Managing T2DM during
Ramadan
Dr. Asrar Said Hashem
Specialist in Internal Medicine (Al-Amiri Hospital)
Fellow of KIMS Endocrine, Diabetes and Metabolism Program
Case-1
• 59 years old gentleman
• T2DM for 4 years
• On
– Metformin 2 gm/ day
– Sitagliptin 100 mg/ day
– Gliclazide MR 60 mg/ day
• A1c 7.2%
• To fast or not to fast?
Case-1
• Pre-Ramadan Medical Assessment
– Individual risk stratification
– Medication changes
– Ramadan-focused diabetic education
Diabetes and fasting Ramadan: summary of recommendations of
the organization of the Islamic Conference
Category 1: very high-risk group
Category 2: high-risk group
severe hypoglycaemia within the last 3 months prior to Ramadan
Patients with moderate hyperglycaemia blood glucose levels
of 10.0–16.5 mmol/L (180–300 mg/dL) or high HbA1C (>
10%)
Patients with a history of recurrent hypoglycaemia
Patients with lack of hypoglycaemia awareness
Patients with renal insufficiency
Patients with advanced macrovascular complications
Patients with sustained poor glycaemic control
Ketoacidosis within the last 3 months prior to Ramadan
People living alone who are treated with insulin or
sulphonylureas
Type 1 diabetes
Patients living alone with comorbid conditions that present
additional risk factors
Acute illness
old age with ill healt
Hyperosmolar hyperglycaemic coma within the previous 3 months
Drugs that may affect cognitive state
Patients who perform intense physical labour
Category 3: moderate risk
Pregnancy
Well-controlled patients treated with short-acting insulin
secretagogues such as repaglinide or nateglinide
Patients on chronic dialysis
Category 4: low risk
Well-controlled patients treated with diet alone, metformin,
or a thiazolidinedione, who are otherwise healthy
Hassanein M, et al. Diabetologia 2009;52:367-8
Case-1
• Low risk
• Good glycemic control
• Rx
– Sitagliptin: no change, given at Iftar
– Metformin: 1000 mg at Iftar, 500 mg at Suhur
– Gliclazide MR: reduce to 30 mg at Iftar
Case-1
• Ramadan-focused diabetic education
– Standard diabetic education
– Monitoring CBG
– When to break the fast
– Diet
– Exercise
READ Study
Ramadan Education and Awareness in Diabetes Program for Muslims with T2DM who
fast during Ramadan
• Determine impact of Ramadan-focused education on weight and
hypoglycemic episodes
– T2DM taking oral glucose lowering agents
• Prospective Analysis
– Group A (n=57) attended 2-hr structured education program
– Group B (n=54) Did not
• Results
– Group A
• Mean wt loss of 0.7 kg
• Decrease in total no. of hypoglycemic attacks (9 → 5)
– Group B
• Mean wt gain of 0.6 kg
• Increase in total hypoglycemic attacks (9 → 36)
Diabet. Med. 27, 327-331 (2010).
QUESTIONS?
Case-2
• 77 years old lady
• T2DM for 14 years
• Complicated by
– Preproliferative Retinopathy
– Peripheral Neuropathy
– Stage 2 CKD
• Hypertension
• Dyslipidemia
• CAD (PCI and stent to LAD in 2011)
Case-2
• On
–
–
–
–
–
–
–
Insulin glargine 42 units/ day
Actrapid insulin 10 – 14 – 8 units pre-meals
Metformin 2 gm/ day
Valsartan 160 mg/ day
Atrovastatin 40 mg/ day
Aspirin 81 mg/ day
Isosorbide mononitrates 30 mg/ day
• A1c 10.6%
• To fast or not to fast?
Case-2
• Pre-Ramadan Medical Assessment
– Individual risk stratification
– Medication changes
– Ramadan-focused diabetic education
Diabetes and fasting Ramadan: summary of recommendations of
the organization of the Islamic Conference
Category 1: very high-risk group
Category 2: high-risk group
severe hypoglycaemia within the last 3 months prior to Ramadan
Patients with moderate hyperglycaemia blood glucose levels
of 10.0–16.5 mmol/L (180–300 mg/dL) or high HbA1C (>
10%)
Patients with a history of recurrent hypoglycaemia
Patients with lack of hypoglycaemia awareness
Patients with renal insufficiency
Patients with advanced macrovascular complications
Patients with sustained poor glycaemic control
Ketoacidosis within the last 3 months prior to Ramadan
People living alone who are treated with insulin or
sulphonylureas
Type 1 diabetes
Patients living alone with comorbid conditions that present
additional risk factors
Acute illness
old age with ill healt
Hyperosmolar hyperglycaemic coma within the previous 3 months
Drugs that may affect cognitive state
Patients who perform intense physical labour
Category 3: moderate risk
Pregnancy
Well-controlled patients treated with short-acting insulin
secretagogues such as repaglinide or nateglinide
Patients on chronic dialysis
Category 4: low risk
Well-controlled patients treated with diet alone, metformin,
or a thiazolidinedione, who are otherwise healthy
Hassanein M, et al. Diabetologia 2009;52:367-8
Case-2
• High risk
• Poor glycemic control
• Patient should be prohibited from fasting
Case-2
• Patient insists on fasting!
– Clearly explain the risks of fasting
– Possible complications
– Ramadan-focused diabetic education
•
•
•
•
Standard diabetic education
Monitoring CBG
When to break the fast
Diet
Major risks associated with fasting in
patients with diabetes
•
•
•
•
Hypoglycemia
Hyperglycemia
Diabetic ketoacidosis
Dehydration and thrombosis
Hypoglycemia
• Risk of severe hypoglycemia in EPIDIAR study
• Ramadan fasting 2001
• 5-fold increase in T1DM
• 7.5-fold increase in T2DM
salti I, Benard e, Detournay B et al. Diabetes Care 2004; 27:2306-11.
Hyperglycemia and DKA
• Severe hyperglycemia requiring hospitalization
• 5-fold increased in T2DM
• 3-fold higher in T1DM
– With or without ketoacidosis
salti I, Benard e, Detournay B et al. Diabetes Care 2004; 27:2306-11.
Dehydration and Thrombosis
• Dehydration → Hard physical labor
• ↑ risk of Thrombosis among diabetics
• ↓ endogenous anticoagulants
• Impaired fibrinolysis
• ↑ clotting factors
Case-2
• Medication Adjustments
– Insulin glargine:
• Dose reduction by 20%
• Given at Iftar
– Actrapid Insulin
• Launch dose at Iftar
• Reduced Dinner dose at Suhur
– Metformin
• 1000 mg at Iftar, 500 mg at Suhur
QUESTIONS?
Case-3
• 65 years old lady
• T2DM for 16 years
• Complicated by
– Proliferative Retinopathy
– Peripheral Neuropathy
– Stage 3 CKD
• Hypertension
• Dyslipidemia
• Admitted to the hospital 3 weeks ago with hyperosmolar
hyperglycemic state (HHS) secondary to urosepsis
Case-3
• On
–
–
–
–
–
Insulin glargine 46 units/ day
Actrapid insulin 12 – 16 – 10 units pre- meals
Lisinopril 20 mg/ day
Amlodipine 10 mg/ day
Atorovastatin 40 mg/ day
• A1c 11.4%
• To fast or not to fast?
Case-3
• Pre-Ramadan Medical Assessment
– Individual risk stratification
– Medication changes
– Ramadan-focused diabetic education
Diabetes and fasting Ramadan: summary of recommendations of
the organization of the Islamic Conference
Category 1: very high-risk group
Category 2: high-risk group
severe hypoglycaemia within the last 3 months prior to Ramadan
Patients with moderate hyperglycaemia blood glucose levels
of 10.0–16.5 mmol/L (180–300 mg/dL) or high HbA1C (>
10%)
Patients with a history of recurrent hypoglycaemia
Patients with lack of hypoglycaemia awareness
Patients with renal insufficiency
Patients with advanced macrovascular complications
Patients with sustained poor glycaemic control
Ketoacidosis within the last 3 months prior to Ramadan
People living alone who are treated with insulin or
sulphonylureas
Type 1 diabetes
Patients living alone with comorbid conditions that present
additional risk factors
Acute illness
old age with ill healt
Hyperosmolar hyperglycaemic coma within the previous 3 months
Drugs that may affect cognitive state
Patients who perform intense physical labour
Category 3: moderate risk
Pregnancy
Well-controlled patients treated with short-acting insulin
secretagogues such as repaglinide or nateglinide
Patients on chronic dialysis
Category 4: low risk
Well-controlled patients treated with diet alone, metformin,
or a thiazolidinedione, who are otherwise healthy
Hassanein M, et al. Diabetologia 2009;52:367-8
Case-3
• Very High risk
• Patient should be prohibited from fasting
Case-3
• Patient insists on fasting!
– Strongly insist against fasting
– Clearly explain the risks of fasting
– Possible complications
Case-3
• Patient insists on fasting !!!
– Ramadan-focused diabetic education
•
•
•
•
Standard diabetic education
Monitoring CBG
When to break the fast
Diet
– Medication Adjustments
• Insulin glargine:
– Same Dose
– Given at Iftar
• Actrapid Insulin
– Launch dose at Iftar
– Reduced Dinner dose at Suhur
QUESTIONS?
Key Points
• Pre-Ramadan Medical Assessment (2-3 months ahead)
– The passion to fast should be directed to improve diabetes-related
targets and reduce the possible complications
• Individual risk stratification
– The risk category for many people could be higher or lower depending
on many changes such as an acute illness, pregnancy, a change in type
of treatment
• Review of medication and plan for changes
Key Points
• Ramadan-focused diabetic education
–
–
–
–
Monitoring CBG
When to break the fast
Diet
Exercise
• Aim for a safe fasting of your diabetic patient
Thank you