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RAMADAN FASTING FOR PATIENTS

RAMADAN FASTING FOR PATIENTS. Prof. Mohamad S. Al-Hadramy Professor of Medicine/Consultant. Ramadan Fasting for Patients.

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RAMADAN FASTING FOR PATIENTS

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  1. RAMADAN FASTING FOR PATIENTS Prof. Mohamad S. Al-Hadramy Professor of Medicine/Consultant

  2. Ramadan Fasting for Patients • A young medical student has a viral upper respiratory tract infection. His temperature was 38.9oC. Congested throat. Chest: clear. Day 1 Ramadan. What is your advice?

  3. Generally, patients are dispensed from fasting. The illness is the intense one that increases by fasting, or recovery is delayed. Ahmad Bin Hanbal was asked, when is the patient dispensed from fasting. “If he could not” he answered. They asked: fever, for example?. He answered: “What disease is more severe than fever?”. Ibn Godamah. Al-Maghny Al-Torky & Al-Helo. eds, 1408,4:403-4

  4. Three (3) categories of patients in fasting: • Patients who are not harmed by fasting, and their recovery is not delayed (e.g., Type 2 DM, controlled by diet. Such patients are advised to fast.

  5. Three (3) categories (cont.): • Patients who are harmed by fasting or their treatment cannot be given with fasting (e.g., IDDM pregnant lady, acute MI, advanced liver failure).

  6. Three (3) categories (cont.): • Patients who are not harmed by fasting but their treatment could be adjusted for proper control (e.g., hypertension, epilepsy, OA).

  7. Asthma: Ibn Othaymeen: The spray used for asthma does not reach the stomach and there is no harm from using it during fasting

  8. Asthma (cont.): Now, we have long acting inhalers (e.g., Salmetrol which could be used after sunset and before dawn.

  9. A 40-year-old smoker with dyspepsia. Upper GI endoscopy showed duodenal ulcer, 10 days before Ramadan. What is your advice?

  10. A study from Tunisia Fifty-seven (57) patients with acute duodenal ulcer. All received Lansoprazole 30 mg per day. Randomized to fasting or dispension. Endoscopy performed at end of Ramadan. Symptoms were not different. Healing rate: Fasting 90%, dispension 88.8%. Patients on Lansoprazole may fast with any risk. Mehdi A, Ajmi S. Gastyroenterol Clin Biol 1997, (11):820-2

  11. A 60-year-old male with long- standing hypetension who was on irregular treatment. He was on Metoprolol 50 mg BD, Frusemide 40 mg QD, Diltiazem 90 mg BD. His serum creatinine was 500 umol/L, Na 131, K 4.5. He wants to fast Ramadan. What is your advice?

  12. Thirty-six (36) patients with moderate to severe chronic renal failure, Creatinine >3 mg/dl; Clearance <35 ml/min Al-Muhanna Saudi Medical J 1998; 19:319-21

  13. Comparison of BUN, S. Creatinine, S. Uric Acid and Caclculated Creatinine Clearance Pre, During and Post Ramadan

  14. Conclusion: During Ramadan, fasting patients with significant renal failure need close monitoring to offer appropriate advice.

  15. Renal transplant: 11 transplant recipients No adverse effect from fasting on alograft. K↑during fasting. Barneih, B. O. et al Saudi K Kidney Dis Transplant 1994; 5:470-473

  16. Renal transplant (cont.): Forty-three (43) transplant recipients with stable renal function. Concentration of urine similar to healthy. Rashed Atl, et al. Lancet 1989, 1:1396

  17. Cyclosporin can be taken during Ramadan at Sahoor and Fatoor. Badrah HM, et al Saudi Kidney Dis Transplant Bull 1993, 4:596

  18. Haemodialysis breaks fasting. Fatwa No. 9944 Ibn Baz Chairman Fatwa, Volume 10, p. 19

  19. One-hundred six (106) patients fasting three hundred nine (309) Ramadan month, on anticoagulant; one hundred eighty-three (183) did not fast in five hundred ninety-four (594) Ramadan months. Incidence of thromboembolic events and haemorrhagic complications were not statistically significant between the two groups. Saur J. N. et al. Annals of Saudi Medicine 1989, (4):538-40

  20. No significant differences in platelets aggregation responses between Ramadan and the non-fasting period. Kordy, M. et al Annals of Saudi Medicine 1991, (11):23-7

  21. Case 1: A 55-year-old diabetic for 15 years is seen before Sha’aban. She has polyuria and parasthesia in her feet. She has no retinopathy. She is on Glibenclamide 10 mg AM, 5 mg PM, Metformin 500 mg TDS, Atorvastatin 10 mg, and Corenitec 20/12/5 QD, Aspirin 100 mg QD. Her weight is 90 kgs. Height 155 cms. Bp 124/76 mmHg. She has diminished pain sense in her feet. FBS 220 mg %, HbA1C – 9; LDL Cholesterol – 98 mg/dl; CPK, SGPT: normal.

  22. Case 1: (cont.) • What other investigations would you consider before advising her for Ramadan fasting? • What is your advice for her for Ramadan? • What is your advice for Omrah?

  23. No fasting for: Brittle DM: Poorly controlled Serious comorbidity (e.g., MI, stroke) History of DKA Pregnancy Severe intercurrent infection (e.g., pneumonia)

  24. No skipping of meals Regimen of treatment No gorging after Maghreb

  25. Adjust diet Adjust treatment (e.g., change to short acting Exercise. When? Recognize hypo, dehydration

  26. Exercise: Fasting does not interfere with exercise capacity Exercise causes no harm in NIDDM

  27. Insulin: • R maghreb and Sahour, NPH late evening • R N of breakfast at Maghreb + R before dawn 0.1 – 0.2 u/kg

  28. Home glucose monitoring PP, before Sahour and sunset Urine ketone, weight for increase  diet / decrease  dehydration

  29. Tabs: BMJ: switch dose of glibenclamide

  30. Repaglinide Mafauzy, Malaysia 235 patients Repag TDS versus Glibenclamide QD or BD 6/52 before and repa in Rama  2 In Ramadan fructosamine decrease with Repag HbA1C NO CHANGE Hypo mid day < with Repag

  31. LISPRO Kadiri et al, Diab Metab 2001; 27:482-6 Morocco Type 1-64 pts: BD NPH + Lispro or regular for 2/52 each, open label, randomised, crossover. Monitoring for 3 days at end of each cycle. 2 H after Maghreb better. Doses similar compliance with time of injection better with Lispro. Hypo Lispro 23 %, regular 48% Episodes: Lispro 0.7, Reg 2.25 episodes/pt/30 days Glycemic control improved and hypo sig Decreased with Lispro

  32. LISPRO Akram Diab Med 1999; 16:861-6 Pakistan Type 2 – 70 patients: Open Label, randomized crossover Regular versus Lispro Patient self reported hypo. Glucose, FBS, 1 h, 2hpp on 3 days at end of period Results: Before sunrise and after sunset were similar. Rise after meal with Lispro was less. Hypo for Lispro 1.3, for regular 2.6 per patient over 14 days. Most hypos in day Insulin Lispro may be more suitable

  33. Case 2: A 28-year-old married lady with type 1 DM is counseled for fasting. She has one child and she plans to have pregnancy. She is on Mixtard 70/30 36 units AM and 14 units PM. She exercises regularly and is sticking to her diet. Physical examination is negative. Sugar profile 99, 112, 116 and 102 mg%. U/Es, LFT, lipid profile, urine analysis are negative. A. What would you tell her?

  34. Thank You !

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