workshop : managing dm 2 during ramadan dr.obaid almutairi
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Workshop : Managing DM 2 during Ramadan DR.Obaid Almutairi. بسم الله الرحمن الرحيم - PowerPoint PPT PresentationTRANSCRIPT
Workshop :Managing DM 2during Ramadan
DR.Obaid Almutairi
بسم الله الرحمن الرحيم
من وبينات للناس هدى القرآن فيه انزل الذي رمضان شهر
كان ومن فليصمه الشهر منكم شهد فمن والفرقان الهدى
اليسر بكم الله يريد اخر ايام من فعدة سفر على او مريضا
ما على الله ولتكبروا العدة ولتكملوا العسر بكم يريد وال
تشكرون ولعلكم ية - ألبقرة سورةآ هداكم
۱۸٥
A large number of Muslim patients with diabetes fast during Ramadan
1The Pew Forum on Religion & Public Life. http://www.pewforum.org/The-Future-of-the-Global-Muslim-Population.aspx (Accessed March 2013); 2Al-Arouj M et al. Diabetes Care 2010;33:1895–902; 3Salti I et al. Diabetes Care 2004;27:2306–11; 4IDF Diabetes Atlas 5th edition. www.idf.org/diabetesatlas/5e/the-global-burden (Accessed March 2013); 5Whiting DR et al. Diabetes Res Clin Pract 2011; 94: 311–21; 6Beshyah SA. Ibnosina J Med Biomed Sci 2009;1:58–60
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• The global prevalence of diabetes is projected to increase in emerging economies, including those with large Muslim populations4,5
• The pattern of daytime fasting and night-time meals and use of anti-diabetic treatment increases the risk of complications, including hypoglycaemia in patients with diabetes2,3
• Although the consensus from religious and medical leaders is that Muslims with diabetes are generally not obliged to fast6 many choose to do so2,3
1.6 billion
(2010)
2.2 billion
(2030)
Global Muslim population1
> 50 million people with diabetes are estimated to fast during Ramadan worldwide2,3
Fasting is a worldwide custom practiced for religious and cultural reasons1
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Religion Examples of fasting practices2–5
Muslim Ramadan: fasting during daylight hours for 29–30 days2,3
Jewish Yom Kippur and Tish’ah B’av: single days of fasting4
Hinduism Single days of fasting4
Christianity Ash Wednesday and Good Friday: single days of fasting4
Mormon Fasting once a month for a single day5
Healthy adult Muslims fasting during the month of Ramadan abstain from food, water, or use of oral medications between dawn and sunset for 29–30 days every year2,3
1Fasting can range from restricting certain foods to complete abstinence from all food and drink: 1Fazel M . J R Soc Med 1998;91:260–63;2Al-Arouj M et al. Diabetes Care 2010;33:1895–902; 3Salti I et al. Diabetes Care 2004;27:2306–11; 4Green V. Br J Nursing 2004;13:658–62; 5Horne BD et al. Am J Cardiol 2008; 102:814–19.
Risks associated with FASTING in patients with diabetes
Diabetes Care, volume 28, NUMBER 9, September 2005
EPI.DIA.R trial (EPIdemilogy DIAbetes in Ramadan) Multi-country epidemiological study (Algeria,
Bangladesh, Egypt, India, Indonesia, Jordan, Lebanon, Malaysia, Morocco, Pakistan, Saudi Arabia, Tunisia & Turkey)
12,273 diabetic patients
Individuals who fast during Ramadan showed a high rate of acute complications
Risks associated with FASTING in patients with diabetes
Diabetes Care, volume 28, NUMBER 9, September 2005
1. Hypoglycemia
2. Hyperglycemia
3. Diabetic ketoacidosis
4. Dehydration and
thrombosis
EPIDIAR study: fasting during Ramadan increases the risk of severe hypoglycaemia and hyperglycaemia in patients with T2DM
1Salti I, et al. Diabetes Care 2004;27:2306–11; 2Al-Arouj M, et al. Diabetes Care 2010;33:1895–9027
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57.5-fold increase* 5-fold increase
P<0.0001 P<0.0001
EPIDIAR = EPIdemiology of DIAbetes and Ramadan; T2DM = type 2 diabetes mellitus
11,173 patients with T2DM; 78.7% chose to fast for at least 15 days during Ramadan1
Higher risk of severe hypoglycaemic events† in overall population during Ramadan‡1,2
Higher risk of severe hyperglycaemic events† in overall population during Ramadan‡1,2
Pre-Ramadan During Ramadan
†Events requiring hospitalization in overall population with T2DM; ‡compared with previous months * There was a 7.5 fold difference of hypoglycaemia in overall population fasting during Ramadan. For patients who fasted for > 15 days difference was, 6.7 fold
Recommendations for Management of Diabetes During Ramadan
Ramadan
Consensus
Conditions associated with “Very High”, “High”, “Moderate” & “Low” risk for adverse events in diabetic patients deciding
to fast RAMADAN
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• Female patient aged 47 years• Type 2 diabetes diagnosed 4 years ago• Poor compliance with diet and exercise regimen
Case study 1
Current treatmentMetformin, 850 mg twice daily SU once daily
BMI 29 kg/m2
Weight 82 kg
HbA1c 8.7%
FBG 9 mmol/L (162 mg/dL)
Diabetes Care, volume 28, NUMBER 9, September 2005
a. Medical Assessment:• 1-2 months before RAMADAN• Specific attention to the:
well-being of the patient Glycemia BP lipids
• Specific medical advice for those who wish to fast against medical recommendations
MANAGEMENT Pre-RAMADAN medical assessment & educational counseling
Diabetes Care, volume 28, NUMBER 9, September 2005
a. Medical Assessment:
• During this assessment, necessary changes in the diet or medication regimen should be made so that the patient initiates fasting while being on stable and effective program
MANAGEMENT Pre-RAMADAN medical assessment & educational counseling
Diabetes Care, volume 28, NUMBER 9, September 2005
b. Educational Counseling: • Educate the patient and his family on:
Signs & symptoms of hypoglycemia BG monitoring Meal planning Physical activity Medication administration Management of acute complications
MANAGEMENT Pre-RAMADAN medical assessment & educational counseling
e. Breaking the fast:• Immediately if hypoglycemia occurs
(BG<60mg/dL, 3.3 mmol/L)• If BG<70mg/dL, 3.9 mmol/L in the few
hours after the start of the fast
• If BG exceeds 300 mg/dL, 16.7 mmol/L
• Sick days
MANAGEMENT
General Considerations
Diabetes Care, volume 28, NUMBER 9, September 2005
a. Individualization
b. Frequent monitoring of glycemia
• Patient must have the means to
monitor his BG multiple times daily
• Very important with patients using
insulin
MANAGEMENT
General Considerations
c. Nutrition:• Healthy and balanced diet• Maintain constant body mass• Avoid ingesting large amount of
carbohydrate and fat (common practice)
MANAGEMENT
General Considerations
c. Nutrition:• “Complex” carbohydrates are advisable at
the predawn meal (delay in absorption)
• Simple carbohydrates more appropriate at the sunset meal
• Increase liquid intake during non-fasting hours
• Delay predawn meal as much as possible
MANAGEMENT
General Considerations
d. Exercise:
• Maintain normal level of physical activity• Excessive physical activity: increased
risk of hypoglycemia (especially before Iftar)
• Tarawih are to be considered as part of the daily exercise
MANAGEMENT
General Considerations
Treatment before Ramadan Treatment during Ramadan
Oral anti-diabetic agents Ensure adequate fluid intake
Biguanides Metformin 1 g at sunset meal and 500 mg at predawn meal
TZDs, AGIs, or incretin-based therapies No change needed
Sulphonylureas once a day Dose should be given before sunset meal. Adjust dose based on glycaemic control and hypoglycaemia risk
Sulphonylureas twice a day Half the usual morning dose at predawn meal and usual dose at sunset meal
Insulin Ensure adequate fluid intake
Premixed or intermediate-acting insulintwice daily
Consider change to long-acting or intermediate insulin in the evening, and short or rapid-acting insulin with meals; take usual dose at sunset meal and half usual dose at predawn meal
Considerations for anti-hyperglycaemic treatment for fasting patients with T2DM
Al-Arouj M et al. Diabetes Care 2010;33:1895–902TZD = thiazolidinedione; AGI, alpha-glucosidase inhibitor;T2DM = type 2 diabetes mellitus; SU = sulphonylureas
Treatment considerations:
• The choice of oral anti-diabetic agent should be individualized with consideration to the risk of hypoglycaemia
• Newer pharmacological agents have lesser hypoglycaemic potential & may have specific advantages during Ramadan
• Caution is advised when using old Su groups
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• Female patient aged 47 years• Type 2 diabetes diagnosed 4 years ago• Poor compliance with diet and exercise regimen
Case study 1
Current treatmentMetformin, 850 mg twice daily SU once daily
BMI 29 kg/m2
Weight 82 kg
HbA1c 8.7%
FBG 9 mmol/L (162 mg/dL)
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• Male patient aged 61 years• Type 2 diabetes diagnosed 16 years ago• Motivated to maintain busy lifestyle
Case study 2
Current treatmentLong Acting Insulin Analog 32 units/dayMetformin 1 g BID
BMI 31 kg/m2
Weight 88 kg
HbA1c 8.0%
FBG 5.6 mmol/L (100 mg/dL)
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