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Dr.adel elnaggar 5 6-2015 pre ramadan management with novomix

ramadan & insulin

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Dr.adel elnaggar 5 6-2015 pre ramadan management with novomix

  1. 1. DR./ADEL ELNAGGAR Endocrinologist Ain Shams University, EGYPT. Postgraduate Diabetes, UK. Dr.Erfan & Bagedo Hospital
  2. 2. diabetes & Ramadan
  3. 3. DIABETES SPOT LIGHTS RAMDAN & DIABETES NOVEL PREMIX INSULIN TOPICS
  4. 4. Risk Factors • Obesity • Race • History of CVD • HTN • Physical inactivity • Familial history • Polycystic Ovary Syndrome • Gestational Diabetes ? ? ? ? ? ? ?
  5. 5. (LACK OF DIABETES PYRAMID STRATEGIES): BASE: Early detection; diagnosis & prevention Programs (Health Education). BODY: Proper scientific socio-economic Management (Qualified Health Care Providers). TOP: Delay or prevent Diabetic Complications (Reduce Morbidity & Mortality).
  6. 6. SAUDI ARABIA 1 IN 4
  7. 7. PANCREAS HORMONES: INSULIN BY BETA CELLS GLUCAGON BY ALPHA CELLS Review of Anatomy and Physiology
  8. 8. • Pancreas secretes 40-50 units of insulin daily in two steps: • Secreted at low levels during fasting ( basal insulin secretion) • Increased levels after eating (prandial) • An early burst of insulin occurs within 10 minutes of eating • Then proceeds with increasing release as long as hyperglycemia is present
  9. 9. Insulin • Insulin allows glucose to move into cells to make energy • Inhibits glucagon activity
  10. 10. Action of Insulin on Carbohydrate, Protein and Fat Metabolism •Carbohydrate • Facilitates the transport of glucose into muscle and adipose cells • Facilitates the conversion of glucose to glycogen for storage in the liver and muscle. • Decreases the breakdown and release of glucose from glycogen by the liver
  11. 11. Action of Insulin on Carbohydrate, Protein and Fat Metabolism •Fat • Stimulates lipogenesis- the transport of triglycerides to adipose tissue • Inhibits lipolysis – prevents excessive production of ketones or ketoacidosis
  12. 12. Action of Insulin on Carbohydrate, Protein and Fat Metabolism •Protein • Stimulates protein synthesis • Inhibits protein breakdown; diminishes gluconeogenesis
  13. 13. What goes wrong in diabetes? • Multitude of mechanisms • Insulin • Regulation • Secretion • Uptake or breakdown • Beta cells • damage
  14. 14. Pre-Diabetes •Impaired fasting glucose (IFG) •FPG- 100-125mg/dL •Impaired glucose tolerance (IGT) •OGTT 140-199mg/dL •HbA1c 6-6.5%
  15. 15. Insulin resistance metabolic syndrome adults obese Central obesity (waist circumference) IGT or IFG High lipid profile LDL-HDL/CHOLESTEROL/TRIGLYCERIDES HIGH BP more than 130/90
  16. 16. MANAGEMENT OF DIABETES Life style modification Diet Exrcise Psychological support
  17. 17. MANAGEMENT OF DIABETES METFORMIN DPP4 PIOGLTAZONES GLP1 ANALOUGES SGLT2 INHIBITORS SUs INSULINs PANCREATIC TRANSPLANTION STEM CELLS METABOLIC SURGERIES
  18. 18. LETHAL WEAPON
  19. 19. • Islamic holy month where fasting is compulsory for all healthy Muslims • Absolute fast between sunrise and sunset. • Muslims fast from: • Food • Liquids • Medication Ramadan
  20. 20. • Children • Elderly • Sick • Pregnant or nursing mothers • Menstruating women • People with chronic illness (e.g. DM, CKD, CVD)
  21. 21. • Which Patients with DIABETES are Exempt from Fasting during RAMADAN??? Patients With High Risk Of Complications. Many Muslims with diabetes insist on fasting during Ramadan. This creates a medical challenges for both patients and physicians. Al-Arouj et al. Diabetes Care 2005;28:2305–11 Salti et al. Diabetes Care 2004;27:2306–11
  22. 22. CNS, central nervous system; GI, gastrointestinal; T2DM, type 2 diabetes mellitus Cernea S & Raz I. Diabetes Care 2011;34(suppl 2):S264–S271 Adipocyte CNS Incretin deficiency GI tract Altered fat metabolism INSULIN RESISTANCE INADEQUATE INSULIN SECRETION ↑ HEPATIC GLUCOSE PRODUCTION ↑ BLOOD GLUCOSE Hyperglucagonaemia ↑ hepatic sensitivity to glucagon  cells α cells Skeletal Muscle Pancreas Muscle Kidney Enhanced glucose reabsorption Pathophysiology Of Type 2 DIABETES
  23. 23. body glucose, which is stored in the liver and muscles, is the body’s main source of energy. Early In The Fast ; this store of glucose is used up first to provide energy. Later In The Fast ; once the stores of glucose run out, fat becomes the next store source of energy for the body.Mahroof,Ramadan Health Guide : a guide to healthy fasting ,Department of Health ,Sept,2007 Physiological Changes That Occur During A Fast In The Normal State During A Fast
  24. 24.  Type 1 Diabetes  Severe Hypoglycaemia Or Ketoacidosis Within Last Three Months Prior To Ramadan  Recurrent Hypoglycaemia  Sustained Poor Glycaemic Control  Acute Illness  Pregnancy  Type 2 diabetes  Moderate hyperglycaemia  Renal insufficiency  Advanced macro vascular complications  Living alone and treated with sulphonylurea or insulin  Comorbid conditions that present additional risk factors Al-Arouj et al. Diabetes Care 2005;28:2305–11 Patients at HIGH RISK of developing COMPLICATIONS during Ramadan VERY HIGH RISK HIGH RISK
  25. 25. Salti et al. Diabetes Care 2004;27:2306–11 • AIM: to study diabetes during Ramadan and investigate the effects of fasting • Population: 12,243 Muslim patients with diabetes in 13 countries • Demographics: Demographics Type 1 diabetes Type 2 diabetes Number 1070 11,173 Male/Female (%) 50/50 49/51 Age (years)* 31 (12.7) 54 (11.0) Duration of diabetes (years)* 10 (7.6) 7.6 (5.8) *Data are mean (SD) Percentage of patients reported fasting at least 15 days: type 1 – 42.8% type 2 – 78.7% Epidemiology of DIABETES and Ramadan (EPI-DIA-R) study
  26. 26. Proportionofpatients(%) Type 1 diabetes (n=899) Type 2 diabetes (n=9775) Body weight changes during Ramadan Adapted from Salti et al. Diabetes Care 2004;27:2306–11 EPIDIAR study - Results
  27. 27. Proportionofpatients(%) Changes in medication during Ramadan Type 1 diabetes Type 2 diabetes Insulin dose (n=980) OAD dose (n=94) Insulin dose (n=1831) OAD dose (n=9476) Adapted from Salti et al. Diabetes Care 2004;27:2306–11 EPIDIAR study - Results OAD, oral anti-diabetic drug
  28. 28. Numberofeventspermonth Type 1 diabetes Type 2 diabetes Severe hyperglycaemia with or without ketoacidosis in patients who fasted ≥15 days 0.00 0.04 0.08 0.12 0.16 0.20 Before Ramadan During Ramadan p=0.0015 Adapted from Salti et al. Diabetes Care 2004;27:2306–11 p=0.67 EPIDIAR study - Results
  29. 29. Type 1 diabetes Type 2 diabetes Before Ramadan During Ramadan p-value Before Ramadan During Ramadan p-value Overall population 0.03 0.14 0.0174 0.004 0.03 <0.0001 Patients who fasted ≥15 days 0.02 0.12 0.9896 0.003 0.02 0.0015 Number of severe hypoglycaemic events during Ramadan (number per month) Data (except p values) are mean Adapted from Salti et al. Diabetes Care 2004;27:2306–11 4.5 Folds 7.5 Folds 6 Folds 6.5 Folds EPIDIAR study - Results
  30. 30. Al-Arouj et al. Diabetes Care 2005;28:2305–11 E Hui et al. BMJ 2010;340:1407–11 RECOMMENDATIONS
  31. 31. • Individualisation • Patient specific recommendations • Frequent monitoring of glycaemia • Crucial for patients with type 1 diabetes and patients with type 2 diabetes who require insulin treatment • This will not break the fast • Nutrition • Healthy and balanced diet • Ingesting large amount of foods rich in carbohydrate and fat should be avoided • Exercise • Maintain normal levels of physical activity • Breaking the fast • Blood glucose <3.3 mmol/L or >16.7 mmol/L Al-Arouj et al. Diabetes Care 2005;28:2305–11; GENERAL CONSIDERATION & RULES for the management of DIABETES during RAMADAN
  32. 32. DIET-CONTROLLED PATIENTS • Risk associated with fasting is low in patients who are adequately controlled with diet alone • Potential risk of postprandial hyperglycaemia if patients overindulge in eating • Daily exercise programme may need to be modified to avoid hypoglycaemia • Fluid restrictions and dehydration may increase the risk of thrombosis Al-Arouj et al. Diabetes Care 2005;28:2305–11 Management of patients with TYPE 2 DIABETES during RAMADAN
  33. 33. Patients treated with oral agents • METFORMIN • Minimal possibility of hypoglycaemia • Timing of doses should be modified • ACARBOSE • Continue with the prescribed doses • taken only with meals • GLITAZONES • Low risk of hypoglycaemia • No change in dose required • SHORT-ACTING INSULIN SECRETAGOGUES • Short duration of action • Twice-daily dosing pre-meals • SULPHONYLUREAS • Increased risk of hypoglycaemia Suitable for use during Ramadan Use with caution during Ramadan Al-Arouj et al. Diabetes Care 2005;28:2305–11 & E Hui et al. BMJ 2010;340:1407–11 Management of patients with TYPE 2 DIABETES during RAMADAN
  34. 34. He Used To Worry About Managing His Diabetes During Ramadan
  35. 35. Managing diabetes during Ramadan can be challenging1 The majority of Muslim patients with type 2 diabetes fast during Ramadan1 proper treatment adjustments, including INSULIN REGIMEN, are necessary to avoid HYPOGLYCAEMIA and HYPERGLYCAEMIA2 1. Salti I et al. Diabetes Care 2004;27:2306–2311. 2. 2. Hassanein M et al. Indian J Endocrinol Metab 2014;18(6):794–799.
  36. 36. NovoMix® 30 adds confidence to control It Is Simple To Adjust Novomix® 30, During Ramadan To Help Minimise The RISK Of Hypoglycaemia Or Hyperglycaemia1 Flexible Mealtime Dosing – Patients Can Eat Immediately After Injecting Novomix® 302 More Effective PPG Control And Lower Risk Of Major And Nocturnal Hypoglycaemia* Vs Human Premix Insulin3,4 1. Hassanein M et al. Indian J Endocrinol Metab 2014;18(6):794–799. 2. NovoMix® 30 Summary of Product Characteristics. 3. Hermansen K et al. Diabetes Care 2002;25:883–888. 4. Davidson JA et al. Clin Ther 2009;31:1641–1651.
  37. 37. Managing diabetes during Ramadan can be challenging1 1. Hassanein M et al. Indian J Endocrinol Metab 2014;18(6
  38. 38. • 1 in 8 Muslim patients with type 2 diabetes continue to fast during Ramadan1 THE MAJORITY OF MUSLIM PATIENTS WITH TYPE 2 DIABETES WILL FAST DURING RAMADAN1 1. Salti I et al. Diabetes Care 2004;27:2306–2311. of patients fasted for at least 15 days in the Epidemiology of Diabetes and Ramadan (EPIDIAR) study1 78.7%
  39. 39. Over the coming decade, the number of fasting hours will progressively increase in the northern hemisphere as Ramadan falls in the summer months. Fasting increases the risk of hypoglycaemia and hyperglycaemia as it can cause profound changes in:1,2 DIETARY HABITS LIFESTYLE SLEEP PATTERNS Despite this, only one third of patients adjust their insulin FASTING DURING RAMADAN present a challenge in Muslim patients with TYPE 2 DIABETES1 1. Salti I et al. Diabetes Care 2004;27:2306–2311. 2. Al-Arouj M et al. Diabetes Care 2005;28(9):2305–2311.
  40. 40. The Working Group for Insulin Therapy in Ramadan developed practical advice for patients on low-ratio premix insulin1 Guidance recommends preparation 2–3 months before Ramadan to include:1 PREPARATION is KEY for management of DIABETES during RAMADAN1 1. Hassanein M et al. Indian J Endocrinol Metab 2014;18(6):794–799. In line with current ADA guidance to include clinical assessment and experience from previous Ramadan Pre-Ramadan individualised assessment To include advice on frequency of blood glucose monitoring, diet, physical activity and when to break the fast Structured education To assess individual response to fasting and insulin needs Trial fasting for 3 days
  41. 41. • The Working Group for Insulin Therapy in Ramadan recommends:1 • The management plan during Ramadan should be individualised • Glycaemic control needs to be ascertained • Dosage will depend on meal size and composition, post- meal fasting period and individual blood glucose targets • Appropriate treatment adjustments are necessary to avoid both hypoglycaemia and hyperglycaemia. It is simple to adjust NovoMix® 30, during Ramadan to help minimise the risk of hypoglycaemia or hyperglycaemia1 Patients FASTING during RAMADAN can be managed with NovoMix® 301 1. Hassanein M et al. Indian J Endocrinol Metab 2014;18(6):794–799.
  42. 42. 1. Hassanein M et al. Indian J Endocrinol Metab 2014;18(6):794–799.
  43. 43. It is simple to adjust NovoMix® 30 for altered mealtimes during Ramadan1 1. Adapted from Hassanein M et al. Indian J Endocrin Metab 2014;18(6):794–799. DOSE BEFORE RAMADAN PRE-IFTAR (SUNSET MEAL) PRE-SUHUR (DAWN MEAL) 30/70 premix insulin (e.g. NovoMix® 30) once daily* Same dose as pre- Ramadan 30/70 premix insulin (e.g. NovoMix® 30) twice daily** Usual morning dose Half usual evening dose 30/70 premix insulin (e.g. NovoMix® 30) three times daily† Usual morning dose Half usual evening dose Patients receiving human premix insulin should be switched to an analogue human premix insulin:1 ■ If immediate injection before meal is preferred1 ■ If frequent hypoglycaemia or marked post- prandial blood glucose excursions1
  44. 44. It is important for patients to monitor blood glucose multiple times each day during RAMADAN1 High risk group (poor control, high risk of hypos) Low risk group (adequate control, low risk of hypoglycaemia) Pre-Suhur Pre-Suhur 2 hours post- Suhur - Midday Midday Pre-Iftar Pre-Iftar 2 hours post- Iftar - If symptoms of hypoglycaemia appear If symptoms of hypoglycaemia appear Reassure Patients That Blood Glucose Testing Does Not Qualify As Breaking The Fast1 The Frequency Of Monitoring Is Dependent On Glycaemic Control Level And Hypoglycaemia Risk1 Insulin Dose Titration And Dosage Adjustment Should Be Based On Pre-meal Blood Glucose Levels1
  45. 45. It is simple to titrate NovoMix® 30 , during Ramadan1 * Pre-Iftar dose to be adjusted based on pre-Suhur blood glucose and pre-Suhur dose to be adjusted based on pre-Iftar blood glucose levels 1. Adapted from Hassanein M et al. Indian J Endocrin Metab 2014;18(6):794–799. Fasting/Pre-Iftar/Pre-Suhur blood glucose level 30/70 premix insulin dose adjustment mmol/L mg/dL Units* < 3.9 < 70 Break the fast and down titrate < 5.0 < 90 -2 5.0–7.0 90–126 0 > 7.0 > 126 +2 > 16.7 > 300 Break the fast and increase dose by 4 units and check ketones It is advisable to titrate the low-ratio premix insulin dose every 3 days.1 A minimum of 2 readings on 2 consecutive days is required to titrate the dose.1 Fasting must be broken if hypoglycaemia occurs.1
  46. 46. NovoMix® 30 offers flexibility in dosing which may be important during Ramadan*1,2 Relativeactionofinsulin Physiological insulin profileTime * HUMAN PREMIX INSULIN 30/70 1. NOVOMIX® 30 SUMMARY OF PRODUCT CHARACTERISTICS. 2. HASSANEIN M ET AL. INDIAN J ENDOCRIN METAB 2014;18(6):794–799.
  47. 47. Human premix insulin* should be administered at least 30 minutes before a meal1 Relativeactionofinsulin Physiological insulin profile Human premix insulin 30/70 30 minutes before a meal1 Time 30minutes * Human premix insulin 30/70 1. Garber AJ et al. Diabetes Obes Metab 2007;9:630–639. During Ramadan, this means after a long day fasting they will need to wait an extra 30 minutes before they can eat
  48. 48. Patients can take NovoMix® 30 immediately BEFORE OR JUST AFTER an important benefit during Ramadan Relativeactionofinsulin Physiological insulin profile Human premix insulin 30/70 30 minutes before a meal3 NovoMix® 30 Immediately before a meal4 Time 30minutes Higher maximum concentration More effective PPG control1 Shorter acting Reduces risk of hypoglycaemia2 Faster start action Flexible mealtime injection – no need to wait 30 minutes before eating3,4 * Human premix insulin 30/70 1. Hermansen K et al. Diabetes Care 2002;25:883–888. 2. Davidson JH et al. Clin Ther 2009;31:1641–1651 3. Garber AJ et al. Diabetes Obes Metab 2007;9:630–639. 4. NovoMix® 30 Summary of Product Characteristics.
  49. 49. Hypoglycaemic Episodes Are More Common During Ramadan
  50. 50. 7.5x greater risk of severe hypoglycaemia during Ramadan*1 Severe HYPOGLYCAEMIC episodes ; were more frequent in patients who changed their OAD dose, insulin dose or level of physical activity1 HYPOGLYCAEMIA is the most common reason for breaking fast during Ramadan2 HYPOGLYCAEMIA has a negative impact on patients’ quality of life and psychological wellbeing3 Fasting during Ramadan increases the risk of HYPOGLYCAEMIC episodes1 *Defined as hospitalisation due to hypoglycaemia 1. Salti I et al. Diabetes Care 2004;27:2306–2311. 2. Elmehdawi RR et al. Libyan J Med 2010;5:5036 - DOI: 10.3402/ljm.v5i0.5036. 3. Davis RE et al. Curr Med Res Opin 2005;21(9):1477–1483.
  51. 51. Significantly fewer MAJOR HYPOGLYCAEMIC events with NovoMix® 30 human premix insulin*1 *Human premix insulin 30/70 **Vs human premix insulin, Odds ratio (95% CI): 0.45 (0.22–0.93), p<0.05 1. Adapted from Davidson JA et al. Clin Ther 2009;31:1641–1651. Trial 038 1234 1353 1394 1466 3002 Overall Odds ratio (95% CI) 0.50 (0.12–1.98) 0.34 (0.01–8.28) 0.57 (0.16–2.00) 0.53 (0.03–8.63) 0.31 (0.06–1.54) 0.25 (0.01–6.62) 0.45 (0.22–0.93) p 0.32 0.50 0.38 0.66 0.15 0.41 <0.05 Favours NovoMix® 30 Favours human premix insulin 0.01 0.1 1 10 100 Test of heterogeneity: I2 = 0% Meta-analysis of major hypoglycaemia in type 2 diabetes patients1 reduction in likelihood of major hypoglycaemia1**
  52. 52. reduction in likelihood of nocturnal hypoglycaemia1** Significantly fewer NOCTURNAL HYPOGLYCAEMIC events with NovoMix® 30 vs human premix insulin*1 *Human premix insulin 30/70 **Vs human premix insulin, Rate ratio (95% CI): 0.50 (0.38–0.67), p<0.01 1. Adapted from Davidson JA et al. Clin Ther 2009;31:1641–1651. Trial 038 1088 1234 1353 1394 1466 1536 3002 3006 Overall Rate ratio (95% CI) 0.57 (0.20–1.58) 0.89 (0.25–3.16) 0.44 (0.22–0.89) 1.03 (0.42–2.53) 1.03 (0.38–2.76) 0.33 (0.21–0.51) 0.44 (0.11–1.47) 1.05 (0.11–10.09) 2.43 (0.31–18.90) 0.50 (0.38–0.67) p 0.28 0.86 0.02 0.95 0.96 0.01 0.17 0.97 0.39 <0.01 Favours NovoMix® 30 Favours human premix insulin 0.1 0.2 1 10 20 Test of heterogeneity: I2 = 32% Meta-analysis of nocturnal hypoglycaemia in type 2 diabetes patients1
  53. 53. A1chieve®: less hypoglycaemia after upgrading to NovoMix® 30 from human premix insulin*1 *Human premix insulin 30/70 1. Adapted from El Naggar NK et al. Diabetes Res Clin Pract 2012;98:408–413. 0.69 0.03 5.31 2.04 Major Eventsperpatient-year 10 6 4 2 0 8 Minor Baseline on human premix insulin* After 6 months on NovoMix® 30
  54. 54. A Well-documented Tolerability Profile1– 8 2002–2014 NovoMix® 30 has been studied in at least 50 RCTs* 2007–2010 PRESENT™ observational study1–3 >22,000 patients 2008–2012 IMPROVE™ observational study4–6 >51,000 patients 2010–2012 A1chieve® observational study7,8 >66,000 patients In 10 Middle East Countries *PubMed search on 2014.07.24 using term ‘biphasic insulin aspart’ and the limit ‘randomised controlled trial’ 1. Adapted from Sharma SK et al. Curr Med Res Opin 2008;24:645–652. 2. Almustafa M et al. Diabetes Res Clin Pract 2008;81(Suppl. 1):S10–15. 3. Güler S et al. Arch Drug Inf 2009; 2:23–33. 4. Valensi P et al. Int J Clin Pract 2009;63:522–531. 5. Yang W et al. Curr Med Res Opin 2009;25:2643– 2654. 6. Gumprecht J et al. Int J Clin Pract 2009;63:966–972. 7. Home P et al. Diabetes Res Clin Pract 2011;94:352–363. 8. El Naggar NK et al. Diabetes Res Clin Pract 2012;93:408–413. of clinical experience*1–8 12 YEARS NovoMix® 30 tolerability profile demonstrated over
  55. 55. THE RISK OF HYPERGLYCAEMIA IS INCREASED DURING RAMADAN
  56. 56. 5x greater risk of severe hyperglycaemia/ketoacidosis during Ramadan1 Excessive reductions in insulin doses to avoid hypoglycaemia or changes to diet and mealtimes can lead to post-prandial hyperglycaemic episodes2 Post-prandial hyperglycaemia is an independent risk factor for cardiovascular and macrovascular disease*3 Fasting during Ramadan increases the RISK of HYPERGLYCAEMIA1 *There is no available data linking repeated short-term episodes of hyperglycaemia during Ramadan to long-term complications 1. Salti I et al. Diabetes Care 2004;27:2306–2311. 2. Hassanein M et al. Indian J Endocrinol Metab 2014;18(6):794–799. 3. 2011 Guideline for Management of PostMeal Glucose in Diabetes. Available at: www.idf.org/2011-guidelinemanagement-postmeal-glucose-diabetes (accessed March 2015).
  57. 57. Every 1% reduction in HbA1c can reduce long-term DIABETES COMPLICATIONS1 *p<0.0001 1. Adapted from Stratton IM et al. BMJ 2000;321:405–412. 37% 21% 14% Microvascular complications* Deaths related to diabetes* Myocardial infarction*
  58. 58. Targeting both PPG and FPG is an important strategy for achieving optimal glycaemic control1 1. 2011 Guideline for Management of PostMeal Glucose in Diabetes. Available at: www.idf.org/2011-guideline-management-postmeal-glucose-diabetes (accessed March 2015). 2. Adapted from Monnier L et al. Diabetes Care 2003;26:881−885. HbA1c PPG FPG Glucose triad2
  59. 59. A1chieve®: NovoMix® 30 reduced PPG and FPG in patients switching from glargine *82.6% of patients were on NovoMix® 30 bid by study end (24 weeks) **p<0.001 †Post- lunch and post-dinner also significant (81.1 and 77.5 mg/dL reduction, respectively) 1. Adapted from Haddad J et al. Diabetes Ther 2013;4:309−319. 187.4 135.1 Baseline Week 24 270.3 187.4 Pre-breakfast FPG Bloodglucose(mg/dL) 300 150 100 50 0 200 250 Post-breakfast PPG** Lower PPG and FPG from baseline at week 24 after switching from glargine to NovoMix® 301
  60. 60. A1chieve®: NovoMix® 30 reduced PPG and FPG in patients switching from a glargine-based basal–bolus regimen1 *p<0.001 **Post-lunch and post-dinner also significant (73.8 and 59.4 mg/dL reduction, respectively) 1. Adapted from Dieuzeide G et al. Prim Care Diabetes 2014;8(2):111−117. 210.8 135.1 Baseline Week 24 259.5 165.8 Pre-breakfast FPG Bloodglucose(mg/dL) 300 150 100 50 0 200 250 Post-breakfast PPG** PPG and FPG from baseline at week 24 after switching to NovoMix® 30 from a glargine-based basal-bolus regimen1 Significantly lower
  61. 61. PRESENTTM: PPG levels significantly improved after upgrading to NovoMix® 30 human premix insulin1 *Human premix insulin 30/70 1. Adapted from Shestakova M et al. Curr Med Res Opin 2007;23(12):3209–3214. Baseline on human premix insulin* After 6 months on NovoMix® 30 275.5 188.3 Bloodglucose(mg/dL) 300 150 100 50 0 200 250 PPG
  62. 62. IMPROVETM: PPG levels significantly improved after upgrading to NovoMix® 30 human premix insulin1 *p<0.0001 **Human premix insulin 30/70 1. Adapted from Shah S et al. Int J Clin Pract 2009;63:574–582. 268.5 169.4 266.7 173 207.2 149.6 Baseline on human premix insulin** After 6 months on NovoMix® 30 PPG breakfast Bloodglucose(mg/dL) 300 150 100 50 0 200 PPG lunch PPG dinner 250
  63. 63. A1chieve®: PPG levels significantly improved at each meal after upgrading to NovoMix® 30 from human premix insulin1 *p<0.001 **Human premix insulin 30/70 1. Adapted from El Naggar NK et al. Diabetes Res Clin Pract 2012;98:408–413. 255.9 178.4 239.6 158.5 221.6 156.8 Baseline on human premix insulin** After 6 months on NovoMix® 30 Post-breakfast Bloodglucose(mg/dL) 300 150 100 50 0 200 Post-lunch Post-dinner 250
  64. 64. COMPLEX REGIMEN REDUCE ADHERENCE MEDICATION
  65. 65. ■During Ramadan, the majority of patients using a basal-bolus regimen will require 3 daily injections5 COMPLEX REGIMEN can reduce adherence,1–4 which may lead to suboptimal treatment 1. Rubin RR. Am J Med 2005;118(5A):27S−34S. 2. Vijan S et al. J Gen Intern Med 2005;20:479−482. 3. Dieuzeide G et al. Prim Care Diabetes 2014;8(2):111–117. 4. Donnelly LA et al. Q J Med 2007;100:345−350. 5. Al-Arouj M et al. Diabetes Care 2010;33(8):1895–1902.
  66. 66. During Ramadan, the majority of patients will receive 2 daily injections of a premix insulin, with meals after sunset and before dawn2 Premixed insulin may be more convenient than adding in bolus mealtime injections, as part of a basal–bolus regimen1 Fewer injections are required with NovoMix® 30 Than A Basal–Bolus Regimen1 1. Inzucchi SE et al. Diabetes Care 2012;35(6):1364–1379. 2. Hassanein M et al. Indian J Endocrinol Metab 2014;18(6):794–799.
  67. 67. IN SUMMARY DIABETICS IN RAMADAN ■Fasting during Ramadan increases the risk of hypoglycaemia ■NovoMix® 30 shows a lower risk of major and nocturnal hypoglycaemia* vs human premix insulin ■Fasting during Ramadan increases the risk of hyperglycaemia ■Post-prandial hyperglycaemia is an independent risk factor for cardiovascular and macrovascular disease ■NovoMix® 30 od provides more effective PPG control vs glargine once daily. HYPOGLYCEMIA HYPERGLYCEMIA
  68. 68. Managing DIABETES During RAMADAN Can Be Challenging1 The majority of Muslim patients with type 2 diabetes fast during Ramadan1 Appropriate treatment adjustments, including insulin regimen, are necessary to avoid hypoglycaemia and hyperglycaemia2 NovoMix® 30 adds confidence to control It is simple to adjust NovoMix® 30, during Ramadan to help minimise the risk of hypoglycaemia or hyperglycaemia Flexible mealtime dosing – patients can eat immediately after injecting NovoMix® 30 More effective PPG control and lower risk of major and nocturnal hypoglycaemia* vs human premix insulin IN SUMMARY
  69. 69. Me At work
  70. 70. Me At home
  71. 71. I need urgent Ophthalmology consultation
  72. 72. THANK YOU DR./ ADEL EL NAGGAR
  • sidimedmostefa

    May. 12, 2017

ramadan & insulin

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