Transcript Document
Workshop : Managing DM 2 during Ramadan
DR.Obaid Almutairi
ميحرلا نمحرلا الله مسب
دهش نمف ناقرفلاو ىدهلا نم تانيبو سانلل ىده نآرقلا هيف لزنا يذلا ناضمر رهش رسيلا مكب الله ديري رخا مايا نم ةدعف رفس ىلع وا اضيرم ناك نمو همصيلف رهشلا مكنم ةي آ نوركشت مكلعلو مكاده ام ىلع الله اوربكتلو ةدعلا اولمكتلو رسعلا مكب ديري لاو ۱۸٥ ةرقبلأ ةروس
A large number of Muslim patients with diabetes fast during Ramadan Global Muslim population 1
1.6 billion (2010) 2.2 billion (2030)
> 50 million people with diabetes are estimated to fast during Ramadan worldwide 2,3 • The global prevalence of diabetes is projected to increase in emerging economies, including those with large Muslim populations 4,5 • 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 diabetes 2,3 • Although the consensus from religious and medical leaders is that Muslims with diabetes are generally not obliged to fast 6 many choose to do so 2,3 1 The Pew Forum on Religion & Public Life. http://www.pewforum.org/The-Future-of-the-Global-Muslim-Population.aspx
(Accessed March 2013); 2 Al-Arouj M et al. Diabetes Care 2010;33:1895–902; 3 Salti I et al. Diabetes Care 2004;27:2306–11; 4 IDF Diabetes Atlas 5 th edition. www.idf.org/diabetesatlas/5e/the-global-burden (Accessed March 2013); 5 Whiting DR et al. Diabetes Res Clin Pract 2011; 94: 311–21; 6 Beshyah SA. Ibnosina J Med Biomed Sci 2009;1:58–60 3
Religion Muslim Jewish Hinduism Christianity Mormon Fasting is a worldwide custom practiced for religious and cultural reasons 1 Examples of fasting practices 2 – 5 Ramadan: fasting during daylight hours for 29–30 days 2,3 Yom Kippur and Tish’ah B’av: single days of fasting 4 Single days of fasting 4 Ash Wednesday and Good Friday: single days of fasting 4 Fasting once a month for a single day 5
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 year 2,3
1 Fasting can range from restricting certain foods to complete abstinence from all food and drink: 1 Fazel M . J R Soc Med 1998;91:260 –63; 2 Al-Arouj M et al. Diabetes Care 2010;33:1895–902; 3 Salti I et al. Diabetes Care 2004;27:2306–11; 2008; 102:814 –19.
4 Green V. Br J Nursing 2004;13:658 –62; 5 Horne BD et al. Am J Cardiol 4
Risks associated with FASTING in patients with diabetes
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 Diabetes Care, volume 28, NUMBER 9, September 2005
Risks associated with FASTING in patients with diabetes
1.
Hypoglycemia
2.
Hyperglycemia
3.
Diabetic ketoacidosis
4.
Dehydration and thrombosis
Diabetes Care, volume 28, NUMBER 9, September 2005
EPIDIAR study: fasting during Ramadan increases the risk of severe hypoglycaemia and hyperglycaemia in patients with T2DM
11,173 patients with T2DM; 78.7% chose to fast for at least 15 days during Ramadan 1 4 3 2 1 0 Higher risk of severe hypoglycaemic events † in overall population during Ramadan ‡1,2
P<0.0001
7.5-fold increase*
0,4 3 Higher risk of severe hyperglycaemic events † in overall population during Ramadan ‡1,2
P<0.0001
6 5 4
5-fold increase
3 2 1 0 During Ramadan 1 5 Pre-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 7 1 Salti I, et al. Diabetes Care 2004;27:2306–11; 2 Al-Arouj M, et al. Diabetes Care 2010;33:1895–902
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
Case study 1
13 • • • Female patient aged 47 years Type 2 diabetes diagnosed 4 years ago Poor compliance with diet and exercise regimen BMI 29 kg/m 2 Weight 82 kg HbA 1c 8.7% FBG 9 mmol/L (162 mg/dL)
Current treatment
Metformin, 850 mg twice daily SU once daily
MANAGEMENT Pre-RAMADAN medical assessment & educational counseling
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 Diabetes Care, volume 28, NUMBER 9, September 2005
MANAGEMENT Pre-RAMADAN medical assessment & educational counseling
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 Diabetes Care, volume 28, NUMBER 9, September 2005
MANAGEMENT Pre-RAMADAN medical assessment & educational counseling
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 Diabetes Care, volume 28, NUMBER 9, September 2005
MANAGEMENT
e.
• •
General Considerations
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
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
Diabetes Care, volume 28, NUMBER 9, September 2005
MANAGEMENT General Considerations
c.
• • • Nutrition: Healthy and balanced diet Maintain constant body mass Avoid ingesting large amount of carbohydrate and fat (common practice)
MANAGEMENT
c.
• Nutrition:
General Considerations
“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
d.
MANAGEMENT
Exercise:
General Considerations
• • • 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
Considerations for anti-hyperglycaemic treatment for fasting patients with T2DM Treatment before Ramadan
Oral anti-diabetic agents Biguanides TZDs, AGIs, or incretin-based therapies Sulphonylureas once a day Sulphonylureas twice a day Insulin Premixed or intermediate-acting insulin twice daily
Treatment during Ramadan
Ensure adequate fluid intake Metformin 1 g at sunset meal and 500 mg at predawn meal No change needed Dose should be given before sunset meal. Adjust dose based on glycaemic control and hypoglycaemia risk Half the usual morning dose at predawn meal and usual dose at sunset meal Ensure adequate fluid intake 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
T reatment 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
TZD = thiazolidinedione; AGI, alpha-glucosidase inhibitor;T2DM = type 2 diabetes mellitus; SU = sulphonylureas Al-Arouj M et al. Diabetes Care 2010;33:1895–902
Case study 1
23 • • • Female patient aged 47 years Type 2 diabetes diagnosed 4 years ago Poor compliance with diet and exercise regimen BMI 29 kg/m 2 Weight 82 kg HbA 1c 8.7% FBG 9 mmol/L (162 mg/dL)
Current treatment
Metformin, 850 mg twice daily SU once daily
Case study 2
24 • Male patient aged 61 years • Type 2 diabetes diagnosed 16 years ago • Motivated to maintain busy lifestyle BMI 31 kg/m 2 Weight 88 kg HbA 1c 8.0% FBG 5.6 mmol/L (100 mg/dL)
Current treatment
Long Acting Insulin Analog 32 units/day Metformin 1 g BID