A 55 year old Saudi male diabetic for 14years .•His diabetes is uncontrolled (HBA1c 11.1 )• He has all chronic complications•With poor diet control and poorcompliance to insulin.•He is on lantus 50 units at bed time andnovorapid 18 units tid and MTF 500 BID
Case scenario 258 year old Saudi male with type II diabetesfor 2 years with HTN and TIA and GERD Admitted with Glibenclamide inducedhypoglycemia(37mg) on 16/02 . Came to clinic for follow up with currentmedication Gliclazide 80mg BID and MTF500 BID. His HBa1c was 7.4 and had 2 episode ofsymptomatic hypoglycemia with RBS 80mglast month at home
The taskBoth these patients want to fastWhat queries ??
Patient Queries• Should I fast?• What dose adjustment to be done?•How often should I monitor Bloodsugar?• What should I do if I develophypoglycemia?
Physician Queries• Is fasting safe in diabetics?•How should fasting patients with type 2diabetes be managed•How should fasting patients with type 1diabetes be managed?•Is fasting safe for pregnant women withdiabetes?
Physician queries•What are absolutecontraindications ?•Which OHA is safe and superior?•Is insulin safe in fasting?•Which type of insulin better?•Which regimen is better?•What are dosage adjustment inRamadan?
The month of Ramadân in which was revealed the Qurân, a guidance for mankind and clear proofs forthe guidance and the criterion (between right and wrong). So whoever of you sights (the crescent on thefirst night of) the month (of Ramadân i.e. is present at his home), he must observe Saum (fasts) thatmonth, and whoever is illor on a journey, the same number [of days which onedid not observe Saum (fasts) must be made up] from other days. Allâh intendsfor you ease, and He does not want tomake things difficult for you. (He wants that you) mustcomplete the same number (of days), and that you must magnify Allâh [i.e. to say Takbîr (Allâhu-Akbar;Allâh is the Most Great) for having guided you so that you may be grateful to Him. (185)
[Observing Saum (fasts)] for a fixed number of days, but ifany of you is ill or on a journey, the same number(should be made up) from other days. And as for those whocan fast with difficulty, (e.g. an old man), they have (a choiceeither to fast or) to feed a Miskîn (poor person) (for every day).But whoever does good of his own accord, it is better for him.And that you fast, is better for you ifonly you know
Importance It is estimated that around 40 to 50 millionindividuals with diabetes worldwide fast during Ramadan The population-based Epidemiology of Diabetes andRamadan, 1422/2001 (EPIDIAR), studyconducted in 13 Islamic countries showed that 43% ofpatients with type 1 diabetesand79% of patients with type 2 diabetes fastduring Ramadan.
Glycemic management optionsduring RamadanStart preparation 2-4 months priorCareful and individual evaluation andopen discussions are key measuresRamadan focused educationPost Ramadan follow up
Ramadan-focused structureddiabetes educationAn awareness campaign aimed at peoplewith diabetes, health care professionals,the religious and community leaders aswell as the general publicRamadan-focused structured educationfor health care professionalsRamadan-focused structured educationfor people with diabetes.
How should fasting patients withtype 2 diabetes be managedMetformin is safe with low risk of hypoglycemiaAcarbose – is also safe with minimum risk of hypo Continue with the prescribed dose(s) of acarbose takenonly with meals during fasting Flatulence is major drawback
Type 2 Diabetes and Ramadan Sulfonylureas Safe is ramadan Chlorpropamide absolutely contraindicated Increased risk of hypoglycemia makes glibenclamideunattractive
Type 2 Diabetes and RamadanINCRETINS Exenatide and liraglutide injections are safe the liraglutide group achieved better glycemiccontrol with fewer episodes of hypoglycemica. Nausea and vomiting are common. Sitagliptin and vildagliptin safe arealternatives Importantly vis-à-vis treatment duringRamadan, do not require titration
Dose reductionsGlitazone without changing the dose;Metformin, two-thirds of the dose wasto be taken before sunset meal and theother third with pre-dawn meal.Morning dose of gliclazide to be reducedby halfLong acting OHA to be given after Iftaar
Insulins and insulin regimensInsulin can be safely used in type 2diabetic individualsDose and timing has to be changed
Insulins and insulin regimensInsulin glargine is also effective andsafe during Ramadan and can begiven as single injection at 10 PMwith or without mealtime short-acting analogues or other oral antidiabetic medication(repaglinide or metformin).
Rapid acting better than regularinsulinRapid onset of action and higher peakwith same doseBetter control of post prandial bloodsugarLesser risk of hypoglycemia especiallylate postmeal period during the fast
Rapid acting better than regularinsulinOffers meal time flexibilitySafe in patients with renal and hepaticimpairment (Insulin Aspart)Safe in pregnancy (Insulin Aspart,Lispro) with better glycemic control.
Suggested insulin regimens for patients withtype 1 diabetes mellitus70% of the pre-Ramadan dose,divided as follows:•60% as insulin glargine given inthe evening and•40% as an ultra-short-actinginsulin (insulin aspart or lispro)given in 2 doses, 1 at Suhur and 1at Iftar
Suggested insulin regimens forpatients with type 1 diabetesmellitusAnother option is to give100% of the pre-Ramadan morningdose of 70/30 premixed insulin at Iftaar 50% of the usual evening dose at Sahur
Type 1 Diabetes and RamadanThe insulin pump canpotentially empowerpatients with diabetes andenable safe fasting duringthe month of Ramadan
Better regimen Basal bolus insulin may be associated with alower risk of hypoglycemia in comparisonwith conventional twice-daily insulin regime Al-Arouji et al recommended the use of 1injection of glargine or 2 injections of detemiralong with a pre-meal rapid-acting insulinanalogue
Blood sugar monitoringduring ramadhan•2 hours post-sahur and 1/2hour pre iftaar•2 hours post-iftaar/dinner•Adjust insulin dose at 3 days’interval
Cautions•Patients who observe the fastshould be advised to monitortheir blood glucose regularly,•Avoid skipping meals orovereating,•Maintain contact with theirphysician throughout the fast
Cautions•Break fast if blood glucosedrops below 60 mg/dL (3.3mmol/L)•OR rises above 300mg/dL (16.7 mmol/L) toavoid diabetic ketoacidosis
Discourage fasting1. Poor diabetescontrol,2. Frequent and severehypoglycemia3. Brittle diabetes
Conclusion The DPP-4 provide an effective and safealternative during Ramadan, either alone or incombination with metformin or sulfonylureas The incritin memetics are also safe duringRamadan, but as yet there are no reports ofusing them during Ramadan
The answer case 1Before Ramadhan During Ramadhan He is on lantus 50units at bed time and novorapid 18units tid and MTF 500 BID Lantus 40 units atbed time 18 units –Iftaar with750 MTF 18 units-dinner 9 units –Sahur with250mg MTF
The answer case 2Before ramadhan During Ramadhan Gliclazide 80mgBID MTF 500 BID. Iftaar- Gliclazide 80mg with 750 mgMTF Sahur- Gliclazide 40mg with 250 mgMTF
ConclusionThe newer sulfonylureas gliclazide MRand glimepride can be safely used duringRamadanAdministration of the long-acting or thepremixed insulin analogues has shownpotential benefit in selected patientswith type 1 and type 2 diabetes
What we an do in KAMC•Organize awarenesscampaign•Risk stratification scoresystem•Print education leaflet
When he saw the moon risingup, he said: "This is my lord."But when it set, he said: "Unlessmy Lord guides me, I shallsurely be among the people whowent astray.
The final wordClinical trials are needed inorder to further evaluate thesafety and efficacy of newhypoglycemic agents and newdiabetes-treating technologiesduring Ramadan
Therefore remember Me (bypraying, glorifying,). I willremember you, and be grateful toMe (for My countless Favors onyou) and never be ungrateful toMe. (152)
References The noble Quran with english translation by Dr mohsin Diabetes and Ramadan: An Update On Use of Glycemic Therapies During FastingMohamed H. Ahmeda and Tarig A. M. Abdu Suggested insulin regimens for patients with type 1 diabetes mellitus who wish to fast duringthe month ofRamadan. Kobeissy A, Zantout MS, Azar ST. Department of Internal Medicine, Division of Endocrinology, American University of Beirut MedicalCenter, Beirut Lebanon. South Asian Consensus Guideline: Use of insulin in diabetes during Ramadan Md Faruque Pathan, Rakesh Kumar Sahay,1 Abdul Hamid Zargar,2 Syed Abbas Raza,3 A. K. AzadKhan,4 Mohammed Ashraf Ganie,5 Nazrul Islam Siddiqui,6 Firoz Amin, Osama Ishtiaq,7 and SanjayKalra8 Recommendations for Management of Diabetes During RamadanUpdate 2010 Monira Al-Arouj, MD,1 Samir Assaad-Khalil, MD, PHD,2 John Buse, MD, PHD,3 Ibtihal Fahdil,MD, PHD,4 Mohamed Fahmy, MD, PHD,5 Sherif Hafez, MD, FACP,6 Mohamed Hassanein,FRCP,7 Mahmoud Ashraf Ibrahim, MD,8 David Kendall, MD,9 Suhail Kishawi,MD,10 Abdulrazzaq Al-Madani, MD,11 Abdullah Ben Nakhi, MD,1 Khaled Tayeb,MD,12and Abraham Thomas, MD13