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Workshop : Managing DM 2 during Ramadan DR.Obaid Almutairi

Workshop : Managing DM 2 during Ramadan DR.Obaid Almutairi. بسم الله الرحمن الرحيم

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Workshop : Managing DM 2 during Ramadan DR.Obaid Almutairi

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  1. Workshop :Managing DM 2 during RamadanDR.ObaidAlmutairi

  2. بسم الله الرحمن الرحيم شهر رمضان الذي انزل فيه القرآن هدى للناس وبينات من الهدى والفرقان فمن شهد منكم الشهر فليصمه ومن كان مريضا او على سفر فعدة من ايام اخر يريد الله بكم اليسر ولا يريد بكم العسر ولتكملوا العدة ولتكبروا الله على ما هداكم ولعلكم تشكرونآية - ألبقرةسورة ۱۸٥

  3. A large number of Muslim patients with diabetes fast during Ramadan Global Muslim population1 2.2 billion (2030) 1.6 billion (2010) > 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 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

  4. Fasting is a worldwide custom practiced for religious and cultural reasons1 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.

  5. Risks associated with FASTING in patients with diabetes • EPI.DIA.R trial (EPIdemilogyDIAbetes 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

  6. Risks associated with FASTING in patients with diabetes Hypoglycemia Hyperglycemia Diabetic ketoacidosis Dehydration and thrombosis Diabetes Care, volume 28, NUMBER 9, September 2005

  7. 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†in overall population during Ramadan‡1,2 Higher risk of severe hyperglycaemic events† in overall population during Ramadan‡1,2 P<0.0001 P<0.0001 5-fold increase 7.5-fold increase* Incidence (events/100 patients/month) 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 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

  8. Recommendations for Management of Diabetes During Ramadan Ramadan Consensus

  9. Conditions associated with “Very High”, “High”, “Moderate” & “Low” risk for adverse events in diabetic patients deciding to fast RAMADAN

  10. Case study 1 • Female patient aged 47 years • Type 2 diabetes diagnosed 4 years ago • Poor compliance with diet and exercise regimen Current treatment Metformin, 850 mg twice daily SU once daily

  11. MANAGEMENT Pre-RAMADAN medical assessment & educational counseling • 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

  12. MANAGEMENT Pre-RAMADAN medical assessment & educational counseling • 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

  13. MANAGEMENT Pre-RAMADAN medical assessment &educational counseling • 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

  14. MANAGEMENT General Considerations • Breaking the fast: • Immediately if hypoglycemiaoccurs (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

  15. MANAGEMENT General Considerations • Individualization • 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

  16. MANAGEMENT General Considerations • Nutrition: • Healthy and balanced diet • Maintain constant body mass • Avoid ingesting large amount of carbohydrate and fat (common practice)

  17. MANAGEMENT General Considerations • 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

  18. MANAGEMENT General Considerations • 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

  19. Considerations for anti-hyperglycaemic treatment for fasting patients with T2DM • Treatment considerations: • The choice of oral anti-diabetic agent should be individualized with consideration to the risk of hypoglycaemia • Newer pharmacological agents have lesser hypoglycaemicpotential & 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

  20. Case study 1 • Female patient aged 47 years • Type 2 diabetes diagnosed 4 years ago • Poor compliance with diet and exercise regimen Current treatment Metformin, 850 mg twice daily SU once daily

  21. Case study 2 • Male patient aged 61 years • Type 2 diabetes diagnosed 16 years ago • Motivated to maintain busy lifestyle Current treatment Long Acting Insulin Analog32 units/day Metformin1 g BID

  22. Thank You

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