Diabetes & Ramadan
Dr. Nizar Albache
Head of Diabetes Research Unit, Aleppo University
President of Syrian Endocrine Society
Carlton citadel Hotel , Aleppo, July 20th
1
Diabetes & Ramadan

Why Muslims should fast ?

When Muslims should fast ?

What are the metabolic changes during fasting and their
consequences on diabetes control ?

Who should not fast ( exempted) ?


Religious recommendations
Medical recommendations

What are the diet advices ?

What are the therapeutic changes or recommendations ?
2
Diabetic Patients in the Muslim Countries

Muslims: 1.1-1.5 Billion around the world

The prevalence of type 2 diabetes in the Muslim
World is very high ( 10-20 %)

What percentage of diabetic patients actually fast ?
20 %
3
T2 Diabetes:
Insulin resistance + insulinopenia
Insulin resistance
Glycemia
Insulin secretion
No
diabetes
Prediabetes
Type 2
Diabetes
Time
4
ß-cell function (%of normal by HOMA)
Decline of ß-cells function determines
the progressive nature of T2DM
100
?
Time of diagnostic
80
60
Pancreatic function
= 50% of normal
40
20
0
-12
-10
-8
-6
-4
-2
0
2
4
6
Time (years)
HOMA=homeostasis model assessment.
UKPDS Group. Diabetes 1995;44:1249-58.
Adapted from Holman RR. Diabetes Res Clin Pract 1998;40(suppl 1):S21-5.
5
ADA/EASD Consensus Guidelines
Treatment Algorithm, 2006
Diagnosis
Step 1
Lifestyle intervention
+ Metformin
HbA1c  7%
Step 2
Add basal insulin
(Most effective)
Add sulfonylurea
(Least expensive)
Add glitazone
(No hypoglycemia)
Additional medications: insulin, sulfonylureas
or TZDs, on the top of metformin
Nathan DM, et al. Diabetes Care 2006;29:8.
6
ADA/EASD guidelines recommend use of basal
insulin as early as the second step in type 2
diabetes management
Tier 1: well-validated core therapies
Lifestyle + Metformin
plus
Basal insulin
At diagnosis:
Lifestyle +
Metformin
Lifestyle + Metformin
plus
Sulfonylureaa
STEP 1
STEP 2
Lifestyle + Metformin
plus
Intensive insulin
STEP 3
Tier 2: Less well validated therapies
Lifestyle + Metformin
plus
Pioglitazone
No hypoglycaemia
Oedema/CHF
Bone loss
Lifestyle + Metformin
plus Pioglitazone
plus Sulfonylureaa
Check HbA1C
every
3 months
until <7%.
Change
treatment if
HbA1C is
≥7%
Lifestyle + metformin
plus
GLP-1 agonistb
a. Sulfonylureas other than
Glybenclamide or chlorpropamide
b. Insufficient clinical safety data; CHF,
congestive heart failure
Nathan DM, et al. Diabetes Care 2008;31:1-12.
No hypoglycaemia
Weight loss
Nausea/vomiting
Lifestyle + Metformin
plus Basal insulin
7
Types 2 Diabetes

Recommendations in case of oral bitherapy failure:
Diet and lifestyle
recommendations
Target not reached at 6 months
HbA1c >7%
Treatment
Met + SU
Met + Glitazones
SU + Glitazones
Oral triple therapy
Met+SU + GIitazones
Insulin therapy
HbA1c >8%
8
New IDF guidelines 2011 in type 2 diabetes:

Two key changes :



A change in the HbA1c target to 7.0% (previously 6.5%)
Algorithm TT :effectiveness, harm, cost and global availability
Each step of the algorithm recommends a preferred
therapy and also alternative therapies:
1.
2.
3.
4.
Metformin as first line therapy(unless contraindicated)
Sulfonylureas are the recommended second line
Third line therapy is either a third oral agent or insulin (basal or
premixed)
Finally insulin should be used if the choice has been to use an
oral agent as the third step, or intensification of insulin therapy if
insulin had been chosen in the previous step.
Stephen Colagiuri, Boden Institute, University of Sydney, Australia; MGSD CASABLANCHA 2011
9
Considerations for Fasting During Ramadan

Religious Considerations: imposition, obligation
Exemption of the sick
10
‫البقرة‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫ب َع َل ْي ُك ُم ال ِّ‬
‫ب َع َلى‬
‫ص َيا ُم َك َما ُك ِت َ‬
‫ين آ َم ُنو ْا ُك ِت َ‬
‫‪َ =183‬يا أَ ُّي َها الَّ ِذ َ‬
‫ون‬
‫ين ِمن َق ْبلِ ُك ْم َل َعلَّ ُك ْم َت َّتقُ َ‬
‫الَّ ِذ َ‬
‫ضا أَ ْو َع َلى َس َف ٍر َف ِع َّدةٌ‬
‫ان ِمن ُكم م َِّري ً‬
‫‪=184‬أَيَّا ًما مَّعْ ُدودَا ٍ‬
‫ت َف َمن َك َ‬
‫ُ‬
‫َ‬
‫ٌ‬
‫َ‬
‫َّ‬
‫ُ‬
‫َ‬
‫َ‬
‫َ‬
‫ْ‬
‫سْ‬
‫ين َف َمن َت َطوَّ َع‬
‫ك‬
‫م‬
‫م‬
‫ا‬
‫ع‬
‫ط‬
‫ة‬
‫ي‬
‫د‬
‫ف‬
‫ه‬
‫ُ‬
‫ن‬
‫و‬
‫ق‬
‫ي‬
‫ُط‬
‫ي‬
‫ين‬
‫ذ‬
‫ل‬
‫ا‬
‫ى‬
‫ل‬
‫ع‬
‫و‬
‫ر‬
‫خ‬
‫أ‬
‫َّام‬
‫ي‬
‫مِّنْ أ‬
‫ِ‬
‫ِ‬
‫ِ‬
‫ِ‬
‫ِ‬
‫َ‬
‫َ‬
‫َ‬
‫َ‬
‫َ‬
‫َ‬
‫ُ‬
‫ٍ‬
‫ٍ‬
‫ُون‬
‫َخي ًْرا َفه َُو َخ ْي ٌر لَّ ُه َوأَن َتصُومُو ْا َخ ْي ٌر لَّ ُك ْم إِن ُكن ُت ْم َتعْ َلم َ‬
‫ي أُ‬
‫ْ‬
‫ِّ‬
‫َّ‬
‫ُ‬
‫َّ‬
‫ً‬
‫رْ‬
‫اس َو َب ِّي َنا ٍ‬
‫ت‬
‫ن‬
‫ل‬
‫ل‬
‫ى‬
‫د‬
‫ه‬
‫ُ‬
‫آنُ‬
‫ق‬
‫ال‬
‫ه‬
‫ي‬
‫ف‬
‫ل‬
‫نز‬
‫ذ‬
‫ان ال‬
‫ِ‬
‫ِ‬
‫ِ‬
‫َ‬
‫َ‬
‫ض َ‬
‫‪َ =185‬ش ْه ُر َر َم َ‬
‫ِ‬
‫ِ‬
‫ْ‬
‫ْ‬
‫ُ‬
‫َ‬
‫رْ‬
‫ق‬
‫ف‬
‫ال‬
‫و‬
‫ُدَى‬
‫ه‬
‫ال‬
‫م َِّن‬
‫ان‬
‫َ‬
‫ان َف َمن َش ِهدَ ِمن ُك ُم ال َّشه َْر َف ْل َيصُمْ ُه َو َمن َك َ‬
‫ِ‬
‫ضا أَ ْو َع َلى َس َف ٍر َف ِع َّدةٌ مِّنْ أَيَّام أ ُ َخ َر ي ُِري ُد َّ‬
‫َّللاُ ِب ُك ُم ْاليُسْ َر َوالَ‬
‫َم ِري ً‬
‫ٍ‬
‫ي ُِري ُد ِب ُك ُم ْالعُسْ َر َولِ ُت ْك ِملُو ْا ْال ِع َّد َة َولِ ُت َك ِّبرُو ْا ََّ‬
‫َّللا َع َلى َما َهدَ ا ُك ْم‬
‫ُون‬
‫َو َل َعلَّ ُك ْم َت ْش ُكر َ‬
‫فتوى مجمع الفقه اإلسالمي الدولي ‪2010‬‬
‫‪‬‬
‫تم تصنيف المصابين بالسكري إلى اربع فئات ‪:‬‬
‫‪ ‬الفئة األولى‪:‬‬
‫المصابين بالسكري ذوو االحتماالت الكبيرة جدا للمضاعفات الخطيرة‬
‫بصورة مؤكدة ‪:‬‬
‫‪‬‬
‫• حدوث هبوط السكر الشديد أو المتكرر أو الفقدان الحس بنقص السكر (خالل‬
‫األشهر الثالثة التي تسبق رمضان)‬
‫• حدوث الغيبوبة السكرية ) الحماض الكيتوني أو فرط التناضح) خالل الشهور‬
‫الثالثة التي تسبق رمضان‬
‫• األمراض الحادة االخرى المرافقة للسكري‬
‫• يمارسون مضطرين أعماال بدنية شاقة‬
‫• يجري لهم غسيل كلى‬
‫• اثناء الحمل‬
‫فتوى مجمع الفقه اإلسالمي الدولي ‪2010‬‬
‫‪ ‬الفئة الثانية‪:‬‬
‫احتمال كبير لحدوث مضاعفات نتيجة الصيام والتي يغلب على ظن‬
‫األطباء وقوعها وتتمثل بـ‪:‬‬
‫•‬
‫ارتفاع السكر (‪300-180‬ملغ‪/‬دسل) و الخضاب السكري < ‪%10‬‬
‫• قصور كلوي‬
‫• اعتالل القلب والشرايين الكبيرة‬
‫• أمراض أخرى تضيف أخطاراً إضافية عليهم‬
‫• الذين يسكنون بمفردهم‬
‫• كبار السن المصابون بأمراض أخرى‬
‫• يتلقون عالجات تؤثر على العقل‬
‫فتوى مجمع الفقه اإلسالمي الدولي ‪2010‬‬
‫‪‬‬
‫•‬
‫•‬
‫حكم الفئتين األولى والثانية‪:‬‬
‫فيتعين شرعا ً على المريض ان يفطر وال يجوز له الصيام‪ ،‬درءاً للضرر عن نفسه‪ ،‬لقوله تعالى‪:‬‬
‫( َوالَ ُت ْلقُو ْا ِبأ َ ْيدِي ُك ْم إِلَى ال َّت ْهلُ َك ِة) البقرة‬
‫كما يتعين على الطبيب المعالج ان يبين لهم خطورة الصيام عليهم‪ ،‬واالحتماالت الكبيرة إلصابتهم‬
‫بمضاعفات قد تكون ‪-‬في غالب الظن‪ -‬خطيرة على صحتهم أو حياتهم‬
‫فتوى مجمع الفقه اإلسالمي الدولي ‪2010‬‬
‫‪‬‬
‫الفئة الثالثة‪:‬‬
‫‪‬‬
‫الفئة الرابعة‪:‬‬
‫‪‬‬
‫حكم الفئتين الثالثة والرابعة‪:‬‬
‫ذوو االحتماالت المتوسطة للتعرض للمضاعفات نتيجة الصيام ويشمل ذلك المصابين بالسكري ذوي‬
‫الحاالت المستقرة والمسيطر عليها بالـ ‪S.U.‬‬
‫ذوو االحتماالت المنخفضة للتعرض للمضاعفات نتيجة الصيام ويشمل ذلك المصابين بالسكري ذوي‬
‫الحاالت المستقرة والمسيطر عليها بمجرد الحمية أو بتناول العالجات ‪METF.‬‬
‫‪‬‬
‫ال يجوز لمرضى هاتين الفئتين اإلفطار‪ ،‬الن المعطيات الطبية ال تشير إلى احتمال مضاعفات ضارة‬
‫بصحتهم وحياتهم بل ان الكثير منهم قد يستفيد من الصيام‪ .‬وعلى الطبيب االلتزام بهذا الحكم وان‬
‫يقدر العالج المناسب لكل حالة على حدة‪.‬‬
Duration of Fast
•
There is variation in the number of days:
Depends on the moon sighting.

•
There is variation in the number Fasting hours:
Depends on the season.

•
There is variation in the Temperature:
•
Effect on total body fluid.
17
Hours of fast during the month of Ramadan Globally
Day
24
hours
22
20
18
16
:2011 ‫حلب رمضان‬
3.55 ‫إمساك‬
19.44 ‫إفطار‬
14
12
‫ ساعة‬15=‫صيام‬
10
8
6
44 ‫درجة الحرارة‬
4
2
0
Winter in the lower pale and in the summer upper pale for the year
18
Change in blood glucose profile
Daily glucose profile during the month of Shawal
20
15
10
5
0
12
6
12
6
12
Patients were asked to test their blood sugar every two hours with a glucometer for
one day during the month of Shawal as part of diet change study regardless of their
diabetes management. There are three peaks for serum blood glucose following meals.
The highest been following lunch and the lowest following breakfast with a mean daily
glucose at 10.2 mmol/L.
19
Change in blood glucose with meal timing
Daily glucose profile during the month of Ramadan
20
Change in blood glucose with meal timing
Daily glucose profile for both months
Risk of hypoglycemia
–
–
–
The change in meal time will affect the glucose level through the day.
There will be a prolonged period of fasting with risk of hypoglycemia.
Sever hyperglycemia occur following the main meal ( ie: Eftar ).
Ramadan Diabetes Study ( unpublished data )
21
Biochemistry of Fasting
Carbohydrate metabolism

In normal subjects fasting will:
•
Decrease in serum glucose to 3.3 - 3.9 mmol ( 60-70 mg/dl ).
•
Gluconeogenesis by liver will stop further drop of blood glucose.
•
Insulin secretion will decrease but glucagon will increase.
•
In diabetic subjects fasting will:
•
Blood glucose fell within physiological limits if properly controled.
•
Drug induced hypoglycemia is the commonest complications.
22
Dietary Change
3000
2900
2800
2700
2950
2800
2600
2500
SHABAN
RAMADAN
Calorie Change
Total daily calorie intake before and during
23
24
EPI.DIA.R
EPIdemiology of DIAbetes
Ramadan 1422/2001
Salti IS et al Diabetes Care 27: 2306-2311, 2004
25
Number of patients by country
(N = 12,914)
Algeria
1,000
Bangladesh
1,370
Egypt
1,089
India
1,056
Indonesia
1,007
Jordan
927
Lebanon
981
Malaysia
Overall
patients
with DM
889
Morocco
837
Pakistan
1,066
Saudi Arabia
827
Tunisia
871
Turkey
994
0
200
400
600
800
1000
1200
Salti IS et al Diabetes Care 27: 2306-2311, 2004
1400
1600
26
Repartition by type of DM
Indonesia 1 6
93
Bangladesh 2 1
97
India
4 2
94
Malaysia
43
92
Turkey
6 4
91
Lebanon
7
88
Pakistan
8
7
Algeria
8
11
Tunisia
10
7
Jordan
10
8
Egypt
5
86
15
Morocco
83
83
type 2 DM
80
10
27
0
DM
unclassifiable
81
5
13
Saudi Arabia
type 1 DM
78
2
20
71
40
type 1 DM = 1,070 patients
type 2 DM = 11,173 patients
DM unclassifiable = 671 patients
60
80
(8.3%)
100
(%)
(86.5%)
(5.2%)
Salti IS et al Diabetes Care 27: 2306-2311, 2004
27
Fasting during Ramadan (1)
(% of patients who fast > 1 day)
DM type 1
Algeria
Bangladesh
Egypt
India
Indonesia
Jordan
Lebanon
Malaysia
Morocco
Pakistan
Saudi Arabia
Tunisia
Turkey
DM type 2
52
61
58
70
80
45
52
92
12
55
77
24
49
0
20
40
60
80
100
Algeria
Bangladesh
Egypt
India
Indonesia
Jordan
Lebanon
Malaysia
Morocco
Pakistan
Saudi Arabia
Tunisia
Turkey
(%)
92
95
91
83
91
88
78
95
83
77
89
73
73
0
20
40
60
80
Overall population
DM type 1 = 54%
DM type 2 = 86%
28
100
Results

Hyperglycemia
3-fold increase in T1D
 5-fold in T2D (from 1 to 5 events/100pts/month)
Excessive reduction in insulin doses (1/3-1/4 of patients
change their insulin dose or OHAs)
Increase in food intake (sugar)


Severe Hypoglycemia


4-fold increase in type 1 diabetes
7-fold increase in type 2 diabetes
Salti IS et al Diabetes Care 27: 2306-2311, 2004
29
The need for guidelines for physicians and
patients
The Diabetes and Ramadan Advisory Board
(supported
by Aventis Intercontinental)
Chairmen:
Ibrahim SALTI, Lebanon; Abdul JABBAR, Pakistan
Members:
Kamel Ajlouni, Jordan; Khalid AL-RUBEAAN, Saudi Arabia;
Fahmy AMARA, Egypt; Mohamed BELHADJ, Algeria; Jamalleddine BELKHADIR, Morocco;
Aissa BOUDIBA, Algeria; Said Nouou DIOP, Senegal; Ugur GORPE, Turkey;
Farid HAKKOU, Morocco; Ak.Azad KHAN, Bangladesh;
Adrien Lohourignon LOKROU, Ivory Coast; Jean-claude MBANYA, Cameroon;
NAGATI, Tunisia; Nadim RAIS, India;
Pradana SOEWONDO, Indonesia; W.Mohamed WAN BEBAKER, Malysia
30
RECOMMENDATIONS OF THE ADVISORY GROUP

In principle, all patients with type 1 should not fast.

However, if a patient insists against medical advice, please consider
the following:

Absolute Contra-indications:







Brittle DM (as defined by the American Diabetes
Association)
Patients on insulin pump
Patients on multiple insulin injections per day
Ketoacidosis or severe hypoglycemia in the last 3 months
before Ramadan
People living alone
Advanced micro- or macro-vascular complications
Pregnancy and lactation
Salti IS et al for the Diabetes and Ramadan Advisory Board.
International Medical Recommendations for Muslim Subjects with
Diabetes Mellitus Who Fast During the Month of Ramadan.
Clinical Diabetes- Middle East, 3:143-145, 2004
31
RECOMMENDED RAMADAN GUIDELINES FOR PATIENTS WITH
DIABETES MELLITUS Type 2:
Continued
Patients with one or more of the following are advised not to fast:

Physiological conditions: Lactation

Co-existing major medical conditions such as:








Acute peptic ulcer
Pulmonary Tuberculosis and uncontrolled infections
Severe bronchial asthma
People prone to urinary stones formation with frequent
Urinary Tract Infections
Cancer
Overt cardiovascular diseases (recent MI, unstable
angina)
Severe psychiatric conditions
Hepatic dysfunction (liver enzymes > 2 x ULN)
Salti IS et al for the Diabetes and Ramadan Advisory Board.
International Medical Recommendations for Muslim Subjects with
Diabetes Mellitus Who Fast During the Month of Ramadan.
Clinical Diabetes- Middle East, 3:143-145, 2004
32
RECOMMENDATIONS OF THE Advisory Group-2

Relative Contra-indications (fast with risk):




Well controlled type1 DM patients
No diabetes keto-acidosis (DKA)
No recent hypoglycemia
Not more than 2 insulin injections per day
Salti IS et al for the Diabetes and Ramadan Advisory Board.
International Medical Recommendations for Muslim Subjects with
Diabetes Mellitus Who Fast During the Month of Ramadan.
Clinical Diabetes- Middle East, 3:143-145, 2004
33
RECOMMENDED RAMADAN GUIDELINES FOR PATIENTS WITH
DIABETES MELLITUS Type 2:

Patients with one or more of the following are advised not to fast:

Conditions related to diabetes:

Nephropathy with serum creatinine more than 1.5 mg/dL

Severe retinopathy

Autonomic neuropathy: gastroparesis, postural hypotension

Hypoglycemia unawareness

Major macrovascular complications: coronary and
cerebrovascular

Poorly controlled diabetes (Mean Random BG > 300)
Multiple insulin injections per day

Salti IS et al for the Diabetes and Ramadan Advisory Board.
International Medical Recommendations for Muslim Subjects with
Diabetes Mellitus Who Fast During the Month of Ramadan.
Clinical Diabetes- Middle East, 3:143-145, 200434
I. General considerations
II. Pre-Ramadan medical assessment and educational
counseling
III. Management of patients with type 1 diabetes
IV. Management of patients with type 2 diabetes:
Diet-controlled patients
Insulin therapy +OHAs
Insulin alone
V. Pregnancy and fasting during Ramadan
VI. Management of hypertension and dyslipidemia
Monira Al-Arouj,, Samir Assaad-Khalil,, John Buse, MDDiabetes Care August 2010 vol. 33 no. 8 1895-1902
35
II. Pre-Ramadan medical assessment and
educational counseling

Medical assessment

Educational counseling
36
I. General considerations: Nutrition


The diet during Ramadan should not differ significantly from a
healthy and balanced diet
It should aim at maintaining a constant body mass :


50–60% maintain their BMI
20–25% gain or lose weight (>3 kg)

Avoid the ingesting of large amounts of foods rich in carbohydrate
and fat

Advise the ingestion of foods containing “complex” carbohydrates at
the predawn meal

Advise Simple carbohydrates at the sunset meal

Fluid intake be increased during non fasting hours
Monira Al-Arouj,, Samir Assaad-Khalil,, John Buse, MDDiabetes Care August 2010 vol. 33 no. 8 1895-1902
37
I. General considerations: Exercise:

Normal levels of physical activity may be maintained

Excessive physical activity may lead to higher risk of hypoglycemia
and should be avoided particularly before the sunset meal

Tarawaih prayer should be considered a part of the daily exercise
program

In some patients with poorly controlled type 1 diabetes, exercise
may lead to extreme hyperglycemia.
38
I. General considerations; Breaking the fast

If hypoglycemia (blood glucose of <60 mg/dl)

If blood glucose reaches <70 mg/dl (3.9 mmol/l) in the
first few hours after the start of the fast especially if
insulin, sulfonylurea drugs, or meglitinide are taken at
predawn fast

if blood glucose exceeds 300 mg/dl

Typical or atypical symptoms of hypoglycemia ?
39
III. Management of patients with type 1 DM
INSULIN THERAPY

It is unlikely that one injection of intermediate- or long-acting insulin
administered before the evening meal would provide adequate insulin
coverage for 24 h:




Less flexible ( fixe dose)
Hypoglycemic risk
Timing during Ramadan
Another option could be to use:


one daily injection of the long-acting insulin analog Glargine
or twice-daily injections of the insulin analog Detemir with premeal
rapid-acting insulin analogs
40
IV. Management of patients with type 2 DM
DIET-CONTROLLED PATIENTS:

the risk associated with fasting is quite low

there is still a potential risk for occurrence of postprandial
hyperglycemia after the predawn and sunset meals

combine this with a regular daily exercise program∼2 h after the
sunset meal (Tarawih)

older age-group, often with hypertension and dyslipidemia, fluid
restriction and dehydration may increase the risk of thrombotic
41
IV. Management of patients with type 2 DM
PATIENTS TREATED WITH ORAL AGENTS:

Metformin: two thirds of the total daily dose be
administered immediately before the sunset meal

Glitazones no change

Sulfonylureas unsuitable for use during fasting because
of the inherent risk of hypoglycemia utilized with caution
Use of chlorpropamide is absolutely
contraindicated(gliclazide MR or glimepiride) have been
shown to be effective

Sulfonylureas Short-acting insulin secretagogues:
repaglinide might be safer than use of
42
IV. Management of patients with type 2 DM
PATIENTS TREATED WITH INSULIN
(similar to those with type 1 diabetes)

Use of intermediate- or long-acting insulin preparations
plus a short-acting, or premixed insulin administered
before meals hypoglycemia is still a risk

Using one injection of a long-acting insulin analog, such as
insulin Glargine

or two injections of NPH, Lente, Detemir insulin
The dosage of each injection should appropriately individualized
Very elderly patients may be at high risk
43
"Basal" Insulins:
intermediate or long-acting
insulins
Reproduce the basal insulin
secretion
Inhibition of hepatic glucose
production
Control of FBG
44
LANMET: Insulin glargine or NPH insulin
with metformin

9-month, comparative study of insulin glargine + metformin
versus NPH + metformin in 110 patients with T2DM
Insulin glargine + metformin
NPH + metformin
Blood glucose (mmol/L)
16
12
Baseline
p=0.0047
8
p=0.07
p=0.0003
Weeks 25 - 36
4
Before
breakfast
After
Before
breakfast lunch
Yki-Järvinen H, et al. Diabetologia 2006;49:442-51.
After
lunch
Before
dinner
After
dinner
22:00
04:00
45
Insulin glargine + OHAs achieves glycaemic control
with low risk of hypoglycaemia

Treat-to-Target is a pivotal landmark trial:

Randomized comparison of OHAs + insulin glargine or NPH titrated
for 24 weeks in 756 overweight insulin-naïve patients with T2DM
NPH
25
8.56 8.61
HbA1c (%)
8
6.96 6.97
7
6
Events per patient-year
9
Insulin glargine
p<0.02
20
17.7
p<0.005
15
13.9
12.9
9.2
10
5
5
Baseline
* Confirmed events of ≤4mmol/L (72 mg/dL)
Riddle M, et al. Diabetes Care 2003;26:3080-6.
Study end
Symptomatic
hypoglycaemia
Confirmed
hypoglycaemia*
46
Percentage of patients with HbA1c <7 % without
nocturnal hypoglycaemia

Better response (HbA1c <7% without nocturnal hypoglycaemia)
in the insulin glargine group vs. NPH
% patients
p<0.05
33%
27%
LANTUS®
NPH
47
V. Pregnancy and fasting during Ramadan
controversy :

pregnant Muslim women are exempt from fasting

some with known diabetes (type 1, type 2, or gestational) insist on
fasting during Ramadan

These women constitute a high-risk group, and their management
requires intensive care

Women with pregestational or gestational diabetes should be strongly
advised to not fast during Ramadan

if they insist on fasting: special attention should be given to their care

Pre-Ramadan evaluation of their medical condition is essential
48
VI. Management of hypertension and dyslipidemia

Dehydration, volume depletion

A tendency toward hypotension may occur with fasting

medications antihypertensive perspiration may need to be
adjusted to prevent hypotension

Dyslipidemia should be checked during Ramadan
49
THANK YOU
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