Practical Management of Type 2 Practical Management of Type 2 Diabetes During the Holy Month Diabetes During the Holy Month
of Ramadanof Ramadan
Dr. Md. Farid UddinDr. Md. Farid UddinHead, Endocrine Unit Head, Endocrine Unit
BSMMU, DhakaBSMMU, Dhaka
Diabetes & RamadanDiabetes & Ramadan
Diabetes Mellitus is a chronic diseaseDiabetes Mellitus is a chronic disease
Fasting is one of the five pillars of IslamFasting is one of the five pillars of Islam
About 50 million people with Diabetes fast About 50 million people with Diabetes fast during Ramadanduring Ramadan
Recent Advancements give us the opportunity Recent Advancements give us the opportunity to offer the patients have a normal or near to offer the patients have a normal or near normal lifenormal life
Frequently asked questions during Frequently asked questions during RamadanRamadan
Can a diabetic patient fast?Can a diabetic patient fast?
What are the risks & benefits What are the risks & benefits associated with fasting?associated with fasting?
What about diet and exercise?What about diet and exercise?
How to adjust drugs?How to adjust drugs?
How to monitor blood sugar?How to monitor blood sugar?
Can a diabetic patient Can a diabetic patient fast during Ramadan? fast during Ramadan?
International Medical Recommendation For Muslim Subjects
With Diabetes Mellitus Who Fast During The Month Of Ramadan
Diabetes and Ramadan Advisory Board
Clinical Diabetes ( Middle East Edition)- Volume 3, Number 3, 2004
Chairman: Ibrahim SALTI, Lebanon
Abdul JABBAR, PakistanMembers:
• Kamel AJONI, Jordan
• Khalid AL- RUBEAAN, Saui Arabia
• Fahmy AMARA, Egypt
• Mohamed BELHADI, Algeria
• Jamalledine BELKHADIR, Morocco
• Aissa BOUDIBA, Algeria
• Said Nouou DIOP, Senegal
• Ugur GROPE, Turkey
• Farid HAKKOU, Morocco
• Ak. Azad Khan, Bangladesh
• Adrien L. LOKROU, Ivory Coast
• Jean Claude MBANYA, Cameroon
• Khemais NAGATI, Tunisia
• Nadim RAIS, India
• Pradana SOEWONDO, Indonesia
• W. N. WAN BEBAKER, Malaysia
A Population-Based Study of Diabetes and Its
Characteristics During the Fasting Month of Ramadan in 13 Countries (EPIDIAR)
DIABETES CARE, VOLUME 27, NUMBER 10, OCTOBER 2004
International Medical Recommendation For Muslim Subjects
With Diabetes Mellitus Who Fast During The Month Of Ramadan
Diabetes and Ramadan Advisory Board
Clinical Diabetes ( Middle East Edition)- Volume 3, Number 3, 2004
Chairman: Ibrahim SALTI, Lebanon
Abdul JABBAR, PakistanMembers:
• Kamel AJONI, Jordan
• Khalid AL- RUBEAAN, Saui Arabia
• Fahmy AMARA, Egypt
• Mohamed BELHADI, Algeria
• Jamalledine BELKHADIR, Morocco
• Aissa BOUDIBA, Algeria
• Said Nouou DIOP, Senegal
• Ugur GROPE, Turkey
• Farid HAKKOU, Morocco
• AK. Azad Khan, Bangladesh
• Adrien L. LOKROU, Ivory Coast
• Jean Claude MBANYA, Cameroon
• Khemais NAGATI, Tunisia
• Nadim RAIS, India
• Pradana SOEWONDO, Indonesia
• W. N. WAN BEBAKER, Malaysia
Insulin
MonitoringEducation & Motivation
Diet
Exercise
Oral Agents
Treatment of Type 2 Diabetes
Treatment Goal for type 2 diabetes
<150 mg/dl (<1.7 mmol/L)TG
<100 mg/dl (<2.6 mmol/L)LDL
>40 mg/dl (> 1.1 mmol/L)HDL
<200 mg/dl (<5.2 mmol/L)Total Cholesterol
<7%HbA1c
110-150 mg/dl (6.1–8.3 mmol/L)
BPG
<160 mg/dl (<8.8 mmol/L)PPG
90-130 mg/dl (5-7.2mmol/L)FPG
<130/80 mm HgBP
<25 kg/ m²BMI
Therapeutic GoalsParameter
Diabetes Care Jan, 2009
Smoking NO
Things Happened During RamadanThings Happened During Ramadan
Eating habits change in many waysEating habits change in many ways– Meal time changeMeal time change– Pattern of mealPattern of meal– Calorie intakeCalorie intakeIncreased in post prandial physical activity Increased in post prandial physical activity during the nighttimes associated with during the nighttimes associated with Tarawih.Tarawih.Psychological changes due to the general Psychological changes due to the general spiritual atmosphere during Ramadan, which spiritual atmosphere during Ramadan, which create a feeling of inner well-beingcreate a feeling of inner well-being
General advice for those who fastGeneral advice for those who fast
Consult your (Muslim) doctor firstConsult your (Muslim) doctor firstPractice fasting in Shaban firstPractice fasting in Shaban firstWith the approval of physician switch to either With the approval of physician switch to either long acting or twice daily medicationlong acting or twice daily medicationElderly patients on NSAID should have Elderly patients on NSAID should have frequent monitoring of renal functionsfrequent monitoring of renal functionsAnticoagulant and Antiepileptic medications Anticoagulant and Antiepileptic medications should be given at night should be given at night
Individualization Individualization
Care must be individualizedCare must be individualized
The management plan will differ for The management plan will differ for each specific patientseach specific patients
Education & Counseling Education & Counseling
Educate the patients regarding– Acute complications & their
management– Blood sugar monitoring– Meal planning– Physical activity– Drug adjustment
What about diet & What about diet & exercise?exercise?
Diet in RamadanDiet in Ramadan
Exercise in RamadanExercise in Ramadan
Physical activity should be reduced during
day time
Exercise can be performed for an hour
after Iftar
Increased prayer during Ramadan should
be taken into account
Adjustment of DrugsAdjustment of Drugs
Full morning dose at Iftar and half of the usual evening dose at Suhur
Sulfonylureas twice daily, e.g., gliclazide 80mg/ glibenclamide 5mg
Patients on oral hypoglycemic agents
No change is needed (modify time & intensity of exercise), ensure adequate fluid intake
Patients on diet and exercise control
During RamadanBefore Ramadan
Dose should be taken at IftarOnce daily sulfonylureas.
Metformin, 1,000 mg at Iftar, 500 mg at Suhur
Biguanide, e.g., Metformin 500 mg thrice daily
Treatment RecommendationsTreatment Recommendations
Treatment RecommendationsTreatment Recommendations
Should be used as usualRepaglinide & Natiglinide
No change is neededThiazolidinedione
During RamadanBefore Ramadan
At IftarDPP4 inhibitor
Ramadan and Insulin
Treatment RecommendationsTreatment Recommendations
Use the usual morning dose at Iftar and half of the usual evening dose at Suhur. e.g., 70/30 premixed insulin, 30 units in evening and 10 units in morning; also consider changing to insulin analogue
e.g., 70/30 premixed insulin twice daily30 units in morning and 20 units in evening
Patients on insulin
During RamadanBefore Ramadan
0 2 4 8 10 12 14 16 18 20 22 24
Pla
sma In
sulin
Le
vels
Hours
NPH (12–16 hr)
Regular (6–8 hr)
Glargine (~22 hr)
Aspart,, Lispro (4–5 hr)
Ultralente (~16–20 hr )
Insulin Profiles – schematic (duration)
Detemir (~20 hr)
INSULIN THERAPY in Diabetes Mellitus
6
Insulin Analogue in Ramadan:• Insulin analogues may help to make fasting safe &
successful
• Insulin analogues allows the patient to plan mealtimes in a more flexible way since they can be injected immediately before or soon after the meal.
• Clinical studies show glycemic control is better with insulin analogue
• Less chance of hypoglycemia
• Consider switching human short and premixed insulin to analogue insulin to improve postprandial glucose control and reduce the risk of hypoglycaemic events
Akbani M.F. et al., Practical Diabetes International, 2005; vol 22, No. 3: 100-104
Al-Arouj M. et al., Diabetes Care, 2005; vol 28: No 9: 2305-2311
Basal-Bolus concept to fit in Ramadan(Insulin Analog)
Bolus
Iftar
Insulin Detemir
Rapid Acting Analog
(Insulin Aspart)
Rapid Acting Analog
(Insulin Aspart)
Rapid Acting Analog
(Insulin Aspart)
SehriDinner
Basal
• Patients need to be reminded of the importance to continue insulin therapy
• Patients on premixed insulin should take their normal morning dose with Iftar and half their usual evening dose with Sehri
• Patients taking insulin 3 times in a day can take combined morning and after lunch dose during iftar and half of the evening dose during sohour
• Patients taking insulin once in a day can take during ifter.
Summary of the guideline for insulin therapy:
What about blood What about blood glucose monitoring?glucose monitoring?
Monitoring Recommendations Monitoring Recommendations
Patients should monitor their blood glucose even Patients should monitor their blood glucose even during the fast to recognize subclinical hypo and during the fast to recognize subclinical hypo and
hyperglycemiahyperglycemia
2 hours post suhur and one hour pre iftar are likely to 2 hours post suhur and one hour pre iftar are likely to pick subclinical hypoglycemiapick subclinical hypoglycemia
1-2 hours post iftar is likely to pick subclinical 1-2 hours post iftar is likely to pick subclinical hyperglycemiahyperglycemia
If blood glucose is noted to be low (<60md/dl), the If blood glucose is noted to be low (<60md/dl), the fast must be brokenfast must be broken
If blood glucose is noted to be (>300mg/dl), ketones If blood glucose is noted to be (>300mg/dl), ketones in urine should be checked and medical advice sought.in urine should be checked and medical advice sought.
Awareness: PostersAwareness: Posters
Ramadan Awareness Activities byRamadan Awareness Activities byBangladesh Endocrine Society & DABBangladesh Endocrine Society & DAB
Awareness: SymposiumAwareness: Symposium
Awareness: Physician’s GuidelineAwareness: Physician’s Guideline
Awareness: Print MediaAwareness: Print Media
Awareness: Press ConferenceAwareness: Press Conference
ConclusionConclusion
Majority of uncomplicated type 2 diabetic Majority of uncomplicated type 2 diabetic patients can fast during Ramadan safelypatients can fast during Ramadan safely
Pre-ramadan education and motivation is Pre-ramadan education and motivation is very important to prevent diabetic related very important to prevent diabetic related complicationscomplications
Islam allows diabetics to have regular blood Islam allows diabetics to have regular blood test while fastingtest while fasting
Individualization and frequent monitoring of Individualization and frequent monitoring of glycemia can significantly reduced the major glycemia can significantly reduced the major risks associated with fasting during Ramadanrisks associated with fasting during Ramadan
Fasting along with regular prayer have been Fasting along with regular prayer have been proved to aid in better control of diabetesproved to aid in better control of diabetes
Acknowledgement
Prof. N Islam- National Professor Prof. A R Khan Prof. M A Taher Prof. Hajera Mahtab Prof. A K Azad Khan Maulana Mohiuddin Khan Prof. Naseem Akhter Chowdhury Prof. Zafar A Latif Prof. Faruque Pathan Prof. Md. Nazrul Islam Siddiqui Dr. M A Hasanat Dr. Mahboob Ullah
Department of Endocrine Medicine, BSMMU BIRDEM
The Daily Star Prothom-Alo
Thank youThank you
Welcome the holy month Welcome the holy month RamadanRamadan