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His diabetes is uncontrolled ( HBA1c 11.1 ) He has all chronic complications With poor diet control and poor compliance to insulin. He is on lantus 50 units at bed time and novorapid 18 units tid and MTF 500 BIDCase scenario 2: Case scenario 2 58 year old Saudi male with type II diabetes for 2 years with HTN and TIA and GERD Admitted with Glibenclamide induced hypoglycemia(37mg) on 16/02 . Came to clinic for follow up with current medication Gliclazide 80mg BID and MTF 500 BID. His HBa1c was 7.4 and had 2 episode of symptomatic hypoglycemia with RBS 80mg last month at homeThe task : The task Both these patients want to fast What queries ?? Patient Queries: Patient Queries Should I fast? What dose adjustment to be done? How often should I monitor Blood sugar? What should I do if I develop hypoglycemia?Physician Queries: Physician Queries Is fasting safe in diabetics? How should fasting patients with type 2 diabetes be managed How should fasting patients with type 1 diabetes be managed? Is fasting safe for pregnant women with diabetes?Physician queries: Physician queries What are absolute contraindications ? Which OHA is safe and superior? Is insulin safe in fasting? Which type of insulin better? Which regimen is better? What are dosage adjustment in Ramadan? شَہۡرُ رَمَضَانَ ٱلَّذِىٓ أُنزِلَ فِيهِ ٱلۡقُرۡءَانُ هُدً۬ى لِّلنَّاسِ وَبَيِّنَـٰتٍ۬ مِّنَ ٱلۡهُدَىٰ وَٱلۡفُرۡقَانِۚ فَمَن شَہِدَ مِنكُمُ ٱلشَّہۡرَ فَلۡيَصُمۡهُۖ وَمَن ڪَانَ مَرِيضًا أَوۡ عَلَىٰ سَفَرٍ۬ فَعِدَّةٌ۬ مِّنۡ أَيَّامٍ أُخَرَۗ يُرِيدُ ٱللَّهُ بِڪُمُ ٱلۡيُسۡرَ وَلَا يُرِيدُ بِڪُمُ ٱلۡعُسۡرَ وَلِتُڪۡمِلُواْ ٱلۡعِدَّةَ وَلِتُڪَبِّرُواْ ٱللَّهَ عَلَىٰ مَا هَدَٮٰكُمۡ وَلَعَلَّڪُمۡ تَشۡكُرُونَ (١٨٥): شَہۡرُ رَمَضَانَ ٱلَّذِىٓ أُنزِلَ فِيهِ ٱلۡقُرۡءَانُ هُدً۬ى لِّلنَّاسِ وَبَيِّنَـٰتٍ۬ مِّنَ ٱلۡهُدَىٰ وَٱلۡفُرۡقَانِۚ فَمَن شَہِدَ مِنكُمُ ٱلشَّہۡرَ فَلۡيَصُمۡهُۖ وَمَن ڪَانَ مَرِيضًا أَوۡ عَلَىٰ سَفَرٍ۬ فَعِدَّةٌ۬ مِّنۡ أَيَّامٍ أُخَرَۗ يُرِيدُ ٱللَّهُ بِڪُمُ ٱلۡيُسۡرَ وَلَا يُرِيدُ بِڪُمُ ٱلۡعُسۡرَ وَلِتُڪۡمِلُواْ ٱلۡعِدَّةَ وَلِتُڪَبِّرُواْ ٱللَّهَ عَلَىٰ مَا هَدَٮٰكُمۡ وَلَعَلَّڪُمۡ تَشۡكُرُونَ ( ١٨٥) The month of Ramadân in which was revealed the Qur'ân , a guidance for mankind and clear proofs for the guidance and the criterion (between right and wrong). So whoever of you sights (the crescent on the first night of) the month (of Ramadân i.e. is present at his home), he must observe Saum (fasts) that month, and whoever is ill or on a journey, the same number [of days which one did not observe Saum (fasts) must be made up] from other days. Allâh intends for you ease, and He does not want to make things difficult for you . (He wants that you) must complete the same number (of days), and that you must magnify Allâh [i.e. to say Takbîr ( Allâhu -Akbar; Allâh is the Most Great) for having guided you so that you may be grateful to Him. (185 )يَّامً۬ا مَّعۡدُودَٲتٍ۬ۚ فَمَن كَانَ مِنكُم مَّرِيضًا أَوۡ عَلَىٰ سَفَرٍ۬ فَعِدَّةٌ۬ مِّنۡ أَيَّامٍ أُخَرَۚ وَعَلَى ٱلَّذِينَ يُطِيقُونَهُ ۥ فِدۡيَةٌ۬ طَعَامُ مِسۡكِينٍ۬ۖ فَمَن تَطَوَّعَ خَيۡرً۬ا فَهُوَ خَيۡرٌ۬ لَّهُ ۥۚ وَأَن تَصُومُواْ خَيۡرٌ۬ لَّڪُمۡۖ إِن كُنتُمۡ تَعۡلَمُونَ (١٨٤): يَّامً۬ا مَّعۡدُودَٲتٍ۬ۚ فَمَن كَانَ مِنكُم مَّرِيضًا أَوۡ عَلَىٰ سَفَرٍ۬ فَعِدَّةٌ۬ مِّنۡ أَيَّامٍ أُخَرَۚ وَعَلَى ٱلَّذِينَ يُطِيقُونَهُ ۥ فِدۡيَةٌ۬ طَعَامُ مِسۡكِينٍ۬ۖ فَمَن تَطَوَّعَ خَيۡرً۬ا فَهُوَ خَيۡرٌ۬ لَّهُ ۥۚ وَأَن تَصُومُواْ خَيۡرٌ۬ لَّڪُمۡۖ إِن كُنتُمۡ تَعۡلَمُونَ (١٨٤) [Observing Saum (fasts)] for a fixed number of days, but if any of you is ill or on a journey, the same number (should be made up) from other days. And as for those who can fast with difficulty, (e.g. an old man), they have (a choice either to fast or) to feed a Miskîn (poor person) (for every day). But whoever does good of his own accord, it is better for him. And that you fast, is better for you if only you knowImportance: Importance It is estimated that around 40 to 50 million individuals with diabetes worldwide fast during Ramadan The population-based Epidemiology of Diabetes and Ramadan, 1422/2001 (EPIDIAR), study conducted in 13 Islamic countries showed that 43% of patients with type 1 diabetes and 79% of patients with type 2 diabetes fast during Ramadan.Glycemic management options during Ramadan : Glycemic management options during Ramadan Start preparation 2-4 months prior Careful and individual evaluation and open discussions are key measures Ramadan focused education Post Ramadan follow up Ramadan-focused structured diabetes education: Ramadan-focused structured diabetes education An awareness campaign aimed at people with diabetes, health care professionals, the religious and community leaders as well as the general public Ramadan-focused structured education for health care professionals Ramadan-focused structured education for people with diabetes.How should fasting patients with type 2 diabetes be managed: How should fasting patients with type 2 diabetes be managed Metformin is safe with low risk of hypoglycemia Acarbose – is also safe with minimum risk of hypo Continue with the prescribed dose(s) of acarbose taken only with meals during fasting Flatulence is major drawbackType 2 Diabetes and Ramadan : Type 2 Diabetes and Ramadan Sulfonylureas Safe is ramadan Chlorpropamide absolutely contraindicated Increased risk of hypoglycemia makes glibenclamide unattractiveType 2 Diabetes and Ramadan : Type 2 Diabetes and Ramadan INCRETINS Exenatide and liraglutide injections are safe the liraglutide group achieved better glycemic control with fewer episodes of hypoglycemica . Nausea and vomiting are common. Sitagliptin and vildagliptin safe are alternatives Importantly vis-à-vis treatment during Ramadan, do not require titrationDose reductions: Dose reductions Glitazone without changing the dose ; Metformin , two-thirds of the dose was to be taken before sunset meal and the other third with pre-dawn meal . Morning dose of gliclazide to be reduced by half Long acting OHA to be given after IftaarInsulins and insulin regimens : Insulins and insulin regimens Insulin can be safely used in type 2 diabetic individuals Dose and timing has to be changedInsulins and insulin regimens : Insulins and insulin regimens Insulin glargine is also effective and safe during Ramadan and can be given as single injection at 10 PM with or without mealtime short-acting analogues or other oral antidiabetic medication (repaglinide or metformin).Rapid acting better than regular insulin : Rapid acting better than regular insulin Rapid onset of action and higher peak with same dose Better control of post prandial blood sugar Lesser risk of hypoglycemia especially late postmeal period during the fastRapid acting better than regular insulin: Rapid acting better than regular insulin Offers meal time flexibility Safe in patients with renal and hepatic impairment (Insulin Aspart ) Safe in pregnancy (Insulin Aspart , Lispro ) with better glycemic control.Suggested insulin regimens for patients with type 1 diabetes mellitus: Suggested insulin regimens for patients with type 1 diabetes mellitus 70% of the pre-Ramadan dose, divided as follows: 60% as insulin glargine given in the evening and 40% as an ultra-short-acting insulin (insulin aspart or lispro ) given in 2 doses, 1 at Suhur and 1 at IftarSuggested insulin regimens for patients with type 1 diabetes mellitus: Suggested insulin regimens for patients with type 1 diabetes mellitus Another option is to give 100% of the pre-Ramadan morning dose of 70/30 premixed insulin at Iftaar 50% of the usual evening dose at SahurExample: ExampleMore Examples: More ExamplesType 1 Diabetes and Ramadan: Type 1 Diabetes and Ramadan The insulin pump can potentially empower patients with diabetes and enable safe fasting during the month of RamadanBetter regimen: Better regimen Basal bolus insulin may be associated with a lower risk of hypoglycemia in comparison with conventional twice-daily insulin regime Al- Arouji et al recommended the use of 1 injection of glargine or 2 injections of detemir along with a pre-meal rapid-acting insulin analogueBlood sugar monitoring during ramadhan: Blood sugar monitoring during ramadhan 2 hours post- sahur and 1/2 hour pre iftaar 2 hours post- iftaar /dinner Adjust insulin dose at 3 days’ intervalCautions: Cautions Patients who observe the fast should be advised to monitor their blood glucose regularly, Avoid skipping meals or overeating, Maintain contact with their physician throughout the fastCautions: Cautions Break fast if blood glucose drops below 60 mg/ dL (3.3 mmol /L) OR rises above 300 mg/ dL (16.7 mmol /L) to avoid diabetic ketoacidosisDiscourage fasting: Discourage fasting Poor diabetes control, Frequent and severe hypoglycemia Brittle diabetesConclusion : Conclusion The DPP-4 provide an effective and safe alternative during Ramadan, either alone or in combination with metformin or sulfonylureas The incritin memetics are also safe during Ramadan, but as yet there are no reports of using them during RamadanSummary : SummaryThe answer case 1: The answer case 1 Before Ramadhan During Ramadhan He is on lantus 50 units at bed time and novorapid 18 units tid and MTF 500 BID Lantus 40 units at bed time 18 units –Iftaar with 750 MTF 18 units-dinner 9 units – Sahur with 250mg MTFThe answer case 2 : The answer case 2 Before ramadhan During Ramadhan Gliclazide 80mg BID MTF 500 BID. Iftaar- Gliclazide 80 mg with 750 mg MTF Sahur - Gliclazide 40 mg with 250 mg MTFConclusion : Conclusion The newer sulfonylureas gliclazide MR and glimepride can be safely used during Ramadan Administration of the long-acting or the premixed insulin analogues has shown potential benefit in selected patients with type 1 and type 2 diabetesWhat we an do in KAMC: What we an do in KAMC Organize awareness campaign Risk stratification score system Print education leafletفَلَمَّا رَءَا ٱلۡقَمَرَ بَازِغً۬ا قَالَ هَـٰذَا رَبِّىۖ فَلَمَّآ أَفَلَ قَالَ لَٮِٕن لَّمۡ يَہۡدِنِى رَبِّى لَأَڪُونَنَّ مِنَ ٱلۡقَوۡمِ ٱلضَّآلِّينَ: فَلَمَّا رَءَا ٱلۡقَمَرَ بَازِغً۬ا قَالَ هَـٰذَا رَبِّىۖ فَلَمَّآ أَفَلَ قَالَ ل َٮِٕن لَّمۡ يَہۡدِنِى رَبِّى لَأَڪُونَنَّ مِنَ ٱلۡقَوۡمِ ٱلضَّآلِّينَ When he saw the moon rising up, he said: "This is my lord." But when it set, he said: "Unless my Lord guides me, I shall surely be among the people who went astray.The final word: The final word Clinical trials are needed in order to further evaluate the safety and efficacy of new hypoglycemic agents and new diabetes-treating technologies during Ramadanفَٱذۡكُرُونِىٓ أَذۡكُرۡكُمۡ وَٱشۡڪُرُواْ لِى وَلَا تَكۡفُرُونِ: فَٱذۡكُرُونِىٓ أَذۡكُرۡكُمۡ وَٱشۡڪُرُواْ لِى وَلَا تَكۡفُرُونِ Therefore remember Me (by praying, glorifying,). I will remember you, and be grateful to Me (for My countless Favors on you) and never be ungrateful to Me. (152)References: References The noble Quran with english translation by Dr mohsin Diabetes and Ramadan: An Update On Use of Glycemic Therapies During Fasting Mohamed H. Ahmed a and Tarig A. M. Abdu Suggested insulin regimens for patients with type 1 diabetes mellitus who wish to fast during the month ofRamadan . Kobeissy A , Zantout MS , Azar ST . Department of Internal Medicine, Division of Endocrinology, American University of Beirut Medical Center, Beirut Lebanon. South Asian Consensus Guideline: Use of insulin in diabetes during Ramadan Md Faruque Pathan , Rakesh Kumar Sahay , 1 Abdul Hamid Zargar , 2 Syed Abbas Raza , 3 A. K. Azad Khan , 4 Mohammed Ashraf Ganie , 5 Nazrul Islam Siddiqui , 6 Firoz Amin , Osama Ishtiaq , 7 and Sanjay Kalra 8 Recommendations for Management of Diabetes During Ramadan Update 2010 Monira Al- Arouj , MD, 1 Samir Assaad-Khalil , MD, PHD, 2 John Buse , MD, PHD, 3 Ibtihal Fahdil , MD, PHD, 4 Mohamed Fahmy , MD, PHD, 5 Sherif Hafez , MD, FACP, 6 Mohamed Hassanein , FRCP, 7 Mahmoud Ashraf Ibrahim , MD, 8 David Kendall , MD, 9 Suhail Kishawi , MD, 10 Abdulrazzaq Al- Madani , MD, 11 Abdullah Ben Nakhi , MD, 1 Khaled Tayeb , MD, 12 and Abraham Thomas , MD 13 You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.