This Presentation Prepared from IDF-DAR,BMJ,ADA & Other guidelines.It will cover to solve problems faced by the physicians during management of DM in the Holy Month of Ramadan specially monitoring of blood glucose,Drug doses,dietary and exercise advice etc.

2. DM & Ramadan

3. Management of diabetic patients
during the holy month of Ramadan
Dr. Md. Rafiqul Islam
Registrar(Medicine)
M Abdur Rahim Medical College
Hospital

4.  Fasting in Ramadan is one of the five pillars
of Islam, therefore, Muslim patients insist on
fasting
 Globally more than 50 million Muslim with
diabetes observe fasting in Ramadan
 Therefore, managing diabetic patients
observe fasting is a challenge for the clinicians
INTRODUCTION

5. 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
01. Can Fam Physician 2014;60:508-10

6. Pathophysiology
Of
Fasting

9. Non Diabetic

11. Diabetic

12. What are the challenges for
a Clinician during Ramadan
 Check eligibility of patient to observe
fasting
 Managing risks associated with fasting
 Blood glucose monitoring while
fasting
 Adjustment of diet, exercise & drugs

13. Eligibility of
patient
to observe
fasting

14. 1. Physically sick ( Quran 2: 184-185)
2. Traveler on a journey ( Quran 2: 184-185)
3. Women during menstruation

15. BMJ Open Diabetes Research and Care 2015;3:e000108. doi:10.1136/bmjdrc-2015-000108

16. BMJ Open Diabetes Research and Care 2015;3:e000108. doi:10.1136/bmjdrc-2015-000108

17. BMJ Open Diabetes Research and Care 2015;3:e000108. doi:10.1136/bmjdrc-2015-000108

18. BMJ Open Diabetes Research and Care 2015;3:e000108. doi:10.1136/bmjdrc-2015-000108

19. Managing Risks
during Ramadan

20. What are the risks
associated with fasting?
 Hypoglycemia
 Hyperglycemia
 Dehydration
 Thrombosis
 Weight changes
03. Diabetes Care. 2010 Aug; 33(8): 1895–1902.

21. But, HYPOGLYCEMIA is
the most sensitive one

22. Recommendations to
avoid hypoglycemia
 To take Suhur close to Suhur time
 Change the schedule and composition of
meals
 Reduce physical activity during day time;
physical exercise can be performed about
one hour after Iftar
02. Clinical Diabetes ( Middle East Edition)- Volume 3, Number 3, 2004

23. 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
02. Clinical Diabetes ( Middle East Edition)- Volume 3, Number 3, 2004

24. Education
&
Counseling

26. Impact of Education & Counseling
Objective:
The aim of study was to
determine the impact of
Ramadan-focused education on
weight & hypoglycemic
episodes during Ramadan in a
Type 2 diabetic Muslim
population taking oral glucose
lowering agents.04. Diabet. Med. 27, 327–331 (2010)

27. Findings: Weight Change
Patients without education gained weight after Ramadan
04. Diabet. Med. 27, 327–331 (2010)

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

29. Blood Glucose
Monitoring
in Ramadan

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

32. Adjustment of
Diet & Exercise

33. Diet in Ramadan
 Drink more water to avoid dehydration
 Avoid sugar (sweetener can be used)
 Avoid foods rich in fat
 Avoid heavy Iftar & light Suhur
 Keep same calorie as before Ramadan
 Take complex carbohydrate at Suhur
 Take Suhur as late as possible
02. Clinical Diabetes ( Middle East Edition)- Volume 3, Number 3, 2004

34. IDF-DAR,APRIL 2016

36. Exercise in Ramadan
 Physical activity should be
reduced during day time
 Exercise can be performed for an
hour after Iftar
 However, increased prayer during
Tarawih should be taken into
account
03. Diabetes Care. 2010 Aug; 33(8): 1895–1902.

37. “And do not kill yourselves [or one another].
Indeed, Allah is to you ever Merciful.”
[An-‐-Nissa: 29]
“and make not your own hands
contribute to (your) destruction”
[Al Baqara: 195].
When To Break Fast

39. Adjustment of Drug

40. Full morning dose at Iftar and half of the
usual evening dose at Suhur
Sulfonylureas twice daily
e.g., gliclazide 80 mg
Patients on oral hypoglycemic agents
No change is needed (modify time and
intensity of exercise), ensure adequate
fluid intake
Patients on diet and exercise
control
During RamadanBefore Ramadan
Same dose should be taken at Iftar
Sulfonylureas once daily
e.g., gliclazide MR
(research brand- DIAMICRON
MR60)
Metformin, 1,000 mg at Iftar, 500 mg at
Suhur
Biguanide,
e.g., Metformin 500 mg thrice daily
Adjustment of Drug/Treatments
03. Diabetes Care. 2010 Aug; 33(8): 1895–1902.

41. As usual at nightGlinide
As usual at nightDPP-4 inhibitor
During RamadanBefore Ramadan
As usual at nightSGLT-2 inhibitor
Adjustment of Drug/Treatments
03. Diabetes Care. 2010 Aug; 33(8): 1895–1902.

42. Insulin therapy
Long- or intermediate-acting basal insulin:
OD –Take at iftar,Reduce dose by 15–30%
BID –Take usual morning dose at iftar,Reduce evening dose
by 50% and take at suhoor
Rapid- or short-acng prandial/bolus insulin:
Take normal dose at iftar,Omit lunch-time dose.
Reduce suhoor dose by 25–50%
Premixed insulin:
OD – Take normal dose at iftar
BID – Take usual morning dose at iftar.Reduce evening dose
by 25–50% and take at suhoor
TID – Omit afternoon dose. Adjust iftar and suhoor doses

43. Dose titraon should be performed every three
days and dose adjustments made according to
BG levels

44. Post-Ramadan
follow-up
• In Eid ul-Fitr, patients with diabetes should be
made aware of overindulgence during this time
• A post-Ramadan follow-up advisable to
discuss medication and regimen readjustments
• It should be stressed that a safe fast one year
does not automatically make them low risk for
the next year

45. Take Home
Messages

46.  Uncomplicated type 2 diabetic patient can fast
in
Ramadan
 Pre-Ramadan education is important to
minimize risks
 Islam allows blood glucose monitoring while

48. THANK YOU