Diabetes and Ramadhan power point slides talking about diabetes management during the month of ramadhan for patients and health provider. how to get well controlled blood glucose during fasting in ramadhan month without hypoglicemia

1. Management of type 2 diabetic patients
during the holy month of Ramadan
Dr. Sumon Rahman Chowdhury
Chittagong Diabetic General Hospital

2.  Fasting in Ramadan is one of the five pillars
of Islam, that is why Muslim patients desire to
fast
 Globally more than 50 million Muslim with
diabetes observe fasting in Ramadan
 Therefore, managing diabetic patients
observing fast is a challenge for the clinicians
INTRODUCTION

3. What happens in Ramadan?
 Eating habit changes in many ways
- Meal time
- Pattern of meal
- Calorie intake
 Increased post-prandial physical
activity during the night associated
with Tarawih
Can Fam Physician 2014;60:508-10

4. Pathophysiology of fasting in people with diabetes
Panel A: Substrate oxidation as a function of daytime fasting. In individuals with diabetes, the
underlying pathophysiology and the medications used to treat the condition both disturb
glucose homeostasis.
Panel B: Recorded measurements of lipid and carbohydrate oxidation during Ramadan fasting.
Substrate oxidation was measured by indirect calorimetry.
IDF-DAR Practical guideline 2021

5. Mean continuous glucose monitoring (CGM)
profiles
of diabetic patients before and during Ramadan
A rapid rise in blood glucose is seen at iftar time
IDF-DAR Practical guideline 2021

6. Effects of fasting in Ramadan: physical & mental
wellbeing
IDF-DAR Practical guideline 2021

7. What are the challenges for
a Clinician during Ramadan
 Check eligibility of patients to
fast
 Manage risks associated with
fasting
 Adjust diet, exercise and drugs
 Counsel to monitor blood

8. Eligibility of patients to
observe fast in
Ramadan

9. As a large number of people with
diabetes fast during Ramadan,
there is an urgent need for
evidence-based, practical
guidance to help them.
IDF and the Diabetes and
Ramadan (DAR) International
Alliance have come together to
deliver a comprehensive set of
guidelines to meet this need
every four years.

10. New IDF-DAR risk stratification
IDF-DAR Practical guideline 2021

11. Risk stratification of people with diabetes before
Ramadan
IDF-DAR Practical guideline 2021

12. Managing risks
associated
with fasting

13. What are the risks associated with fasting?
Diabetes and Ramadan: Practical Guidelines. International Diabetes Federation (IDF) in collaboration with the Diabetes and Ramadan (DAR) International Alliance. 2016 April

14. Recognized factors that may influence fast during
Ramadan
IDF-DAR Practical guideline 2021

15. EPIDIAR study: mean numbers of severe
hypoglycemia and hyperglycemia during Ramadan
compared with before
In Ramadan hypoglycemia increased by 7.5 times
as well as hyperglycemia increased by 5 times
IDF-DAR Practical guideline 2021

16. But HYPOGLYCEMIA is the concerned one

17. Recommendations to
avoid hypoglycemia
 Take Suhur close to Suhur time
 Keep same calorie during Ramadan as
before
 Change the schedule and composition of
meals
 Reduce physical activity during day time
Clinical Diabetes ( Middle East Edition)- Volume 3, Number 3, 2004

18. General advices
to minimize risks
 Consultation with a doctor much before
Ramadan
 Practice fasting in the month of Shaban
 Switch to long acting drug (preferably once
daily)
 Care must be individualized: management
plan will differ for each specific patient
Clinical Diabetes ( Middle East Edition)- Volume 3, Number 3, 2004

19. Pre-Ramadan Assessment and Education
IDF-DAR Practical guideline 2021

20. Targets of Ramadan-focused diabetes education
IDF-DAR Practical guideline 2021

21. Positive impacts of Ramadan-focused education
IDF-DAR Practical guideline 2021

22. Findings: Hypoglycemic Events
Patients without education experienced 4 times
hypoglycemia
Diabet. Med. 27, 327–331 (2010)

23. Blood Glucose
Monitoring
in Ramadan

24. Blood glucose monitoring in Ramadan as per Islam
Both National & International Scholars of Islam
permit blood glucose monitoring while fasting!!
A Physician's Guide to Manage Diabetes Mellitus in Ramadan

25. Recommended timings to check blood
glucose levels during Ramadan fasting
IDF-DAR Practical guideline 2021

26. IDF-DAR Practical guideline 2021
When to break fast?

27. Adjustment of
Diet &
Exercise

28. Diet in Ramadan
Complex carbohydrates are recommended for the Suhoor meal
Simple carbohydrates are recommended for the Iftar meal.
IDF-DAR practical guideline 2021

29. Exercise in Ramadan
 Rigorous exercise should be avoided,
particularly during the last hours of fasting
 People with diabetes should be encouraged
to maintain their normal physical activity
during Ramadan; they should be reminded that
the physical exertions involved in Taraweeh
prayers
IDF-DAR practical guideline 2021

30. Adjustment of Drug

31. Adjustment of metformin
IDF-DAR practical guideline 2021

32. Adjustment of other OADs
 Acarbose: NO DOSE MODIFICATION is required
 Pioglitazone: NO DOSE MODIFICATION is required, but dose
should be taken with Iftar
 Short-acting insulin secretagogues : The daily dose of short-
acting insulin secretagogues (based on a three-meal dosing) may
be REDUCED or REDISTRIBUTED
 GLP 1 agonists: DOSE-TITRATED prior to Ramadan (at least 2–4
weeks) is required
 (DPP-4) inhibitors: DO NOT REQUIRE TREATMENT
MODIFICATIONS during Ramadan
IDF-DAR practical guideline 2021

33. Adjustment of Sulfonylurea
IDF-DAR practical guideline 2021

34. Adjustment of SGLT-2 inhibitors
 SGLT2Is are recommended to be administered at the
time of evening meal (Iftar)
 Increasing fluid intake during the non-fasting hours of
Ramadan is recommended
 SGLT2I do not require treatment modifications during
Ramadan, but if an individual is on multiple medications a
review of the doses should be made to avoid the risk of
hypoglycemia
IDF-DAR practical guideline 2021

35. Adjustment of Insulin
IDF-DAR practical guideline 2021

36. Adjustment of Insulin
IDF-DAR practical guideline 2021

37. Adjustment of Insulin
IDF-DAR practical guideline 2021

38. Suitable OAD
in Ramadan

39. Objective:
Among the 2nd generation
sulfonylureas- glimepiride &
gliclazide MR (research
brand- DIAMICRON MR60),
which one is more suitable
during Ramadan considering
efficacy & safety?
Research article
published in Journal of
Indian Medical
Association in 2005
JIMA Vol. 103, No. 08, August 2005

40. DIAMICRON MR60) is associated with 50%
less hypoglycemia compared to glimepiride
JIMA Vol. 103, No. 08, August 2005
Conclusion:
Gliclazide MR (research brand- DIAMICRON MR60) is
safer and thereby more suitable during Ramadan.

41. Objective:
To evaluate the efficacy &
safety of gliclazide MR
(research brand- DIAMICRON
MR60) at the dosage of 60mg
at breakfast or Iftar over
Muslim type 2 diabetic
patients observing fasting in
Ramadan from Bangladesh,
India & Pakistan.
Original paper published
in International Journal of
Clinical Practice in 2010
Int J Clin Pract, July 2010, 64, 8, 1090–1094

42. Conclusion:
Patients undertaking Ramadan fast can safely maintain
glycemic control with evening administration of
gliclazide MR 60mg.
DIAMICRON MR60 reduces HbA1c <7% in
3 months including a period of Ramadan
Int J Clin Pract, July 2010, 64, 8, 1090–1094

43. Objective:
To compare the incidence of
hypoglycemia in Muslim
fasting type 2 diabetic
patients (from Middle East)
treated with DPP-4 inhibitor
or SU in Ramadan.
Original paper published
in IJCP (International
Journal of Clinical
Practice) in 2011
Int J Clin Pract, November 2011, 65, 11, 1132–1140

44. DIAMICRON MR60 causes least hypoglycemia!!
Hypoglycemia 2 times more with glimepiride
compared to DIAMICRON MR60 in Ramadan
Int J Clin Pract, November 2011, 65, 11, 1132–1140

45. Objective:
To compare the incidence of
hypoglycemia in fasting
Muslim patients with type 2
diabetes (from India &
Malaysia) treated with SU or
DPP-4 inhibitor.
Original paper published
in CMRO (Current
Medical Research &
Opinion) in 2012
Curr Med Res Opin 2012; 281–8.

46. Hypoglycemia 5 times more with glimepiride
compared to DIAMICRON MR60 in Ramadan
DIAMICRON MR60 causes least hypoglycemia!!
Curr Med Res Opin 2012; 281–8.

47. Objective:
To observe efficacy &
tolerability of DIAMICRON
MR60 at the dosage of 1.5 to
2 tablets at breakfast (or Iftar
in Ramadan) over
Bangladeshi type 2 diabetic
patients.
Abstract published in
AACE Congress in 2013
AACE 2013 Abstract#245

48. DIAMICRON MR60 reduces HbA1c by 1.9%
in 6 months including a month of Ramadan
5
5.5
6
6.5
7
7.5
8
8.5
9
Base line After 6 months
-
1.9% n= 359
8.9%
7.0%
Baseli
ne
After 6
months
AACE 2013 Abstract#245
with <1%
hypoglycem
ia

49. Objective:
A meta analysis of 3
randomized trials, including
2,426 fasting type 2 diabetic
patients; to assess the
incidence of hypoglycemia
among patients treated with
gliclazide MR60 or DPP-4
inhibitors.
Meta Analysis published
in Diabetes Research &
Clinical practice journal
in 2015
Diabetes Res Clin Pract. 2015;109:226-232

50. Conclusion:
Gliclazide MR (research brand- DIAMICRON MR60) is an
effective OAD, therefore, suitable for type 2 diabetic
patients in Ramadan.
Diamicron MR60 and DPP-4 inhibitors
have similar low risk of hypoglycemia
Diabetes Res Clin Pract. 2015;109:226-232

52. Objective:
DIA-RAMADAN was an
international, real world,
prospective, observational
study conducted in 09
countries- Bangladesh, Egypt,
India, Indonesia, Kuwait,
Malaysia, Pakistan, Saudi Arabia
and United Arab Emirates,
including 1214 patients.
The aim of DIA-RAMADAN
study was to explore the safety
and effectiveness of gliclazide
MR60mg in patients with type 2
diabetes planning to fast during
Ramadan.
d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 6 3 ( 2 0 2 0 ) 1 0 8 1 5 4

53. Gliclazide MR60 (research brand- DIAMICRON
MR60)
maintains effective blood glucose control
d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 6 3 ( 2 0 2 0 ) 1 0 8 1 5 4

54. Achieved 7% HbA1c: New sub analysis of DIA-
RAMADAN study
Abstract of DAR Congress 2021

55. Risk of hypoglycemia is very low with
Gliclazide MR60 (research brand- DIAMICRON
MR60)
Only 1.6% symptomatic/asymptomatic hypoglycemia in
Ramadan
d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 6 3 ( 2 0 2 0 ) 1 0 8 1 5 4

56. Conclusion:
With Gliclazide MR 60 mg without dose adjustment during
Ramadan, patients can fast safely with a low risk of
hypoglycaemia and no risk of severe hypoglycaemia, even
in prolonged fasting period, whilst maintaining glycemic
control and weight.
No risk of severe hypoglycemia
d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 6 3 ( 2 0 2 0 ) 1 0 8 1 5 4

57. Take Home
Messages

58.  Uncomplicated T2DM patients can fast in
Ramadan
 Pre-Ramadan education is important to
minimize risks
 Islam allows blood glucose monitoring while
fasting
As per evidences DIAMICRON MR60 is a
suitable OAD for type 2 diabetic patients
CONCLUSION

59. THANK YOU