

24hrs



d. Typically, patients will need to use 2 daily

injections of NPH as intermediate-acting

insulin, administered before the predawn

and the sunset meals, in combination with

a short-acting insulin to cover food intake

at the associated meal.



e. There is an increased risk of hypoglycemia

around midday due to peaking of the early

morning insulin dose

f. Using the long-acting insulin ultralent is an

option, with twice daily injections at 12 hrs

intervals & a rapid- or short-acting insulin

should be added before the 2 meals.



g. Other options:

• Glargine once daily or

• Detemir twice daily

• Along with premeal rapid-acting insulin

analogs


h. Clinical studies with other types of insulin

during fasting are limited.


Low risks of complications for type 2

diabetic patients well controlled with diet

alone

Potential risk of postprandial

hyperglycemia after predawn and sunset

meals if patients overindulge in eating

Distributing calories over 2 or 3 smaller

meals may help preventing excessive

hyperglycemia

MANAGEMENTMANAGEMENTIV- Management of patients with IV- Management of patients with type 2type 2 diabetes diabetes


The choice of oral agents should be

individualizedindividualized


IV- Management of patients with IV- Management of patients with type 2type 2 diabetes diabetes

Patients treated with oral agentsPatients treated with oral agents


a. Metformin:

Metformin alone: safer because of the

minimal risk of hypoglycemia

Recommendations for the dose in

Ramadan:

• 2/3 of the total daily dose immediately

before the sunset meal

• 1/3 before the predawm meal





b. Glitazones:

Glitazone monotherapy: low risk of

hypoglycemia

Recommendations for the dose:

• Usually no change in the dose is

required





c. Sulfonylureas:

Use should be individualized and utilized

with caution

Chlorpropamide is absolutely contra-

indicated during Ramadan (prolonged

hypoglycemia)





c. Sulfonylureas:

New members of the SU family (e.g.

Gliclazide MR) have been shown to be

effective, resulting in a lower risk of

hypoglycemia





d. Short acting insulin secretagogues:

Useful be cause of their short duration of

action.

Can be taken twice daily:

• Before sunset meal

• Before predawn meal





Problems similar to those of the patients

with type 1 diabetes but with less incidence

of hypoglycemia

Aim: To maintain necessary levels of basal insulin

To suppress Hepatic Glucose Output to near-

physiologic levels during the fasting period.



Patients treated with insulinPatients treated with insulin


Judicious choice of intermediate or long-

acting insulin preparations + short-acting

insulin before meals would be an effective

strategy

Special risk of hypoglycemia Patients who had required insulin for a number

of years

Very elderly diabetic patients





May provide adequate coverage:

One injection of a long-acting insulin

analog or

2 injections of NPH, lente or Detemir

insulin before the sunset and pre-dawn

mealsAs long as the dose/injection is properly individualized





May provide acceptable glycemic control in

patients with reasonable basal insulin

secretion:

Single injection of intermediate-acting

insulin, before the sunset meal





Most patients will require short-acting insulin

administered in combination with the

intermediate- or long-acting insulin at the sunset

meal (to cover for the large caloric load of Iftar)

Many will need additional dose of short-acting

insulin at predawn





The overall dosage of medications,

especially that of insulin, must be adjusted

in conjunction with the weight loss or gain

that may occur during Ramadan





Pregnancy is a state of increased insulin

resistance and insulin secretion and of reduced

hepatic insulin extraction

Elevated BG & HbA1c levels in pregnancy are

associated with increased risk of major congenital

malformations

Fasting during pregnancy would be expected to

carry a high risk of morbidity-mortality to the fetus

and the mother (controversies exist)


IV- IV- PregnancyPregnancy and fasting during and fasting during

RAMADANRAMADAN


Muslim women are exempted from fasting during

RAMADAN: those who insist on fasting constitutes

a high-risk group



RAMADANRAMADAN


Women with pre-gestational/gestational diabetes:

Should be strongly advised to not fast

Those who insist of Fasting:

• Special attention to their care

• Essential pre-Ramadan evaluation of their medical

condition

• Pre-conception care

• Emphasis on achieving near-normal BG and A1c values

• Counseling about maternal and fetal complications

associated with poor glycemic control

• Education on self-management skills



RAMADANRAMADAN


Ideally, patients should be managed in high risk

clinics staffed by an Obstetrician, Diabetologists,

a nutritionist and diabetes nurse educators

The management of pregnant patients during

RAMADAN is based on appropriate diet and

intensive insulin therapy



RAMADANRAMADAN


May occur in Ramadan, especially if fasting is

prolonged or associated with excessive

perspiration:

Dehydration

Volume depletion

Tendency toward hypotension

Dosage of antihypertensive medications may

need to be adjusted


V-V- Hypertension Hypertension and dyslipidemiaand dyslipidemia


Carbohydrate & fat intake is commonly

increased in Ramadan:

Counseling to avoid this excessive

intake

Continue the lipid- cholesterol lowering

agents previously prescribed


V- Hypertension and V- Hypertension and dyslipidemiadyslipidemia


Fasting carries a risk of complications for diabetic

patients

Type 1 diabetic patients should be strongly

advised not to fast (hypo- hyperglycemia)

Type 2 diabetic patients, who fast Ramadan, are

at relatively lower risk of hypo- hyperglycemia

Conclusion(s)Conclusion(s)


Patient’s decision to fast should be made after

discussion with his/her physician

Patients who insist of fasting should undergo pre-

Ramadan assessment & receive appropriate

education/counseling

Close follow-up is essential to reduce the risk of

complications

Conclusion(s)Conclusion(s)

Recommendations for Management of Recommendations for Management of Diabetes During RamadanDiabetes During Ramadan


Kindly pick-up your

copy of the

Ramadan Ramadan

Consensus Consensus before

leaving the

meeting room

recommendations for management of diabetes during ramadan diabetes care, volume 28, number 9,...

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