Bangladesh Med J. 2016 May; 45 (2)

Practice Point Avoid heavy Iftar Keep same calorie as before Ramadan Take complex carbohydrate at Suhur Frequently asked questions for safe fasting in Ramadan : How to adjust drugs? Take Suhur as late as possible Fariduddin M1, Chowdhury MAJ2 Exercise in Ramadan Physical activity should be reduced during day time Can a diabetic patient fast? Elderly patients on NSAID should have frequent Exercise can be performed for an hour after Iftar or after Most of the uncomplicated diabetic patients can fast during monitoring of renal functions Tarawih Ramadan safely. But for safe fasting patients need to go for Anticoagulant and Antiplatelet medications should be Increased prayer during Ramadan should be taken into the followings: given at night account Pre-Ramadan assessment at least three months before What are Pre-Ramadan assessment at least 3 months How to adjust drugs? Ramadan before Ramadan? For oral anti Diabetic Drug Ramadan focused structured education & motivation Assessment of glycemic status Patient centered individualized management plan Assessment of complications & co-morbid conditions Proper follow-up Assessment of patient’s ability Physician’s Role for safe fasting Patients who are advised not to fast according to the Guidance and advice to minimize the risk of hypoglycemia: International Ramadan Advisory Board consisting of To take Suhur close to Suhur time Medical Experts and Religious Scholars To keep the same calorie during Ramadan as before Conditions related to diabetes: To change in the schedule, amount and composition of Advanced nephropathy meals Severe retinopathy To reduce physical activity during the day time; however Autonomic neuropathy physical exercise can be performed about one hour after Hypoglycemic unawareness Iftar Major macrovascular diseases What are Pre-Ramadan assessment at least 3 months Recent hyper-osmolar state or DKA before Ramadan? Poorly controlled diabetes (Mean RBG> 300) Assessment of glycemic status Multiple insulin injections per day Assessment of complications & co-morbid conditions * Tips: DPP-4 inhibitors are less hypoglycemic in Ramadan. Assessment of patient’s ability Physiological conditions: Modern sulfonylurea (gliclazide MR and glimepiride) is Pregnancy better compared to conventional one considering risk of Individualization Lactation hypoglycemia. Avoid glibenclamide in Ramadan Care must be individualized e management plan will dier for each specic patient Co-existing major medical conditions such as: For insulin Acute peptic ulcer General advice for those who wants to fast Severe Pulmonary Tuberculosis First consultation with a doctor for pre Ramadan medical Severe infection assessment & education Severe bronchial asthma Practice fasting in Shaban rst Recurrent stones formation With the approval of physician, switch to either long Cancer with poor general condition acting or twice daily medication Overt cardiovascular diseases (Recent MI) Severe psychiatric conditions 1. *Professor Dr M Fariduddin, Professor & former Hepatic dysfunction (liver enzymes > 2 × ULN) Chairman, Department of Endocrinology *Tips: Individualization is very important Bangabandhu Sheikh Mujib Medical University, Dhaka. Email: [email protected] What about diet and exercise? 2. Professor M A Jalil Chowdhury, Professor & former Diet in Ramadan Chairman, Department of Medicine, Bangabandhu Drink more water at night to avoid dehydration Sheikh Mujib Medical University, Dhaka Avoid sugar and sugar containing drinks specially during *For correspondence Iftar (sweetener can be used)

118 Bangladesh Med J. 2016 May; 45 (2)

Avoid heavy Iftar Keep same calorie as before Ramadan Take complex carbohydrate at Suhur Frequently asked questions for safe fasting in Ramadan : How to adjust drugs? Take Suhur as late as possible Fariduddin M1, Chowdhury MAJ2 Exercise in Ramadan Physical activity should be reduced during day time Can a diabetic patient fast? Elderly patients on NSAID should have frequent Exercise can be performed for an hour after Iftar or after Most of the uncomplicated diabetic patients can fast during monitoring of renal functions Tarawih Ramadan safely. But for safe fasting patients need to go for Anticoagulant and Antiplatelet medications should be Increased prayer during Ramadan should be taken into the followings: given at night account Pre-Ramadan assessment at least three months before What are Pre-Ramadan assessment at least 3 months How to adjust drugs? Ramadan before Ramadan? For oral anti Diabetic Drug Ramadan focused structured education & motivation Assessment of glycemic status Before Ramadan During Ramadan Patient centered individualized management plan Assessment of complications & co-morbid conditions Proper follow-up No change is needed Assessment of patient’s ability Patients on “diet Modify time & intensity of exercise Physician’s Role for safe fasting and exercise” Patients who are advised not to fast according to the Ensure adequate fluid intake Guidance and advice to minimize the risk of hypoglycemia: International Ramadan Advisory Board consisting of Metformin 500 mg To take Suhur close to Suhur time Medical Experts and Religious Scholars At Iftar: 1,000 mg To keep the same calorie during Ramadan as before thrice daily At Suhuur: 500 mg Conditions related to diabetes: To change in the schedule, amount and composition of DPP4 inhibitor As usual at night Advanced nephropathy meals Severe retinopathy SGLT2 inhibitor As usual at night To reduce physical activity during the day time; however Figure-1: Opinion of Muslim scholars regarding blood glucose Autonomic neuropathy Glinide As usual at night physical exercise can be performed about one hour after test and insulin adminstration during Ramadan Hypoglycemic unawareness Sulfonylurea Once Daily: At Iftar: Iftar Major macrovascular diseases Morning dose Full Morning dose Can a patient monitor blood sugar while fasting? What are Pre-Ramadan assessment at least 3 months Recent hyper-osmolar state or DKA Sulfonylurea Twice Daily: At Iftar: Full Morning dose Islam allows diabetics to have regular blood test while before Ramadan? Poorly controlled diabetes (Mean RBG> 300) Morning & Evening dose. At Suhur: ½ Evening dose fasting Assessment of glycemic status Multiple insulin injections per day Assessment of complications & co-morbid conditions * Tips: DPP-4 inhibitors are less hypoglycemic in Ramadan. Patients should monitor their blood glucose even during Assessment of patient’s ability Physiological conditions: Modern sulfonylurea (gliclazide MR and glimepiride) is the fast to recognize subclinical hypo and hyperglycemia Pregnancy better compared to conventional one considering risk of If blood glucose is noted to be low (<70mg/dl), the fast Individualization Lactation hypoglycemia. Avoid glibenclamide in Ramadan Care must be individualized must be broken Co-existing major medical conditions such as: e management plan will dier for each specic patient For insulin If blood glucose is noted to be (>300mg/dl), ketones in Acute peptic ulcer Before Ramadan urine should be checked & medical advice sought General advice for those who wants to fast Severe Pulmonary Tuberculosis During Ramadan Severe infection First consultation with a doctor for pre Ramadan medical Premixed insulin 30 Conclusion assessment & education Severe bronchial asthma Morning: (30 U) At Iftar: Full M orning Dose (30 U) Uncomplicated type 2 diabetic patients can fast during Recurrent stones formation Practice fasting in Shaban rst Dinner: (20 U) At Suhur: ½ Dinner Dose (10 U) Ramadan safely With the approval of physician, switch to either long Cancer with poor general condition acting or twice daily medication Overt cardiovascular diseases (Recent MI) Split Mi xed (R+N) Pre-Ramadan education and motivation is very R+0+50%of R Severe psychiatric conditions R+0+R important to prevent diabetic related complications Hepatic dysfunction (liver enzymes > 2 × ULN) N+0+N N+0+50%of N Islam allows diabetics to have regular blood test while

*Tips: Individualization is very important R+R+R R+R+50% of R fasting 0+0+50% of N 0+0+N Fasting along with regular prayer have been proved to aid What about diet and exercise? At the same time Basal Analogue in better control of diabetes Diet in Ramadan 20-30% dose reduction Drink more water at night to avoid dehydration Individualization & frequent monitoring of glycemia can * Tips: Insulin Analogues are less hypoglycemic compared Avoid sugar and sugar containing drinks specially during to conventional insulin. Premixed Analogues can be given signicantly reduce major risks associated with fasting in Iftar (sweetener can be used) just before meal. Ramadan.

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