Dr farid uddin

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