Management of type 2 diabetes in Ramadan fasting

1. Management of type 2 diabetes in Ramadan fasting UkanduIgwe Senior Registrar Endocrinology, Diabetes and Metabolism Unit Lagos University Teaching Hospital

3. Outline • Introduction • Pathophysiology of fasting • Risks associated with fasting in diabetes • Risk assessment • Management • Summary

4. Introduction • ~1.57 billion Muslims worldwide • 23% of world population of 6.86 billion • Ramadan is holy month in Islam • All healthy Muslims fast

5. Introduction • Type 2 DM 6.6% worldwide (20-79 years) • 43% of type 1 and 79% of type 2 fast during Ramadan • > 50 million with DM fast during Ramadan

6. Introduction • In Ramadan, abstain from eating, drinking, use of oral medications, smoking • From pre-dawn to after sunset • No restriction to food and drink between sunset and dawn • Most people take 2 meals

7. Introduction • Fasting not meant to add hardship • But many insist on it

8. Introduction • Pathophysiology of fasting • Risks associated with fasting in diabetes • Risk assessment • Management • Summary

9. Pathophysiology of fasting • During fasting, blood glucose reduces, causing reduced insulin secretion • Catecholamines and glucagon increase, with more glycogenolysis and gluconeogenesis

10. Pathophysiology of fasting With more fasting • Depletion of glycogen stores • Reduced insulin causes increased free fatty acids (FFA) from adipocytes • FFA oxidized to ketones

11. Pathophysiology of fasting • Ketones are used as fuel by skeletal muscles, cardiac muscles, adipocytes, kidneys, liver… • Glucose spared for erythrocytes and brain • Liver glycogen stores (70-80g) last about 12h

12. Pathophysiology of fasting • These processes are well coordinated in non-DM individuals • But in DM these are perturbed by the underlying pathophysiology and by pharmacological agents

13. Pathophysiology of fasting • In type 1, glucagon may fail to rise appropriately in response to dropping glucose • Some type 1 also have defective epinephrine secretion (autonomic neuropathy and recurrent hypoglycaemia)

14. Pathophysiology of fasting • In severe insulin deficiency, prolonged fasting leads to glycogenolysis, gluconeogenesis and excessive ketogenesis • Resultant hyperglycaemia and ketoacidosis

15. Pathophysiology of fasting • May have similar findings in type 2 • Ketoacidosis uncommon and hyperglycaemia not so severe

16. Introduction • Pathophysiology of fasting • Risks associated with fasting in diabetes • Risk assessment • Management • Summary

17. Risks associated with fasting in diabetes • Hypoglycaemia – more in type 1 • Hyperglycaemia • Diabetes ketoacidosis (DKA) • Dehydration and thrombosis

18. Risks associated with fasting in diabetes Hyperglycaemia • Increased incidence x5 of severe hyperglycaemia requiring hospital admission • Glycaemic control improves, deteriorates or remains same • Hyperglycaemia may be due to excessive reduction of dose to prevent hypoglycaemia • Also increased food consumption, especially sugary drinks

19. Risks associated with fasting in diabetes DKA • Increased risk, especially if glycaemia is poor • Also from excessive reduction in insulin dose on assumption of reduced food intake

20. Risks associated with fasting in diabetes Dehydration, thrombosis • Limited fluid • Hyperglycaemia also causes osmotic diuresis • May have orthostatic hypotension, especially in autonomic neuropathy • Contracted intravascular space leads to increased hypercoagulable state, with more risks of thrombosis and stroke

21. Introduction • Pathophysiology of fasting • Risks associated with fasting in diabetes • Risk assessment • Management • Summary

22. Risk assessment Very high risk • Severe hypoglycaemia within 3 months prior to Ramadan • History of recurrent hypoglycaemia • Hypoglycaemia unawareness • Sustained poor glycaemic control • DKA within 3 months prior to Ramadan • Type 1 DM • Acute illness • Hyperosmolarhyperglycaemic coma within 3 months prior to Ramadan • Performing intense physical labour • Pregnancy • Chronic dialysis

23. Risk assessment High risk • Moderate hyperglycaemia (150-300mg/dl or HbA1C 7.5-9.0%) • Renal insufficiency • Advanced macrovascular complications • Living alone and treated with insulin or sulphonylurea • Pre-morbid conditions that present additional risk factors • Old age with ill health • Treatment with drugs that may affect mentation

24. Risk assessment Moderate risk • Well-controlled DM treated with short-acting insulin secretagogue

25. Risk assessment Low risk • Well-controlled DM treated with lifestyle, metformin, acarbose, thiazolodinedione, and/or incretin-based, in otherwise healthy patients

26. Introduction • Pathophysiology of fasting • Risks associated with fasting in diabetes • Risk assessment • Management • Summary

27. Management • Decision to fast personal • Careful assessment of risks • Medical recommendations most times is ‘don’t fast’ • But if patients insist, they should be aware of risks

28. General considerations • Individualization: most crucial issue • Frequent glycaemic monitoring • Nutrition • Avoid large carbohydrates and fats at Iftar • Complex carbohydrates at Suhur and eat as late as possible • Increase water during non-fasting hours • Exercise – normal, not excessive. Kneeling and bending

29. Breaking the fast • Must break immediately if: • Blood glucose < 60mg/dl • Blood glucose < 70mg/dl in the first few hours, especially if on insulin, sulphonylureas or meglitinides • Blood glucose > 300mg/dl • Avoid fasting on sick days

30. Pre-Ramadan medical assessment • Should be 1-2 months before fast • Diet plan • Good control of BP, glucose, lipids

31. Ramadan-focused structured diabetes education • Structured education very important in management of DM • Opportunity to empower patient, not only about Ramadan • But usually lack of harmony between medical and religious advice

32. Ramadan-focused structured diabetes education 3 components • Awareness campaign: people living with diabetes, health care professionals, public • Ramadan-focused structured education for health care professionals • Ramadan-focused structured education for people living with diabetes

33. Ramadan-focused structured diabetes education Health care professionals should be trained to deliver structured patient education • Understanding of fasting and DM • Risk stratification • Options to achieve safer fasting

34. Ramadan-focused structured diabetes education Education delivered • Individually or in group sessions • DM centres • Primary health care centres • Mosques… • Simple, structured method • In patient’s own language

35. Ramadan-focused structured diabetes education • Study in the UK, 111 patients • At end of Ramadan, those in Ramadan-structured diabetes education had 50% reduction in hypoglycaemia than those without education • Also lost small amount of weight

36. Management of type 1 • Very high risk • Intensive insulin recommended • Close monitoring and frequent dose adjustment • Basal-bolus best • May also use pre-meal rapid acting + once/twice daily intermediate/long-acting • Continuous subcutaneous insulin infusion is good but costly

37. Management of type 2 Diet-controlled • Low risk • Distribute calories over 2-3 smaller meals

38. Management of type 2 Patients on oral antidiabetic • Metformin safe, but may modify dosing (⅓:⅔) • Glitazones • Low risk of hypoglycaemia • But maximum effects 2-4 weeks, so cannot be quickly substituted

39. Management of type 2 • Sulphonylureas • Individualize • Chlorpropamide: relative contraindication • Maybe glibenclamide too • 2nd generation better • But use with caution

40. Management of type 2 • Short-acting insulin secretagogues • Repaglinide and meglitinide twice daily • Lower risk of hypoglycaemia • Alpha-glucosidase inhibitors • Usually no effects on fasting blood glucose • So usually used in combination

41. Management of type 2 • Incretin-based • Not independently associated with hypoglycaemia • Exenatide can be given before meal. Reduced appetite, weight loss • Liraglutide once daily • DPP4 inhibitors are among best tolerated antidiabetic • Do not require titration

42. Management of type 2 • VIRTUE • Vildagliptin experience compared with sulphonylureas observed • >1300 patients • Vildagliptinvssulphonylureas • Less incidence of hypoglycaemia in vildagliptin • VERDI • Vildagliptinexperience during Ramadan in patients with diabetes • Multicentre in France • Also lower episodes of hypoglycaemia in vildagliptin • More fasting completion too

43. Management of type 2 Insulin • Aim is to maintain basal insulin level • Intermediate- or long-acting insulin + short-acting • Some will require only basal • Analogue said to be better

44. Management of type 2 Insulin pump • Provides continuous delivery • Patient self-administers bolus with meal or in hyperglycaemia • Hypoglycaemia can be prevented by rapid adjustment of dosing • Most patients will need to reduce rate of basal and increase bolus doses

45. Recommended changes to treatment regimen in patients with type 2 diabetes whofast during Ramadan

46. Recommended changes to treatment regimen in patients with type 2 diabetes whofast during Ramadan

47. Pregnancy • Increased risk for mother and fetus • If patient insists, intensive care • Pre-gestational care, with emphasis on achieving near-normal HbA1C • Appropriate diet and insulin • More frequent monitoring and insulin adjustment

48. Hypertension and dyslipidaemia • May need to adjust dose of antihypertensives • Diuretics may not be OK • Continue agents for dyslipidaemia

49. Summary • Fasting carries risks • Type 1 very high risk • Decision to fast should be made after appropriate discussion • Those who insist should have pre-Ramadan assessment, education, instructions • Some pharmacological agents may cause less hypoglycaemia

50. References • Al-Arouj M, Asaad-Khalil S, Buse J, Fahdil I, Fahmy I, Hafez S, et al. Recommendations for management of diabetes during Ramadan. Diabetes Care 2010 (33): 1895-1902 • Hui E, Bravis V, Hanif W, Malik R, Chowdhury TA, Suliman M, et al. Management of people with diabetes wanting to fast during Ramadan. BMJ 2010 (340): 1407-11 • Halimi S, Levy M, Huet D. Experience with vildagliptin in type 2 diabetic patients fasting during Ramadan in France: Insights from the VERDI Study. Diabetes Ther (2013): 4:385-398