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RAMADAN ANDMEDICINES OPTIMISATION

D r M G P a t e l F R P h a r m s P h D F e l l o w o f N I C E

S o u t h A s i a n H e a l t h F o u n d a t i o n - C h a i r C V D

B M J D i a b e t e s A w a r d W i n n e r ( 2 0 1 5 )

m . p a t e l @ h u d . a c . u k

OVERVIEW

Influence of religion, culture and ethnicity

Principles of Ramadan and its impact

Diabetes and its prevalence

Diabetes and associated risk among SouthAsian populations

Supporting patients during Ramadan

PRE – KNOWLEDGE DIABETES. MEDICINES ANDFASTING DURING RAMADAN1. Fasting ?

2. Monitoring of blood glucose levels?

3. Wake up for Suhoor?

4. Ear drops?

5. GTN tablets?

6. Salbutamol inhaler?

7. Mouthwash /gargles?

8. Intravenous feeding?

9. Nose drops?

10.Eye drops?

Recommendations of the 9th Fiqh-Medical seminar “An Islamic View of Certain ContemporaryMedical Issues,” Casablanca, Morocco, 14-17 June 1997(www.islamset.com/search/index.html).

SOUTH ASIAN POPULATION:UK CENSUS 201156,075,912 people living in England and Wales56,075,912 people living in England and Wales

• 1.4m were Asian/Asian British: Indian• 1.1m were Asian/Asian British: Pakistani• 0.4m were Asian/Asian British: Bangladeshi• Overall South Asian/South Asian British account for 5.3% of UK population

(Indian, Pakistani, Bangladeshi)

London most ethnically diverse area and Wales the leastLondon most ethnically diverse area and Wales the least

• 38% Asian/Asian British: Indian population based in London• Other areas include West Yorkshire as well as the Midlands, and Greater

Manchester

Office of National Statistics(2011)

SOUTH ASIANS: LANGUAGE

92% of population of England and Wales (aged 3 andover) speak English as main language (English orWelsh in Wales)

Only138,000 people say don’t speak English at all (lessthan 0.5%)

Second most reported main language was Polish (1%,546,000), followed by Punjabi (0.5%, 273,000) andUrdu (0.5%, 269,000)

Office for National Statistics (2013)

SOUTH ASIANS: RELIGION Muslims are 2nd largest religious group in England/Wales - with

2.7 million people (4.8 % of the population) Showed increase in all other main religions, aside from Christianity. Number of Muslims increased the most by1.8% since 2001 census

Main religions Minority religions

Office for National Statistics (2011)

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Public Health England. 2013

HEALTH - TYPE 2 DIABETESBY ETHNIC GROUP (PER100)

White 1.7All ethnic minorities 5.7African Caribbean 5.3All South Asians 6.2Indian or African Asian 4.7Pakistani or Bangladeshi 8.9Chinese 3.0

Diabetes UK: Facts and Stats 2014Hansard 10.02.2014. Last accessed: January 2015

IHD IN MEN AGED 20-74YRSBangladeshi 151 ( 136-167)

• Pakistani 148 (138-158)

• Indian 142 (137-147)

• Irish 124 (120-127)

• White 100

• Caribbean 62 (58-67)

• Chinese 44 (36-54)

Gill et al http://hcna.radcliffe-oxford.com/bemgframe.htm

IHD IN WOMEN AGED 20-74YRS

Indian 158 (148-168)Irish 120 (114-126)Pakistani 111 (93-130)White 100Bangladeshi 91 ( 60-133)Caribbean 86 (77-96)Chinese 43 (30-60)

Gill et al http://hcna.radcliffe-oxford.com/bemgframe.htm

LIFESTYLE RISK FACTORSSmoking27% smokecompared to21% nationally(40% inBangladeshimales), highestdeath rateattributable tosmoking inLondon)

Physical Activity18% participate insport/active recreationcompared to 21%nationally. Lowest levelsin Bangladeshi females

Alcohol50% have not had analcoholic drink in thepast year but 40% ofwhite populationclassified as problemdrinkers compared to20% nationally

Healthy Eating90% eat less than 5 a daycompared to 70%nationally

People who adopt four healthybehaviours would expect to liveon average fourteen yearslonger than those who adoptnone (based on EPIC-Norfolk)

4 in 10 of the Tower Hamletspopulation adopt only onehealthy behaviour (mainlyalcohol abstinence)

Unpublished data sourced from local PublicHealth Organisation

REASONS BEHIND POOR HEALTH

Comparatively low socio-economic position

Late diagnosis of certainconditions contributes to

poor survival rates

Language barriers

Cultural barriers:‘taboos’ in certainreligions leads to

underreporting of illness

Fatalism

Higher genetic risk factors:including diabetes and

high blood pressure

Lifestyle factors:High level of smoking

amongst some SAcommunities

Lifestyle factors:High fat diets and low

levels of exercise

Diabetes in BMECommunities (2014)

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ETHNICITY, CULTURE & HEALTHINEQUALITIES Ethnic group: A group of people who share characteristics

such as language, history, religion, nationality, geographicaland ancestral origins and place (Bhopal Dept of Health)

Health Inequalities: Differences in health status or in thedistribution of health determinants between differentpopulation groups (WHO)

Cultural competence: ‘Ability of systems to provide care topatients with diverse values, beliefs, and behavioursincluding tailoring delivery to meet patients’ social, culturaland linguistic needs’ Betancourt & Carrillo (2002)

What about medicines in South Asians?

BIG concern...

e.g. for those on statins

1/4 with muscle aches took NO action

Half spoke to GP for advice

50% thought awareness and understanding ofS/E better if explained in own language

• Nearly a quarter (24%) of people with highcholesterol don’t realise it significantly increasestheir risk of heart disease

• Nearly a third (29%) of people with high bloodpressure unaware of the link with heart disease

WHY IS THIS STILL A PROBLEM I? LANGUAGE, CULTURE, HEALTHBELIEFS & ATTITUDESExample with Insulin therapy 212 consecutive South Asian patients who required

insulin 122 (57.5%) were happy to commence insulin

immediately 47 (22.1%) reluctant to start insulin 43 (20.3%) refused insulin – variety of reasons:

22 (10.4%) – needles the prime reason

Khan H, Lasker SS, Chowdhury TA. Prevalence and reasons for insulin refusalamongst Bangladeshi patients with poorly controlled type 2 diabetes in East London.Diabetic Medicine 2008; 25: 1108-1111

DEFINITION OF ADHERENCE‘The extent to which a person's behaviour - takingmedication, following a diet and/or executing lifestylechanges - corresponds with agreed recommendationsfrom a healthcare provider‘

World Health Organisation (WHO) 2004

Video:http://www.patientvoices.org.uk/flv/0239pv384.htm

WHO (2015) available [online]: http://apps.who.int/medicinedocs/en/d/Js4883e/6.html

In 2009 the National Institute of Clinical

Excellence produced guidance around

supporting medication adherence – recently

updated 2015

NICE MEDICINES ADHERENCEGUIDELINE CG 76

www.nice.org.uk

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AIM OF THE CONSULTATION

Effective treatment

To assist the patient to make an informed choice, asfar as is possible

A regimen that does not interfere with the patientdaily life

A treatment in line with the patients beliefs

CONCERNS PATIENT ABOUT TAKINGMEDICINES

Sociological literature identifies following ways of thinkingabout medicines and medicine taking: The perceived efficacy of the medicine. The danger of becoming ‘immune’ over time The ‘unnaturalness’ of manufactured medicines. The danger of addiction or dependence An anti-drug attitude Balancing risks and benefitsManaging everyday life Discrepancies between the doctors and patients perceptions of risk

WHO’S AT RISK OF NON-COMPLIANCE/NON-CONCORDANCE? Poly-pharmacy

Elderly

Patients who do not enter alliance with honesty & openness

Mental health service users

Patient who do not feel the direct benefit of treatment

Financial difficulty

RELIGION –ISLAM

RAMADAN

When do Muslims fast?On the 9th month of lunar calendar Islamic calendar is 354 daysFasting lasts from dawn (Sahur) to dusk (Iftar)Duration of fast 28 -30 days.

What does fasting entail?Arabic origin Sawm: “abstention from smoking, eating,

drinking, sexual activity, consuming oral medications……

RAMADANWho fasts?Ramadan should be practiced by all healthy, responsible

and sane Muslims after the age of pubertyExemptions? If considered to detrimental to individual’s health

“….Allah intends every facility for you; He does not want to put you todifficulties. (He wants you) to complete the prescribed period and toglorify Him in that. He had guided you; and perchance you shall begrateful.” (2:185).

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RAMADANThose considered exempt:The frail, elderly and childrenPatients with a chronic condition whereby fasting would be

detrimental to their healthCannot understand the purpose of fasting i.e. those who

have learning difficulties or are mentally insaneTravellers (those travelling greater than 50 miles)*Acutely unwell*Pregnant and breast feeding women*

NB: Where fasting is with difficulty they have a choice either to fast or to feed apoor person for every day. (Surah Baqarah: Ayah 184)

Festival of Eid ul-fitr marks end of Ramadan

RAMADAN

Psychological changes A practice in self sacrifice and appreciate what one has Time for charity Time for self-reflection Feelings of anger during this holy month may nullify

the benefit of fasting Participating in fasting allows individuals to attain

spiritual peace

RAMADAN

Physiological changes when fasting:Decreased insulin secretion and glucose levels Increased glycogenolysis and gluconeogenesis Increased levels of regulatory hormones (glucagon and

catecholamine) Increased fatty acid production and ketones

In Type 1 diabetics & those with insulin deficiency Excessive glycogenolysis, gluconeogenesis and ketogenesis.

PATHOPHYSIOLOGY OF FASTING

RAMADAN BIOCHEMICAL CHANGES RELIGIOUS FESTIVALS

https://www.diabetes.org.uk

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RELIGIOUS FESTIVALS

RELIGIOUS FESTIVALS

RELIGIOUS FESTIVALS

Cultural information

Fasting is not required in Sikhism but is a matter of choice.

RELIGIOUS FESTIVALS

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IMPACT OF FASTING

Ramadan and Diabetes: A guide for patientswww.mcb.org.uk

POTENTIAL RISKS WHEN FASTING

1 Hypoglycaemia

2 Hypergylaemia

3 Dehydration

4 Ketoacidosis

MEDICATIONS AND RAMADAN

Area of contention and uncertainty Medications which do NOT invalidate the fast

Medications that DO invalidate the fast

FASTING DURING RAMADAN

Most diabetics will fast even if at highrisk – EPIDIAR studyHealthcare professionals (HCP) can usetable below for those fasting:Low risk category can fast withoutseeking advice from HCP.Moderate risk category can reducetheir risk by seeking appropriate advicefrom HCP before fasting commences.High risk patients are recommendednot to fast - ↑risk of hypoglycaemia andworsening diabetic control

DIABETES RECENT CLINICAL TRIALSVECTORVECTOR

VECTOR ConcordanceVECTOR Concordance

TREAT 4 RamadanTREAT 4 Ramadan

VIRTUEVIRTUE

STEADFASTSTEADFAST

Hassanein M, et al. Curr Med Res Opin. 2011;27:1367

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SUGGESTED CHANGESBefore Ramadan During Ramadan

Diet controlled No change needed health lifestyle advise reiterated

Biguanides:Metformin 500 TDSMetformin SR 1000mg OD

Metformin 1000mg (sunset-Iftar), 500mg (sunrise Suhur)Metformin 100mg (sunset-Iftar)

ThiazolidinedionesSGLT 2 Inhibitors

No changeNo Change in Dose but be aware of dehydration in hot climate.

Sulphonylurea:Gliclazide 80mg BDGlimepiride 4mg OD

Gliclazide 80mg (sunset-Iftar), 40mg (sunrise-Suhur)Glimepiride 4mg (sunset-Iftar)

Prandial regulators:Repaglinide 4mg BD

No change (taken with Iftar and Suhur)

Incretin mimetics:Linagliptin 5mg OD

No change (taken with Iftar), if taken with SU, dose of SU will needreducing

Exenetide10mcg BD

Liraglutide 1.2 mg OD

No change (taken with Iftar), if taken with SU, dose of SU will needreducing be aware that the gap between two injection of Byettashould be more than 6 hrs.

No change in dose required

Insulins:Once daily Glargine 20 units Glargine 16 units (20% decrease in dose) with Iftar

Pre Mixed InsulinHumalog Mix 25 30 and 20 units

10 units (sunrise Suhur) and 30 units (sunset-Iftar). Swap the dose togive more with Ifter and reduce Suhur dose)

Novorapid/Humalog10 units TDS with each meal

Omit afternoon dose. Twice daily with Iftar and Suhur meals

Adapted from Karamat MA et al (2010) J R Soc Med 103: 139−47

DIABETES MANAGEMENT FORRAMADAN Pre Ramadan counselling Medical assessment Education During Ramadan

Lifestyle modification Nutrition Exercise

Breaking fast

REVIEW MEDICINES

At agreed intervals, review patients’ knowledge,understanding and concerns about medicines andwhether they think they still need the medicine

Offer repeat information and review, especially whentreating long-term conditions with multiple medicines

Ask about adherence when reviewing medicines

KEEPING HEALTHY DURING HAJJDuties and rites during Hajj are physically demandingMakkahMina

It is obligatory that everyone going: Is well prepared Takes necessary preventative measures Maintains good health

Alsafadi, Goodwin & Syed (2011) Diabetes care during Hajj

PREPARATIONS BEFORE THEJOURNEY Know the symptoms of a “hypo” and how to treat it Keep a sugary snack with you Keep insulin in the fridge if possible BUT always keep it away from

direct sunlight. Storage devices for Insulin Take plenty of needles and take advise on how to dispose the needles. Check blood sugars regularly especially if you are on Insulin ID card/medic alert bracelet About 2 months before going on Hajj see your GP/Nurse inform

them that you are going on Hajj and request an annual review ofdiabetes.

Alsafadi, Goodwin & Syed (2011) Diabetes care during HajjITEM CODE: PHGB/NPR/1214/0010

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SUMMARY Fasting occurs in religions other than Islam

Monitor blood glucose levels regularly as well as otherbiochemical parameters – this does not break the fast.

Also refer to doctor or diabetes team before fasting ifnecessary.

If feeling ill – important that fast is broken

Tailor therapy accordingly using oral and injectablemedications during fasting

ADVICE DURING RAMADANPractical advice Accurate distribution of twice daily dosing is difficult to achieve

between SAHUR and IFTAR Drug-food interactions may be more prominent resulting in ↑or ↓

availability Patients should ideally undergo a medication review 1-2 months

before RamadanDrug advice Angina – can change to 24hr patch for symptom control Smoking cessation Consider change to sustained release preparations Asthmatics – important to continue with inhalers

SACHE across major UK regions

Prevalence of diabetes in selected CCGs

Bradford 11.0%

Sandwell & West Birmingham 10.1%

Harrow 10.1%

Brent 9.5%

Newham 10.2%

Contents and delivery

DVDs, slide presentations, visual aids,leaflets/supporting materials in differentlanguages 12 Places of worship and community centres:

• Leeds• Dewsbury• Sheffield• Leicester• London• Birmingham• Glasgow

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Community engagement

Outcomes

• Lifestyle changes - moderation generally moreeffective than stopping

• Places of worship and community centres idealareas for engagement

• Access to the various S. Asian communities &across up to three generations

• Access to both men and women• Potential for wider third sector involvement

Slaying myths...EDUCATION AND MYTHS

• Accredited course BME Diabetes 2015 – supporting black and minorityethnic patients with diabetes

• Some slide contents have been reviewed by Janssen to ensure compliancewith the ABPI Code of Practice for the Pharmaceutical Industry.

• Speakers may express personal opinions that are not necessarily shared byJanssen.

• Janssen-Cilag Ltd, 50-100 Holmers Farm Way, Buckinghamshire, HP12 4EG,UK

Diabetes in Black and Minority Ethnic Groups– Accredited Course

THANK YOU FOR ATTENDING

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Thank You

Date of Preparation: April 2015Item Code: PHGB/NPR/1214/0010k