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Medical Management of Diabetes During Ramadan <ul><ul><li>Jennifer Hamilton, MD </li></ul></ul><ul><ul><li>August, 2007 CE...
Ramadan <ul><li>Holy month in Islam </li></ul><ul><li>From sunrise to sunset: </li></ul><ul><ul><li>No food </li></ul></ul...
Ramadan <ul><li>Holy month in Islam </li></ul><ul><li>From sunrise to sunset: </li></ul><ul><ul><li>No food </li></ul></ul...
 
Eating During Ramadan <ul><li>Usually two meals </li></ul><ul><li>65% of calories at post-sunset meal! </li></ul><ul><li>S...
Medications during Ramadan <ul><li>Ear, eye drops </li></ul><ul><li>Transdermals, creams, ointments </li></ul><ul><li>Supp...
Warning: limited data <ul><li>Ramadan is never the same </li></ul><ul><li>Studies may not be generalizable </li></ul>
Ramadan: a lunar month <ul><li>2007: September 13 – October 12 </li></ul><ul><li>2008: September 1 – September 30 </li></u...
Diabetes, Fasting, and Ramadan <ul><li>2001/1422 Epidemiology of Diabetes and Ramadan (EPIDAR) study in 13 countries </li>...
During fasting <ul><li>Glucose, insulin levels fall </li></ul><ul><li>Glucagon    gluconeogenesis from glycogen </li></ul...
Risks during fasting <ul><li>Hypoglycemia:  </li></ul><ul><ul><li>hospitalizations increased 4.7 times for Type I (3/100 t...
Risks during fasting <ul><li>DKA </li></ul><ul><li>Dehydration </li></ul><ul><ul><li>Orthostatic hypotension    syncope, ...
Risks during fasting <ul><ul><li>“ Most often, the recommendation will be to not undertake fasting. </li></ul></ul><ul><ul...
Very High Risk <ul><li>Severe hypoglycemia within the last 3 months prior to Ramadan </li></ul><ul><li>Patient with a hist...
High Risk <ul><li>Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mg/dl, A1C 7.5–9.0%) </l...
Better candidates <ul><li>Moderate risk </li></ul><ul><ul><li>Well-controlled patients treated with short-acting insulin s...
Type II DM <ul><li>Diet-Controlled </li></ul><ul><ul><li>Change timing and intensity of exercise to reduce risk of hypogly...
Type II DM <ul><li>Insulin sensitizers/glitazones </li></ul><ul><ul><li>Low risk of hypoglycemia </li></ul></ul><ul><ul><l...
Type II and insulin <ul><li>Much higher risk of trouble! </li></ul><ul><li>Studies are limited! </li></ul><ul><li>Shorter-...
Type I Diabetes <ul><li>Just don't do it. </li></ul>
Type I Diabetes <ul><li>Just don't do it. </li></ul><ul><li>Frequent monitoring </li></ul><ul><li>Break the fast if hypogl...
Other concerns <ul><li>Hypertension </li></ul><ul><li>Drug scheduling & interactions </li></ul><ul><ul><li>Change to longe...
Before Ramadan <ul><li>Talk with your patients </li></ul><ul><li>Do they want to attempt the fast? </li></ul><ul><li>Share...
Way Before Ramadan <ul><li>Consider talking with an imam at a local mosque </li></ul><ul><li>How is Ramadan approached by ...
Sources <ul><li>N Aadil, IE Houti, and S Moussamih, “Drug Intake During Ramadan,”  BMJ, 329(7469), 2 October 2004, 778-782...
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Medical Management During Ramadan

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Medical Management During Ramadan

  1. 1. Medical Management of Diabetes During Ramadan <ul><ul><li>Jennifer Hamilton, MD </li></ul></ul><ul><ul><li>August, 2007 CE </li></ul></ul><ul><ul><li>Rajab, 1428 AH </li></ul></ul>
  2. 2. Ramadan <ul><li>Holy month in Islam </li></ul><ul><li>From sunrise to sunset: </li></ul><ul><ul><li>No food </li></ul></ul><ul><ul><li>No drinking </li></ul></ul><ul><ul><li>No smoking </li></ul></ul>
  3. 3. Ramadan <ul><li>Holy month in Islam </li></ul><ul><li>From sunrise to sunset: </li></ul><ul><ul><li>No food </li></ul></ul><ul><ul><li>No drinking </li></ul></ul><ul><ul><li>No smoking </li></ul></ul><ul><ul><li>And no oral medications </li></ul></ul><ul><li>Specific exemption in the Qur'an if fasting would be harmful </li></ul>
  4. 5. Eating During Ramadan <ul><li>Usually two meals </li></ul><ul><li>65% of calories at post-sunset meal! </li></ul><ul><li>Some studies suggest that calories, carbohydrates drop </li></ul><ul><li>Increased fried foods </li></ul>
  5. 6. Medications during Ramadan <ul><li>Ear, eye drops </li></ul><ul><li>Transdermals, creams, ointments </li></ul><ul><li>Suppositories </li></ul><ul><li>Injections (except IV feeding) </li></ul><ul><li>Oxygen </li></ul><ul><li>Sublingual nitroglycerin </li></ul>
  6. 7. Warning: limited data <ul><li>Ramadan is never the same </li></ul><ul><li>Studies may not be generalizable </li></ul>
  7. 8. Ramadan: a lunar month <ul><li>2007: September 13 – October 12 </li></ul><ul><li>2008: September 1 – September 30 </li></ul><ul><li>2009: August 21 – September 19 </li></ul><ul><li>2010: August 11 – September 9 </li></ul><ul><li>2015: June 18 – July 17 </li></ul>
  8. 9. Diabetes, Fasting, and Ramadan <ul><li>2001/1422 Epidemiology of Diabetes and Ramadan (EPIDAR) study in 13 countries </li></ul><ul><ul><li>79% of Type II DM fast </li></ul></ul><ul><ul><li>43% of Type I DM fast </li></ul></ul><ul><ul><li>Estimate 40-50 million people with DM observe the Ramadan fast </li></ul></ul>
  9. 10. During fasting <ul><li>Glucose, insulin levels fall </li></ul><ul><li>Glucagon  gluconeogenesis from glycogen </li></ul><ul><li>Free fatty acids  ketones </li></ul>
  10. 11. Risks during fasting <ul><li>Hypoglycemia: </li></ul><ul><ul><li>hospitalizations increased 4.7 times for Type I (3/100 to 14/100) </li></ul></ul><ul><ul><li>Increased 7.5 times for Type II (0.4/100 to 3/100) </li></ul></ul><ul><li>Hyperglycemia </li></ul><ul><ul><li>No consistent study finding </li></ul></ul><ul><ul><li>EPIDAR: increase in hospitalization in both types of DM </li></ul></ul>
  11. 12. Risks during fasting <ul><li>DKA </li></ul><ul><li>Dehydration </li></ul><ul><ul><li>Orthostatic hypotension  syncope, falls </li></ul></ul><ul><ul><li>Electrolyte abnormalities </li></ul></ul><ul><ul><li>Thrombosis? </li></ul></ul>
  12. 13. Risks during fasting <ul><ul><li>“ Most often, the recommendation will be to not undertake fasting. </li></ul></ul><ul><ul><li>However, patients who insist on fasting need to be aware of the associated risks and be ready to adhere to the recommendations of their health care providers to achieve a safer fasting experience.” </li></ul></ul>
  13. 14. Very High Risk <ul><li>Severe hypoglycemia within the last 3 months prior to Ramadan </li></ul><ul><li>Patient with a history of recurrent hypoglycemia </li></ul><ul><li>Patients with hypoglycemia unawareness </li></ul><ul><li>Acute illness </li></ul><ul><li>Pregnancy </li></ul><ul><li>Patients on chronic dialysis </li></ul><ul><li>Patients with sustained poor glycemic control </li></ul><ul><li>Ketoacidosis within the last 3 months prior to Ramadan </li></ul><ul><li>Type 1 diabetes </li></ul><ul><li>Hyperosmolar hyperglycemic coma within the previous 3 months </li></ul><ul><li>Patients who perform intense physical labor </li></ul>
  14. 15. High Risk <ul><li>Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mg/dl, A1C 7.5–9.0%) </li></ul><ul><li>Patients with renal insufficiency </li></ul><ul><li>Patients living alone </li></ul><ul><li>Drugs that may affect mentation </li></ul><ul><li>Patients with advanced macrovascular complications </li></ul><ul><li>People living alone that are treated with insulin or sulfonylureas </li></ul><ul><li>Patients with comorbid conditions that present additional risk factors </li></ul><ul><li>Old age with ill health </li></ul>
  15. 16. Better candidates <ul><li>Moderate risk </li></ul><ul><ul><li>Well-controlled patients treated with short-acting insulin secretagogues such as repaglinide or nateglinide </li></ul></ul><ul><li>Low risk </li></ul><ul><ul><li>Well-controlled patients treated with diet alone, metformin, or a thiazolidinedione who are otherwise healthy </li></ul></ul>
  16. 17. Type II DM <ul><li>Diet-Controlled </li></ul><ul><ul><li>Change timing and intensity of exercise to reduce risk of hypoglycemia </li></ul></ul><ul><ul><li>Eat two or 3 times a night </li></ul></ul><ul><li>Metformin </li></ul><ul><ul><li>Low risk of hypoglycemia </li></ul></ul><ul><ul><li>Change dosing schedule to after sunset meal (2/3) and before dawn meal (1/3) </li></ul></ul>
  17. 18. Type II DM <ul><li>Insulin sensitizers/glitazones </li></ul><ul><ul><li>Low risk of hypoglycemia </li></ul></ul><ul><ul><li>May not need to change dose </li></ul></ul><ul><li>Sulfonylureas </li></ul><ul><ul><li>High risk of hypoglycemia </li></ul></ul><ul><li>Short-acting insulin secretagogues </li></ul><ul><ul><li>Reschedule doses </li></ul></ul>
  18. 19. Type II and insulin <ul><li>Much higher risk of trouble! </li></ul><ul><li>Studies are limited! </li></ul><ul><li>Shorter-acting insulins may be better </li></ul><ul><ul><li>Lispro at each meal? (Less hypoglycemia than human insulin) </li></ul></ul><ul><ul><li>Intermediate-acting insulin at sunset meal? </li></ul></ul>
  19. 20. Type I Diabetes <ul><li>Just don't do it. </li></ul>
  20. 21. Type I Diabetes <ul><li>Just don't do it. </li></ul><ul><li>Frequent monitoring </li></ul><ul><li>Break the fast if hypoglycemia or hyperglycemia develop </li></ul>
  21. 22. Other concerns <ul><li>Hypertension </li></ul><ul><li>Drug scheduling & interactions </li></ul><ul><ul><li>Change to longer-acting medications? (naproxyn vs. ibuprofen) </li></ul></ul><ul><ul><li>Change to other forms of medication? </li></ul></ul><ul><ul><li>“empty-stomach” medications </li></ul></ul><ul><ul><li>Food interactions </li></ul></ul>
  22. 23. Before Ramadan <ul><li>Talk with your patients </li></ul><ul><li>Do they want to attempt the fast? </li></ul><ul><li>Share concerns </li></ul>
  23. 24. Way Before Ramadan <ul><li>Consider talking with an imam at a local mosque </li></ul><ul><li>How is Ramadan approached by the local congregation? </li></ul>
  24. 25. Sources <ul><li>N Aadil, IE Houti, and S Moussamih, “Drug Intake During Ramadan,” BMJ, 329(7469), 2 October 2004, 778-782. </li></ul><ul><li>M . al-Arouj et al, “Recommendations for management of diabetes during Ramadan,” Diabetes Care, 28(2005), 2305-2311. </li></ul><ul><li>B.Benaji et al, “Diabetes and Ramadan: Review of the literature,” Diabetes Research and Clinical Practice 73(2006), 117-125. </li></ul>

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