dm and ramadhan-dr hanisah arsyad
TRANSCRIPT
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MANAGEMENT OF MANAGEMENT OF DIABETES DURING DIABETES DURING RAMADANRAMADAN
Dr Hanisah ArshadFamily Medicine SpecialistKlinik Kesihatan BakriMuar District of Health
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IntroductionRisk associated with fasting in
Diabetics patientDiabetis Patient……Is it possible
to fast?How to manage Diabetes
patients who decide to fast?
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Muslim Population and DMMuslim Population and DMWorld wide• 1.1 -1.5 billion of Muslim• Diabetes prevalence 4- 6%• EPIDIAR study 1422/2011 – 43% T1DM and
79% T2DM fasting during Ramadan• 40-50 million people with DM fasting
Malaysia• Prevalence of T2DM above 30 yrs old 14.9%
( NHMS 2006)• Estimated 2 million Malaysian had T2DM• 1.2 million are Muslim
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RamadhanRamadhan 9 month of Islamic lunar calendarDuration 29 – 30 daysDuration of daily fast
- Malaysia 14 hrs- Other countries may up to 20 hours
Meal consumption - 2 meals- after sunset ( Iftar) and before dawn (
Sahur)
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Puasa Ramadan -WAJIB
“ Wahai orang-orang yang beriman ! Kamu diwajibkan berpuasa sebagaimana diwajibkan atas orang-orang yang dahulu daripada kamu, supaya kamu bertakwa ”. (Ayat 183, Surah Al Baqarah)
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Diabetis Patient……Diabetis Patient……Is it possibble to fast?Is it possibble to fast?
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Memang puasa itu wajib! tetapi punya kelonggaran
“(Puasa yang diwajibkan itu ialah) beberapa hari yang tertentu; maka sesiapa di antara kamu yang sakit, atau dalam musafir, (bolehlah ia berbuka), kemudian wajiblah ia berpuasa sebanyak (hari yang dibuka) itu pada hari-hari yang lain; dan wajib atas orang yang tidak terdaya berpuasa (kerana tua dan sebagainya) membayar fidyah iaitu memberi makan orang miskin. Maka sesiapa yang dengan sukarela memberikan fidyah, maka itu adalah satu kebaikan baginya” Ayat 184, Surah Al Baqarah
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Diabetes is exempted for fastingIt is a chronic metabolic disorder
- at risk of complicationBUT…. Many pt with DM insist to
fastENSURE ….. Aware the potential
risk…….Appropiate advice
given
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Risks Associated With Risks Associated With Fasting in Diabetes PatientsFasting in Diabetes Patients
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Epidemiology of Diabetes and Epidemiology of Diabetes and Ramadhan 1422/2001 (EPIDIAR) Ramadhan 1422/2001 (EPIDIAR) StudyStudy• Large epidemiological study• Population based• Conducted in 13 Islamic country, involved
12,243 diabetes patients
• Results:1. Increased risk of severe hypoglycemia were more frequent during Ramadhan
2. Fivefold increase of severe hyperglycemia
EPIDIAR Study,Diabetes Care 27:2306-2311, 2004www.fms-malaysia.org
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Other risk associated with fasting
3. Diabetic ketoacidosis - esp in T1DM
4. Dehydration - due to limitation of fluid intake, hot climate, osmotic diuresis
5. Thrombosis - due to hypercoagulable state ( increase clotting factors, reduced anticoagulant
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Fasting not allowed:Fasting not allowed:
1. Poorly controlled type I or type II diabetic patients2. Diabetic patients known to be incompliant in terms of
diet , drug regimens and daily activity3. Diabetic patients with serious complications such as
unstable angina or uncontrolled hypertension4. Patients with a history of diabetic ketoacidosis5. Diabetic patients will inter-current infections6. Elderly patients with any degree of alertness
problems7. Two or more episodes of hypoglycemia and/or
hyperglycemia during Ramadan.8. Gestational DM on Insulin therapy9. Less than 12 years
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Allow fasting in: 1. Patients who do not have the
mentioned criteria2. Patient who accept medical advisement.
Encourage fasting in: Overweight NIDDM patients whose
diabetes is stable with weight levels 20% above the ideal weight or body mass index (body weight, kg/height, meters squared) greater than 28.
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How to manage Diabetes How to manage Diabetes patients who decide to patients who decide to fast?fast?
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1.Pre ramadan medical assessment 1.Pre ramadan medical assessment and educational counsellingand educational counselling1.1 Pre Ramadan medical assessment
- look for overall well being - glucose control, BP control, lipids control - advice the potential risk
1.2 Educational counseling/ Ramadan focus education - VERY IMPORTANT to patients and family - educate on self care, sign and sx of hypo/hyperglicemia, BG monitoring, meal planning, drug admin, management of acute complication
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2. Ramadan Focus 2. Ramadan Focus EducationEducation2.1 Care must be individualized
Management plan differ for each patient
2.2 Frequent monitoring of glucose levelBefore sahur, 2hrs after Sahur2hrs before Iftar, 2 hrs after Iftar
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2.3 NutritionIS A CHALLENGE…………
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Tips on nutrition/dietTips on nutrition/diet1. Iftar
- don’t delay Iftar- limit intake of high sugar/ high fat food →weight gain- break fast with dates/ tamar 1-2 seeds- take main meal later ( around Isyak prayer) → complex carbo, ↑fibre, ↓ salt, a lot water
2. Sahur - have Sahur as late as possible → to avoid long fasting- eat adequate balance meal- drink a lot of water
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Sabda Rasulullah s.a.w.;
“Senantiasalah umatku berada dalam kebaikan selama mereka menyegerakan berbuka dan melambatkan sahur”.(Riwayat Imam Ahmad dari Abu Zarr r.a.)
2.4 Exercise - maintain normal physical activity- avoid excessive physical activity
2.5 Breaking the fast – immediately- when having hypoglycemia symptoms- hypoglycemia ( BG < 3.5 mmol/l)- BG reaches < 3.9 mmol/l in the first few hours of fasting- BG > 16 mmol/l
Recommendation for Mx of Diabetes During Ramadan, Diabetes Care, 28:2305- 2311, 2005
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CPG in Insulin Therapy by MOH, 2010 www.fms-malaysia.org
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Treatment regime Treatment regime adjustment..adjustment..
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Patient on diet controlNo change neededAdequate fluid intake
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Patient on OHAPatient on OHA
In general, insulin sensitizer associated with lower risk of hypoglycemia
1. Sulphonylurea ( ↑insulin secretion) - use with caution - use Chlorpropamide is CI - SU 2x/ day eg: Glibenclamide, Gliclazide → full dose at Iftar, half dose during sahur - SU once daily eg: Gliclazide MR → dose given at Iftar
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2. Metformin ( insulin sensitizer)- 2/3 given at Iftar, 1/3 at sahur
3. Glitazones (rosiglitazone, pioglitazone) - No change in dose required
4. Short acting insulin secretagogue
- Repaglinides, Nateglinides - can be taken twice during Iftar and Sahur
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Insulin adjustmentInsulin adjustment
Short acting insulin + intermediate
Humulin N, Insulitard
Humulin 30/70, Mixtard 30/70
CPG in Insulin Therapy, MOH 2010www.fms-malaysia.org
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Management of people with diabetes wanting to fast during Ramadan, BMJ 2010;340:c3053 www.fms-malaysia.org
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ConclusionConclusion1. Fasting during Ramadan for Diabetes
patients carries a risk – discuss the risk with the patient
2. Patients who insists on fasting should undergone assessment and receive appropriate education.
3. The management plan should be highly individualized and close follow up is essential
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'RAMADHAN' akan dtg menziarahi kita sekeluarga bila2 masa sahaja lagi. Dia dtg bersama isterinya iaitu REZEKI dan juga 2 anaknya ...SAHUR dan IFTAR serta 3 org cucunya iaitu RAHMAT,BARAKAH dan KEAMPUNAN.Mereka akan pulang selepas 30 hari dgn menaiki pesawat TAQWA airlines.
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