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

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In this slide set we present recommendations on the management of Diabetes during the period of Ramadan. Preparations prior to fasting, management during the period and adjustments to be made.

In this slide set we present recommendations on the management of Diabetes during the period of Ramadan. Preparations prior to fasting, management during the period and adjustments to be made.

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  • 1. Managing Diabetes During Ramadan and Fasting During Lent Alan Chang, MD, FPCP, FPSEM Jeremy Robles, MD, FPCP, FPSEM
  • 2. 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
  • 3. 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
  • 4. 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”
  • 5. 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
  • 6. 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
  • 7. 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
  • 8. 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
  • 9. Ramadan impact on Individuals • Physiological Changes • Fasting > 8 hours • Reduced Glucose levels & Insulin Secretion • Glycogenolysis & Gluconeogenesis occurs • Increased counter regulatory hormones (Glucagon & Cathecolamine) • Increased fatty acid production & ketones NHS Gilani A. Ramadan and your Diabetic patient: A resource pack for Healthcare Professional 2011
  • 10. Ramadan impact on Individuals • 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 NHS Gilani A. Ramadan and your Diabetic patient: A resource pack for Healthcare Professional 2011
  • 11. 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 Metabolism No significant change expected. Increased total cholesterol & decreased TGL in new studies. Micro & Macro Complications Variable and individualised
  • 12. 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
  • 13. 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.
  • 14. 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
  • 15. 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.
  • 16. Pre-Ramadan Assessment & 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 Hassan Chamsi-Pasha and Khalid S. Aljabri. Avicenna J Med. 2014 Apr-Jun; 4(2): 29–33.
  • 17. Case Q2 • Before starting Ramadan, Abdul should undergo rigorous physical assessment A. True B. False
  • 18. Pre-Ramadan Assessment & 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.
  • 19. 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
  • 20. Changes in Lifestyle, Weight & meds during Ramadan (EPIDIAR) Study EPIDIAR 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
  • 21. 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 caffeine NHS Gilani A. Ramadan and your Diabetic patient: A resource pack for Healthcare Professional 2011
  • 22. 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
  • 23. 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
  • 24. 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 intervals Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4
  • 25. Ramadan impact on Individuals 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
  • 26. 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
  • 27. Medical Management (Oral - Injectable Meds)
  • 28. 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 Hassan Chamsi-Pasha and Khalid S. Aljabri. Avicenna J Med. 2014 Apr-Jun; 4(2): 29–33.
  • 29. 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 Hassan Chamsi-Pasha and Khalid S. Aljabri. Avicenna J Med. 2014 Apr-Jun; 4(2): 29–33.
  • 30. 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 Hassan Chamsi-Pasha and Khalid S. Aljabri. Avicenna J Med. 2014 Apr-Jun; 4(2): 29–33.
  • 31. South Asian Consensus Guideline: Use of insulin in Diabetes during 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
  • 32. South Asian Consensus Guideline: Use of insulin in Diabetes during Ramadan Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4 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 Risk Well controlled patients treated with short acting insulin secretagogues Low Risk Well controlled patients treated with diet, MET, TZD or otherwise healthy
  • 33. South Asian Consensus Guideline: Use of insulin in Diabetes during Ramadan • Premix Insulin (eg. 70/30 insulin) Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4 Before Ramadan During Ramadan Morning Dose Pre-Breakfast Sahur Half dose of Pre-dinner Evening Dose Pre Dinner Iftar Full Pre- Breakfast dose
  • 34. South Asian Consensus Guideline: Use of insulin in Diabetes during Ramadan • Basal Bolus (eg. Basal Long Acting + Prandial) Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4 Before Ramadan During Ramadan Morning Dose Full prandial dose Sahur Half prandial dose Lunch Dose Full prandial dose - Evening Dose Full basal Analog Full prandial dose Iftaar Full basal Analog Full prandial dose x 2
  • 35. South Asian Consensus Guideline: Use of insulin in Diabetes during Ramadan • Split Mix Insulin (eg.Intermediate + Short Acting) Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4 Before Ramadan During Ramadan option A option B option A option B Morning Dose SA IA + SA Sahur half SA + half IA half SA + half IA Lunch Dose SA - - Evening Dose IA + SA IA + SA Iftaar SA x 2 IA + SA
  • 36. South Asian Consensus Guideline: Use of insulin in Diabetes during Ramadan • Bi-phasic insulin (eg. Biphasic + Metformin) Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4 Before Ramadan During Ramadan Option A Option B Morning Dose Biphasic Insulin Sahur Metformin Half Biphasic Dose + Met Lunch Dose Evening Dose Metformin Iftaar Biphasic Insulin Biphasic Insulin
  • 37. South Asian Consensus Guideline: Use of insulin in Diabetes during 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
  • 38. South Asian Consensus Guideline: Use of insulin in Diabetes during 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 Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4
  • 39. 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.
  • 40. 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
  • 41. 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.
  • 42. Thank you! Alan Chang, MD, FPCP, FPSEM Jeremy Robles, MD, FPCP, FPSEM
  • 43. Credits to: Dr. Patricia Gatbonton & Dr. Alan Chang Who presented the original lecture in 2012 Dr. Aniza Pala-Mohammad for articles used in updating this slide set.