Diabetes Management In Ramadan By :SHOROUK MOUSSA Lecturer of Internal medicine and Endocrinology Cairo University
A large number of Muslim patients with diabetes fast during Ramadan
Global Muslim population1
1.6 billion 2.2 billion (2010) (2030)
> 50 million people with diabetes are estimated to fast during Ramadan worldwide2,3
• 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 3 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 Frequently asked questions
• Can a diabetic patient fast Ramadan, SAFELY??? • What are the risks?? • What about diet and exercise?? • How to adjust medications??
Many patients with diabetes insist on fasting during ramadan creating medical challenge for themselves and their physicians
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 Muslim patients with diabetes fasting during Ramadan.
. Individuals who fast during Ramadan showed a high rate of acute complications
Diabetes Care, volume 28, NUMBER 9, September 2005 HYPOGLYCEMIA
11,173 patients with T2DM; 78.7% chose to fast for at least 15 days during It has been estimated that 1 Ramadan hypoglycemia accounts for 2-4%of mortality in Higher risk of severe hypoglycaemic events† in overall population during Ramadan‡1,2 patients with T1DM much lesser with T2DM P<0.0001
4 3 3 7.5-fold increase*
EPIDIAR study showed that 2 fasting during Ramadan
patients/month) increased the risk of severe Incidence
100 100 1 0.4 hypoglycemia (7.5 fold in T2DM and 4.7 foldin 0
(events/ patients with type T1DM Pre-Ramadan During Ramadan 11
†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 EPIDIAR = EPIdemiology of DIAbetes and Ramadan; T2DM = type 2 diabetes mellitus 1Salti I, et al. Diabetes Care 2004;27:2306–11; 2Al-Arouj M, et al. Diabetes Care 2010;33:1895–902
HYPERGLYCEMIA
EPIDIAR study: 5 fold increase in the incidence of Higher risk of severe hyperglycaemic events† severe hyperglycemia in patients in overall population during Ramadan‡1,2 with type 2 DM. 3fold increase in the incidence of severe hyperglyemia with or 5-fold increase P<0.0001 6 without ketoacidosis in patients 5 with type 1 DM 5 4 3 2 1 1 0
Pre-Ramadan During Ramadan Hyperglycaemia
May be due to excessive reduction of medication dosages to prevent hypoglycaemia.
Increase in food and/or sugar intake during Nonfasting hours
Diabetic ketoacidosis
• Patients with diabetes, especially those with type I DM, who fast during Ramadan are at increased risk for development of diabetic ketoacidosis, particularly if they grossly hyperglycaemic before Ramadan
Dehydration and Thrombosis
• Hypercoagulable states in diabetes might be exacerbated, due to an increasing in clotting factors, decrease in endogenous anticoagulants and impaired fibrinolysis enhancing the risk of thrombosis and stroke • Increased blood viscosity secondary to dehydration may enhance the risk of thrombosis • Increased incidence of retinal vein occlusion
Conditions associated with “Very High”, “High”, “Moderate” & “Low” risk for adverse events in diabetic patients deciding to fast RAMADAN
Fasting is NOT recommended May choose Not to fast May choose to fast with caution
May choose to fast
Pre-Ramadan medical assessment
Medical Assessment: • 1-2 months before RAMADAN
• Approach should be individualized Specific attention to the: Physical well-being assessment of the patient Glycemic control BP control Lipids control Diabetes-related complications Diabetes-unrelated comorbidities
• Specific medical advice for those who wish to fast against medical Diabetes recommendationsCare, volume 28, NUMBER 9, September 2005
• Dose and timing of anti-hypertensive medications may need to be adjusted to prevent hypotension. • Diuretics should be used with caution to avoid volume depletion. • Lipid lowering medications: should be continued without the need for dose adjustment, as it is common practice to have higher intake of foods rich in carbohydrates and saturated fats during Ramadan.
Structured Diabetes Education
Patients who received diabetes education and fewer episodes of hypoglycemia Key areas in Ramadan focused Education BG monitoring & When to stop fasting
Meal planning and dietary advice
Physical activity timing and intensity
Recognize and Management of acute complications
•( Signs & symptoms of hypoglycemia, hyperglycemia and dehdration) Self monitoring
• Confirm that blood glucose testing doesn’t constitute breaking fast. • Teaching patients who fast how to test their blood sugar • Encouraging people with diabetes to test their blood sugar especially if they feel any symptoms related to hypoglycemia or hyperglycemia
Timing and frequency of SMBG based on treatment • Insulin therapy Diabetic patients who are in the moderate to high risk categories are advised to monitor their blood glucose: • Pre-meal and 2-hour post pre-dawn meal (sahur) • Mid-day • Pre-meal and 2-hour post sunset meal (iftar) Bedtime Timing of SMBG could reflect adequacy of insulin dose Oral anti-diabetic (OAD) therapy To monitor when symptomatic
BREAK THE FAST IF NECESSARY
BLOOD GLUCOSE ≤ 60 mg/dl
BLOOD GLUCOSE < 70 mg/dl early in the day
Stop fasting even if hypoglycemia occurs to close to the time of Iftar
Blood glucose > 300 esp type I DM Check ketoned in blood or urine
Sick days or unusual symptoms ( vomiting, SOB… Nutrition in Ramadan
• DO I need to go on a special diet during Ramadan ????
• If you are already following a balanced diet, then there is a big chance that you do not have to change the ingredients of your diet. • In fact, you should eat as you normally do, with the only difference being the time you eat your meals, rather than quantity or type of food consumed. Nutrition in Ramadan
• Aim at maintain a constant body weight • Divide food into to 2-3 meals : iftar, dinner and suhur • Healthy and balanced diet • Limit amount of sweet food taken at iftar
Limit food high in saturated fat & fried food
• Encourage High fibre foods (whole grain cereals/brown rice/beans/fruits/vegetables/salads)
• Choose sugar free type of drinks • Drink plenty of water during non fasting hours: (Drink 8-10 cups of water between Iftar and Sahour meals.)
Suhur meal: Should be taken as late as possible before the fasting time starts, and including foods that are rich in complex carbohydrates, such as whole grain bread or vegetables Complex carbohydrates take more time to digest, absorb and ingest, keeping the body fueled for more hours throughout the fasting day. Brown rice, wholemeal bread, brown rice vermicelli and oats are examples of complex carbohydrates
Ramadan Nutritional Facts and Tips Some interesting information to note: There are 250 calories in one piece of fried samboosa and 125 calories in a baked samboosa. • Try baking samboosa instead of frying and consume one to two pieces maximum. Also, try to use light fillings, like low fat cheese.
• Try to eat/drink low fat soup options, like vegetable and lentil soups. If you plan to have a cream soup, replace the cream with skimmed milk.
• Cheese or walnut katayef can range from 200 to 400 calories a piece. Avoiding these foods is recommended; however, if you choose to eat them once in a while, bake them instead of frying and choose low fat fillings and reduce the density of the sugar syrup.
Exercise in Ramadan
It is very hot during Ramadan and fasting is very tiring, so I can’t exercise” • Normal physical activity may be maintained • Excessive Physical activity should be reduced during day time (higher risk of hypoglycemia) • Tarawaeeh praying should be considered a part of the of the daily excercise program.
• It is good to do some moderate exercise just before you break your fast at Iftar, and again just before going to bed, as well as right before Suhoor.
Management Of Type I DM
Fasting at Ramadan carries a very high risk for type I diabetic patients
The risk is particularly exacerbated in: Poorly controlled patients. Those with limited access to medical care. Hypoglycemic unawareness , unstable glycemic control, or recurrent hospitalizations. Unwilling or unable to monitor their blood glucose levels several times daily. If The Patient Insists On Fasting: Basal-bolus regimen is the preferred protocol of management tend to be safer, with fewer episodes of hyper and hypoglycemia. A frequently used option is once or twice daily injections of intermediate or long acting insulin along with premeal rapid acting insulin.
Management Of Patients With Type II DM Metformin (low risk) Patients treated with Metformin alone may safely fast because the possibility of hypoglycemia is minimal The timing of the doses can be modified to provide two thirds of the total daily dose with the sunset meal and the other third before the predawn meal If taking modified release metformin once daily take dose at Iftar
Management Of Patients With Type II DM
Glitazones (low risk): TZDs are not associated with hypoglycemia , though they can amplify the hypoglycemic effects of SU, Glinides, and insulin Associated with: weight gain Increased appetite Require 2-4 weeks to exert substantial antihyperglycemic effects SO they cannot be quickly substitiuted for agents associated with hypoglycemia during periods of fasting. No adjustment of doses required
Management Of Patients With Type II DM
Alpha –glucosidase inhibitors • Modest effects on fasting glucose • Usually used in combination with other agents • Associated with mild to moderate gastrointestinal side effects Management Of Patients With Type II DM
Sulphonylureas
May not be used as a first choice during Ramadan
Avoid use of: Glibenclamide, Glyburide, Chlorpropamide ( prolonged and unpredictable hypoglycaemia)
Gliclazide, Glimepiride, Glipizide have lower risk • Majority of our type II diabetic patients are treated with metformin and sulphonylureas Sulphonylureas once daily Morning dose e.g Gliclazide MR Full morning dose at Iftar Glimepiride
Full morning dose at Iftar Sulphonylureas twice daily Half evening dose at suhur e.G Gliclazide
Management Of Patients With Type II DM
Short acting insulin secretagogues • Members of this group (repalglinide and nateglinide ) are useful because of their short duration of action • They could be taken twice daily before the sunset and predawn meals without dose adjustment. INCRETIN-BASED THERAPY
GLP-1 receptor agonist
DPP-4 inhibitors
DPP-4 Inhibitors
• Among the best tolerated drugs for the treatment of diabetes • Can be considered as an alternative to sulphonylurea if risk of hypoglycemia is high . BENEFITS: • Inhibit DPP-4, an Low risk of hypoglycemia enzyme that degrade Weight neutral incretin hormones Well tolerated including GLP-1and GIP. • Enhance insulin secretion in a glucose dependant manner • Suppress elevated Side effects: glucagon secretion in Possible acute pancreatitis a glucose-dependant No significant GI side effects manner (SGLT-2) Inhibitors
Block reabsorption Benefits: of filtered glucose Insulin-independent action in kidneys Low risk of hypoglycemia
Leads to glucosuria, improved glycemic control CONCERNS Increase in urinary tract infections Increase in genital infections Used in caution Potential for volume depletion (due when initiating in to osmotic diuresis) the following Electrolyte imbalance patients Possible increased risk of bladder elderly, renal cancer(dapagliflozin) impairment, high Euglycemic ketoacidosis? CV risk • .
(FDA) has recently issued a warning regarding (DKA) associated with SGLT2 inhibitor use and a review of the issue by the European Medicines Agency is in progress.
It is not known whether the use of an SGLT2 inhibitor during Ramadan increases the risk of DKA
There are no consensus guidelines on SGLT2 inhibitor use during Ramadan Practical tips on the use of SGLT2 inhibitors Before Ramadan
• Ensure that patients were appropriately selected for SGLT2 inhibitors (assess) • Ensure absence of contraindications e.g. worsening renal function, use of diuretics • Avoid starting SGLT2 inhibitors immediately before Ramadan Practical tips on the use of SGLT2 inhibitors during Ramadan • Avoid starting SGLT2 inhibitors immediately before Ramadan During Ramadan • Take the medication with the first evening meal (Iftar) (monitor) • Encourage intake of adequate fluids at night (approximately extra 500 mL) • Avoid excessive intake of salt, coffee or tea • Observe hydration status (volume and colour of urine) • Observe blood pressure if home monitoring is readily available • Report symptoms to clinic/surgery • If in doubt stop medications and conduct an interim diabetes review After Ramadan:
Treatment with insulin
• The key factor for insulin therapy during Ramadan is to provide adequate insulin to prevent the post meal hyperglycaemia and also prevent hypoglycaemia during the period of fast.
The use of basal (glargine or detemir) and rapid-acting insulin analogs (lispro, aspart, and glulisine) has been shown to be superior to human insulin formulations (NPH and regular) during Ramadan by reducing the risk of hypoglycemia. Basal insulin: Taken at bedtime or any time after iftar meals. Reduce glargine dose by 20% May require dose reduction if there is daytime hypoglycaemia. Bolus / Prandial insulin: Sahur – Usual pre-Ramadan breakfast or lunch dose. May require dose reduction to avoid daytime hypoglycaemia. Lunch – Omit. Iftar – Usual pre-Ramadan dinner dose. May require dose increment. *Total insulin requirement for Type 1 diabetics who are on basal bolus regimen while fasting during Ramadan may require dose reduction by 15-30% of their pre-Ramadan dose requirements. Premixed insulin
• Consider changing premixed insulin to :
long acting in the evening and short or rapid acting with meals
Use Mix 50 instead Of Mix 30 to avoid postprandial hyperglycemia
Before Ramadan During Ramadan
Morning (30 U) Iftar: full morning dose(30U) Dinner (20 U) Suhur :1/2 dinner dose Algorithm for premixed insulin titration during Ramadan (adapted from Hassanein et al23) Fasting pre-Iftar pre-Suhoor BG Insulin adjustment >16.6 mmol/L (300 mg/dL) Increase insulin daily dose by 20% >10 mmol/L (180 mg/dL) Increase insulin daily dose by 10%
5.5–10 mmol/L (100–180 mg/dL) No change <5.5 mmol/L (100 mg/dL) or symptoms Reduce insulin daily dose by 10% <3.9 mmol/L (70 mg/dL) Reduce insulin daily dose by 20%
<2.8 mmol/L (50 mg/dL) Reduce insulin daily dose by 30–40% PREGNANCY AND FASTING
Muslim pregnant women are exempted from fasting • Type 1 DM • Type 2 DM • Gestational DM They should be strongly advised not to fast during Ramadan These women constitute a high risk group and their management requires intensified care. Carry home message
• Diabetic patients who fast are at higher risk of hypoglycaemia, hyperglycemia and ketoacidosis with increased rate of hospitalization. • Risk stratification is important to identify patients who are at risk of developing complications during fasting. • Pre-Ramadan medical review and education concerning self- care during Ramadan is important. • Appropriate meal planning & modification in intensity and timing of physical activity is important to maintain optimal glycemic control and optimal weight. • Adjustment for oral anti-diabetic medications and insulin should be individualized to lower the risk of hypoglycaemia when fasting during Ramadan
• Implementation of guidelines requires effective communication with, and education of all those involved, including patients, HCPs, religious leaders, and the wider community. Education, communication and accessibility are all critical to the success of the guidance provided in this document. Safer fasting
• Pre Ramadan Assessment and Education • Individualization • Frequent monitoring • Nutrition • Physical activity • Breaking the fast • Medication adjustment
• Starting meals with a small amount of food that is rich in simple carbohydrates and can be absorbed quickly by the body, such dates or milk, is recommended. • Consuming large meals at Iftar and/or foods that are high in fat and carbohydrates should be avoided. 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 Ramadan1
Higher risk of severe hypoglycaemic events† Higher risk of severe hyperglycaemic events† in overall population during Ramadan‡1,2 in overall population during Ramadan‡1,2
P<0.0001 P<0.0001
4 3 5-fold increase 3 7.5-fold increase*
6 2 5
5 patients/month)
Incidence 4
100 100 1 0.4 3 0 2 (events/ 1 1 Pre-Ramadan During Ramadan 69 0 †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 EPIDIAR = EPIdemiology of DIAbetes and Ramadan; T2DM = type 2 diabetes mellitus 1Salti I, et al. Diabetes Care 2004;27:2306–11; 2Al-Arouj M, et al. Diabetes Care 2010;33:1895–902
DIABETES EDUCATION DURING RAMADAN
Key areas in Ramadan focused education: • Educate the patient and his family on: Meal planning and dietary advice Physical activity timing and intensity BG monitoring When to stop fasting Recognize and Management of acute complications ( Signs & symptoms of hypoglycemia, hyperglycemia and dehdration)
Diabetes Care, volume 28, NUMBER 9, September 2005
Considerations for anti-hyperglycaemic treatment for fasting patients with T2DM
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 insulin Consider change to long-acting or intermediate insulin in the evening, and twice daily short or rapid-acting insulin with meals; take usual dose at sunset meal and half usual dose at predawn meal
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
TZD = thiazolidinedione; AGI, alpha-glucosidase inhibitor;T2DM = type 2 diabetes mellitus; SU = sulphonylureas Al-Arouj M et al. Diabetes Care 2010;33:1895–902 Avoid eating more than three dates per day. Each date provides 20 calories and contains one teaspoon of sugar. It is best to start your Iftar meal with dates to get your blood sugar back to normal levels.