Diabetes Mellitus and Fasting Ramadan may 2015

Fasting Ramadan & Diabetes
Do It Right
Mohammad Daoud, MD
Consultant Endocrinologist
KAMC –NGHA
Jeddah- Saudi Arabia

DM & Fasting Ramadan
Frequently asked questions
Can a diabetic patient fast Ramadan, safely?
What are the risks & benefits ?
What about diet and exercise?
How to adjust Medications ?

Remember…
Most of the data are “Expert opinion “ based
Avoid use of the terms “indications” or
“contraindications” for fasting
Focus on better risk stratification and best medical
advice that can be provided to the patient
Working with patients’ “Choice to Fast ” to make
their fasting as safe as possible

Sura Al-Baqara
Verse 183 /185
O you who have believed, fasting is decreed / prescribed upon you as it
was decreed upon those before you that you may
become righteous (may ward off (evil)
ْ‫وا‬ُ‫ن‬َ‫م‬‫َا‬‫ء‬ َ‫ين‬ِ‫ذ‬َّ‫ٱل‬ ‫َا‬‫ه‬ُّ‫ي‬َ‫أ‬ٰٓ‫َـ‬‫ي‬ُ‫ام‬َ‫ي‬ِ‫ٱلص‬ ُ‫م‬ُ‫ڪ‬ ۡ‫ي‬َ‫ل‬َ‫ع‬ َ‫ب‬ِ‫ت‬ُ‫ك‬َ‫ك‬ۡ‫م‬ُ‫ڪ‬ِ‫ل‬ ۡ‫ب‬َ‫ق‬ ‫ن‬ِ‫م‬ َ‫ين‬ِ‫ذ‬َّ‫ٱل‬ ‫ى‬َ‫ل‬َ‫ع‬ َ‫ب‬ِ‫ت‬ُ‫ك‬ ‫َا‬‫م‬
َ‫ون‬ُ‫ق‬َّ‫ت‬َ‫ت‬ ۡ‫م‬ُ‫ك‬َّ‫ل‬َ‫ع‬َ‫ل‬
(١٨٣)
ِ‫اس‬َّ‫ن‬‫ل‬ِ‫ل‬ ‫ى‬ ً۬‫د‬ُ‫ه‬ ُ‫َان‬‫ء‬ ۡ‫ر‬ُ‫ق‬ۡ‫ٱل‬ ِ‫ه‬‫ي‬ِ‫ف‬ َ‫ل‬ِ‫نز‬
ُ
‫أ‬ ٰٓ‫ى‬ِ‫ذ‬َّ‫ٱل‬ َ‫ان‬َ‫ض‬َ‫م‬َ‫ر‬ ُ‫ر‬ ۡ‫ہ‬ َ‫ش‬‫ا‬َ‫ق‬ ۡ‫ر‬ُ‫ف‬ۡ‫َٱل‬‫و‬ ‫َى‬‫د‬ُ‫ه‬ۡ‫ٱل‬ َ‫ن‬ِ‫م‬ ً۬‫ت‬‫َـ‬‫ن‬ِ‫َي‬‫ب‬َ‫و‬ِۚ‫ن‬
ُۖ‫ه‬ ۡ‫م‬ُ‫ص‬َ‫ي‬ۡ‫ل‬َ‫ف‬ َ‫ر‬ ۡ‫ہ‬ َّ‫ٱلش‬ ُ‫م‬ُ‫نك‬ِ‫م‬ َ‫د‬ِ‫ہ‬ َ‫ش‬ ‫َن‬‫م‬َ‫ف‬‫يض‬ِ‫ر‬َ‫م‬ َ‫ان‬َ‫ڪ‬ ‫ن‬َ‫م‬َ‫و‬‫ا‬ۡ‫ن‬ِ‫م‬ ً۬‫ة‬َّ‫د‬ِ‫ع‬َ‫ف‬ ً۬‫ر‬َ‫ف‬ َ‫س‬ ‫ى‬َ‫ل‬َ‫ع‬ ۡ‫و‬َ‫أ‬
َۗ‫ر‬َ‫خ‬
ُ
‫أ‬ ‫ام‬َّ‫ي‬َ‫أ‬ِ‫ب‬ ُ‫يد‬ِ‫ر‬ُ‫ي‬ َ‫َل‬َ‫و‬ َ‫ر‬ ۡ‫س‬ُ‫ي‬ۡ‫ٱل‬ ُ‫م‬ُ‫ڪ‬ِ‫ب‬ ُ ‫ه‬‫ٱَّلل‬ ُ‫يد‬ِ‫ر‬ُ‫ي‬َ‫ر‬ ۡ‫س‬ُ‫ع‬ۡ‫ٱل‬ ُ‫م‬ُ‫ڪ‬َ‫ة‬َّ‫د‬ِ‫ع‬ۡ‫ٱل‬ ْ‫وا‬ُ‫ل‬ِ‫م‬ ۡ‫ڪ‬ُ‫ت‬ِ‫ل‬َ‫و‬
ُ‫ك‬ ۡ‫ش‬َ‫ت‬ ۡ‫م‬ُ‫ڪ‬َّ‫ل‬َ‫ع‬َ‫َل‬‫و‬ ۡ‫م‬ُ‫ك‬‫َٮ‬‫د‬َ‫ه‬ ‫َا‬‫م‬ ‫ى‬َ‫ل‬َ‫ع‬ َ َّ‫ٱَّلل‬ ْ‫وا‬ُ‫ر‬ِ‫َب‬‫ڪ‬ُ‫ت‬ِ‫ل‬َ‫و‬َ‫ون‬ُ‫ر‬
(١٨٥)

Fasting Ramadan
Muslims are almost approaching 2 billions
persons
≈ 25% of Earth’s population
…increasing
Like wise …
DM-type 2 prevalence is increasing

A large number of Muslim patients with
diabetes fast during Ramadan
6
1The Pew Forum on Religion & Public Life. http://www.pewforum.org/The-Future-of-the-Global-Muslim-Population.aspx (Accessed March 2013); 2Al-Arouj
M et al. Diabetes Care 2010;33:1895–902; 3Salti I et al. Diabetes Care 2004;27:2306–11; 4IDF Diabetes Atlas 5th edition. www.idf.org/diabetesatlas/5e/the-
global-burden (Accessed March 2013); 5Whiting DR et al. Diabetes Res Clin Pract 2011; 94: 311–21; 6Beshyah SA. Ibnosina J Med Biomed Sci
2009;1:58–60
• The global prevalence of diabetes is projected to increase in emerging economies, including
those with large Muslim populations4,5
• The pattern of daytime fasting and night-time meals and use of anti-diabetic treatment increases
the risk of complications, including hypoglycaemia in patients with diabetes2,3
• Although the consensus from religious and medical leaders is that Muslims with diabetes are
generally not obliged to fast6 many choose to do so2,3
1.6 billion
(2010)
2.2 billion
(2030)
Global Muslim population1
> 50 million people with diabetes are estimated to fast
during Ramadan worldwide2,3

Fasting
Occurs during the month of Ramadan
and
Voluntary fasting
( ex: 1-2 days /wk; Monday andThursdays
13th - 15th o days of Lunar months …)

Fasting Ramadan
Time of the year ...Never the same
# of hours fastedVaries greatly
Climate ; WinterVs. Summer
2015 Ramadan ; Summer June-July
about 15 hours
(Fajr 4:14 to 4:25 am …
Sunset 7:10 to 7: 10 pm)

Pathophysiology of fasting in Normal
Individuals

Pathophysiology of fasting in Diabetes

Fasting Ramadan
Physiologic changes:
↓ Glucose and insulin levels
↑Glucagon / Catechol-amines →
↑Gluconeo-genesis
↑ Glycogeno-lysis
Free fatty acids → Ketones
(Ketones are fuel by skeletal /cardiac muscles, liver, kidney, and adipose
tissue, thus sparing glucose for continued utilization by brain and RBCs)

Fasting Ramadan and DM
Patho-Physiologic changes:
Defected secretion of insulin :
Risk of hyperglycemia /DKA
Defected secretion of Glucagon / Catecholamines :
Risk of hypoglycemia

EPIDIAR study group Results of the epidemiology of diabetes and Ramadan
1422/2001 (EPIDIAR) study. , Salti Iet al -Diabetes Care 2004;27:2306–2311

EPI.DIA.R trial (EPIdemilogy DIAbetes in
Ramadan)
 Multi-country epidemiological study (Algeria,
Bangladesh, Egypt, India, Indonesia, Jordan, Lebanon,
Malaysia, Morocco, Pakistan, Saudi Arabia, Tunisia &
Turkey)
 12,273 diabetic patients
 Individuals who fast during Ramadan showed a
high rate of acute complications
Diabetes Care, volume 28, NUMBER 9, September 2005

How Many Diabetics Fast?
Type 1 DM Type 2 DM
≈ 43% ≈ 79%
Salti I, et al. EPIDIAR study. Diabetes Care 2004;27:2306

50% … did not change
their lifestyle
Lifestyle changes involved :
Physical activity
Sleep duration
Food, sugar, and fluid intake
Only 25% on OADs adjusted Rx
1/3 rd on insulin adjusted Rx

Diabetes Mellitus and Fasting Ramadan may 2015

‫والشرع‬ ‫الطب‬Fiqh and Medicine
www.fiqhacademy.org.sa
‫مجمع‬‫اإلسالمي‬ ‫الفقه‬‫الدولي‬
‫الد‬ ‫اإلسالمي‬ ‫الفقه‬ ‫لمجمع‬ ‫عشرة‬ ‫التاسعة‬ ‫الدورة‬ ‫والتوصيات‬ ‫القرارات‬‫ولي‬-
‫الشارقة‬ ‫إمارة‬)‫المتحدة‬ ‫العربية‬ ‫اإلمارات‬ ‫دولة‬(
26-30‫نيسان‬)‫إبريل‬(2009‫م‬/- 5 -1‫األولى‬ ‫جمادى‬1430

Fiqh Islamic Academy
‫الدولي‬ ‫اإلسالمي‬ ‫الفقه‬ ‫مجمع‬
Patients are divided into groups according to risk:
First group: Very high risk
Second group: High risk

1st and 2nd groups
should not fast

‫إ‬‫من‬ ‫التأكد‬ ‫على‬ ‫مبني‬ ‫والثانية‬ ‫األولى‬ ‫الفئتين‬ ‫حكم‬ ‫ن‬
‫ما‬ ‫بحسب‬ ‫بحصوله‬ ‫الظن‬ ‫غلبة‬ ‫أو‬ ‫البالغ‬ ‫الضرر‬ ‫حصول‬
،‫المختص‬ ‫الثقة‬ ‫الطبيب‬ ‫يقدره‬‫على‬ ‫شرعا‬ ‫فيتعين‬
‫فيهما‬ ‫الواردة‬ ‫الحاَلت‬ ‫إحدى‬ ‫عليه‬ ‫تنطبق‬ ‫الذي‬ ‫المريض‬‫أن‬
‫الصيام‬ ‫له‬ ‫يجوز‬ ‫وَل‬ ‫يفطر‬،‫نفسه‬ ‫عن‬ ‫للضرر‬ ‫ا‬‫درء‬ ،
‫تعالى‬ ‫لقوله‬( :‫النساء‬)
( :ُ‫ك‬ِ‫ب‬ َ‫ان‬َ‫ك‬ َ‫اَّلل‬ ‫ه‬‫ن‬ِ‫إ‬ ْ‫م‬ُ‫ك‬ َ‫س‬ُ‫نف‬َ‫أ‬ ْ‫وا‬ُ‫ل‬ُ‫ت‬ْ‫ق‬َ‫ت‬ َ‫َل‬َ‫و‬‫ا‬‫يم‬ِ‫ح‬َ‫ر‬ ْ‫م‬)
‫المجمع‬ ‫ويؤكد‬‫بالصيام‬ ‫تضرره‬ ‫مع‬ ‫صام‬ ‫من‬ ‫أن‬
‫فإنه‬‫صومه‬ ‫صحة‬ ‫مع‬ ‫يأثم‬

Very High Risk High Risk
DIABETES CARE,VOLUME 33, NUMBER 8, AUGUST 2010
Note:This classification is based largely on expert opinion and not
on scientific data derived from clinical studies

Fiqh Islamic Academy
‫الدولي‬ ‫اإلسالمي‬ ‫الفقه‬ ‫مجمع‬
Third group: Moderate risk
Fourth group: low risk

3rd and 4th groups
should fast

‫المجمع‬ ‫ورأى‬‫هاتين‬ ‫لمرضى‬ ‫اإلفطار‬ ‫جواز‬ ‫بعدم‬
‫الفئتين‬‫َل‬ ‫الطبية‬ ‫المعطيات‬ ‫كون‬ ‫إلى‬ ‫استنادا‬ ،
‫بصحتهم‬ ‫ضارة‬ ‫مضاعفات‬ ‫احتمال‬ ‫إلى‬ ‫تشير‬
‫من‬ ‫يستفيد‬ ‫قد‬ ‫منهم‬ ‫الكثير‬ ‫إن‬ ‫بل‬ ‫وحياتهم‬
‫وأن‬ ‫الحكم‬ ‫بهذا‬ ‫اَللتزام‬ ‫األطباء‬ ‫داعيا‬ ، ‫الصيام‬
‫حدة‬ ‫على‬ ‫حالة‬ ‫لكل‬ ‫المناسب‬ ‫العالج‬ ‫يقدروا‬

Moderate Risk
Low Risk
DIABETES CARE,VOLUME 33, NUMBER 8, AUGUST 2010
Note:This classification is based largely on expert opinion and not
on scientific data derived from clinical studies

Risks associated with FASTING in patients
with diabetes
1. Hypoglycemia
2. Hyperglycemia : DKA / HHS
3. Dehydration and thrombosis
4. Hospitalizations

EPIDIAR study: fasting during Ramadan increases the risk of severe
hypoglycaemia and hyperglycaemia in patients with T2DM
30
1Salti I, et al. Diabetes Care 2004;27:2306–11; 2Al-Arouj M, et al. Diabetes Care 2010;33:1895–902
Incidence
(events/100patients/month)
0.4
3
0
1
2
3
4
1
5
0
1
2
3
4
5
6
7.5-fold increase* 5-fold increase
P<0.0001 P<0.0001
EPIDIAR = EPIdemiology of DIAbetes and Ramadan; T2DM = type 2 diabetes mellitus
11,173 patients with T2DM;
78.7% chose to fast for at least 15 days during Ramadan1
Higher risk of severe Hypoglycemic events†
in overall population during Ramadan‡1,2
Higher risk of severe Hyperglycaemic
events†
in overall population during Ramadan‡1,2
Pre-Ramadan During Ramadan
†Events requiring hospitalization in overall population with T2DM; ‡compared with previous months
* There was a 7.5 fold difference of hypoglycaemia in overall population fasting during Ramadan. For patients who fasted for > 15 days difference was, 6.7 fold

Fasting Ramadan
Hyper- glycemia Risk
Higher risk of hospitalization in both types of DM
Type 2DM
5 X increase in incidence of severe hyperglycemia
EPIDIAR study group / Diabetes Care 2004;27:2306–2311
Type 1 DM
3 X increase
More DKA with prior poor control

Fasting Ramadan
Hyper- glycemia Risk
Benghazi Diabetes and Endocrine Centre
(BDEC)
493T2DM patients fasting during Ramadan
10.7% experienced hyperglycemia

Nearly 20% of SU-Treated Muslim Patients With Type 2 DM
Experienced Symptomatic Hypoglycemia During Ramadan Fasting1
Mean daily doses of SUs were: 2.8 mg for glimepiride, 129.3 mg for gliclazide, 10.7 mg for glibenclamide (glyburide), and 6.6 mg for glipizide.
SU=sulfonylurea.
1. Aravind SR et al. Curr Med Res Opin. 2011;27(6):1237–1242.
16.8
14.0
25.6
27.6
19.7
0
5
10
15
20
25
30
Patients,%
Glimepiride
Gliclazide
Glibenclamide
Glipizide
Overalln=428 n=386 n=535 n=29 n=1378
Incidence of Symptomatic Hypoglycemia During Ramadan in
2009
by Treatment Group

6.7% of SU-Treated Muslim Patients With Type 2 DM
Experienced Severe Hypoglycemia During Ramadan Fasting1
Incidence of Severe Hypoglycemia During Ramadan in 2009
by Treatment Group
SU=sulfonylurea.
1. Aravind SR et al. Curr Med Res Opin. 2011;27(6):1237–1242.
5.1
2.6
10.8
6.9 6.7
0
2
4
6
8
10
12
Patients,%
Glimepiride
Gliclazide
Glibenclamide
Glipizide
Overall
n=428
n=386
n=535 n=29 n=1378

 Dehydration
 Orthostatic hypotension esp. with autonomic
neuropathy
 Syncope, falls, injuries, and bone fractures
-Adjust patients' BP medication
-Drink sugar free / caffeine free drinks frequently
throughout the evening and before dawn.
Fasting Ramadan
other risks

Thrombosis ?
 Volume contraction / Increased blood viscosity may
exacerbate the hyper- coagulable state **
 Increased incidence of retinal vein occlusion #
 No data concerning the effect of fasting on mortality
Fasting Ramadan
Other risks
**24Akhan G, Kutluhan S, Koyuncuoglu HR. Is there any change in stroke incidence during Ramadan? Acta Neurol
Scandin 2000;101:259–261
#25Alghadyan AA. Retinal vein occlusion in SaudiArabia: possible role of dehydration.
AnnOphthalmol 1993;25:394–398
@TemizhanA, et al B. Is there any effect of Ramadan fasting on acute coronary heart disease events? Int J Cardiol
1999;70:149–153

DM and Fasting Ramadan
Management
 Pre Ramadan assessment
 Individualization
 Frequent monitoring of glycemia
 Nutrition & Exercise
 Breaking the fast
 Medications adjustment

Pre-RAMADAN assessment
 Medical Assessment:
1-3 months before RAMADAN
Specific attention to the:
Well-being of the patient
Glycemia, BP and lipids
Specific medical advice for those who wish
to fast against medical recommendations
Necessary changes in the diet or medication
regimen should be made

Pre-RAMADAN assessment
Educational Counseling:
Educate the patient and his family on:
Signs & symptoms of hypoglycemia
BG monitoring ; risk of hypoglycemia,even
not fasting !!?
Meal planning
Physical activity
Medication administration
Management of acute complications

DM and Fasting
Management
-Decide on fasting Vs. non fasting
-Diet: assess pattern / amounts of food intake /habits ;
to be able to match with a good Rx plan
Pre Ramadan fasting experience / prior Rx plan success

DM and Fasting
Trial fast in pre-Ramadan period
For 3 consecutive days before Ramadan should be
advised
Ex: Fasting the 13th, 14th, and 15th day of Shaban.
Can assess the risks of hypo- and hyper glycemia
Can help as a guide for medications adjustments

DM and Fasting
BGM
Frequent monitoring of glycemia:
esp. in the first few days
esp. with Insulin use or insulin secretagogues
To verify Safe DM control:
Early morning , noon ,late afternoon , before sunset
To verify Adequate DM control:
After Iftar , late night and before Sohour

BGM for high risk groups
Consider BGM done at the following times
1. Pre-Suhur
2. 2 hours post-Suhur
3. Midday
4. Pre-Iftar
5. 2 hours post-Iftar
6. Whenever symptoms of hypoglycemia occur
7- Midnight blood glucose if needed
Management ofType 2 diabetes in Ramadan: Low-ratio premix insulin working
group practical advice

Nutrition
Aim to not overeat
-Healthy and balanced diet
-Avoid large quantities of fried foods and CHO-meals
- Sohour (pre-dawn meal):
- Delay as late as possible
- Use “complex” carbohydrates
-Aim at maintaining a constant body mass
- Plenty of fluid during non-fasting hours

Dietary Patterns & Glycemic Control and Compliance
to Dietary Advice Among Fasting Patients
With DM During Ramadan
Positive pattern
CHO intake < 50 % of energy;
Distributed (i.e:3-4 meals)
= Effective diet assuring normoglycemia
= Better DM control
Diabetes Care 2014;37:e47–e48 | DOI: 10.2337/dc13-2063

Dietary Patterns & Glycemic Control and Compliance
to Dietary Advice Among Fasting Patients
With DM During Ramadan
Diabetes Care 2014;37:e47–e48 | DOI: 10.2337/dc13-2063

Activity/Exercise
-Maintain Normal levels of physical activity/ safe timing
-Avoid Excessive physical activity :
Higher risk of hypoglycemia (especially before Iftar)
-Avoid late daytime (close to Iftar time) sleeping
-High risk of hyperglycemia in poorly controlled DM 1
-Prayer activity is generally safe including Ishaa’ andTaraweeh

- BG ≤ 60 mg/dl [3.3 mmol/l])
- BG < 70 mg/dl (3.9 mmol/l) early in the day
Stop fasting even if the hypoglycemia occurs
close to the time of Iftar
- BG > 300 mg/dl ( 16.7 mmol/l) ; esp.Type 1 DM
ketones in blood or urine should be checked
- Sick days / Unusual symptoms (Vomiting, SOB,…)
Frequent Monitoring Key
Break the Fast if Necessary

DM and Fasting
Adjustment of Medications

DM and Fasting
DM Type 1
Don’t Fast ?
Fasting at Ramadan carries a very high
risk for people with type 1 diabetes
Still with the new safer formulation of insulin ;
Fasting maybe possible but with possible
compromise of inadequate control

DM Type 1
If the patient Insists on fasting :
Basal-bolus regimen
(or Insulin pump)
is the preferred protocol of management
Tends to be safer, with fewer episodes
of hyper- and hypoglycemia

Lispro Compared with Regular Human
Insulin During Ramadan
Kadiri A et al. Diabetes Metab (Paris) 2001;27:482-6.
0
3
5
4
1
2
Fasting 1 -h 2-h
Postprandial time
*
Humalog
Regular insulin
* P = 0.026
0
3
5
4
1
2
Fasting 1 - 2-
Postprandial time
*
Humalog
Regular insulin
* P = 0.026
Postprandial Blood GlucoseBloodglucoseexcursion(mmol/L)

Lispro Compared with Regular Human
Insulin During Ramadan
Kadiri A et al. Diabetes Metab (Paris) 2001;27:482-6.
Episodesofhypoglycemia
Hypoglycemia by Time of Day
0
5
10
15
20
000
Insulin Lispro
Regular insulin
Sunrise
meal
Sunrise
meal
Sunset
meal
2-h 6-h 2-h 6-h
27
5
12
27
11
5
2
4
3
0
5
10
15
20
000
Regular insulin
Sunrise
meal
Sunrise
meal
Sunset
meal
2-h 6-h 2-h 6-h
27
5
12
27
11
5
2
4
3

Premix analogue
(Vs. human premix insulin)
Better average glycemic control
Better meal time flexibility
Less likely to cause post-prandial
hypoglycemia

DM and Fasting
Type 2 DM
Diet-controlled / Metformin
Low risk of Hypoglycemia
Fasting is of benefit /Safe
Change dosing schedule to after sunset meal (2/3)
and before dawn meal (1/3)
Or Full dose at Iftar (ex:Metfromin XR)
No need to decrease dose if Solo

Type 2 DM
Sulfonylureas
Risk of hypoglycemia
If well adjusted …can fast with least possible risk
Avoid use of
Chlorpropamide ,Glyburide /Glibenclamide
Gliclazide, Glimepiride and Glipizide
have lower risk

Short-Acting
Insulin Secretagogues
Repaglinide and Nateglinide
Taken twice daily before the sunset and predawn meals.
Repaglinide Vs Glibenclamide : less hypoglycemia
*
*Mafauzy M. Repaglinide versus glibenclamide treatment of type 2 diabetes during
Ramadan fasting. Diabetes Res Clin Pract 2002;58:45–53

Type 2 DM
Safer New Choices
Glitazones ;Pioglitazone
Glucosidase inhibitors
Acarbose,miglitol, and voglibose
Bromocriptine
GLP-1 Agonists : Exenatide and Liraglutide,…
DPP-4 -I : Sitagliptin, Linagliptin ,…
No hypoglycemia on its own
Provides an excellent choice in Ramadan

DPP-4 I vs SU
 Patients (1066) on SU (with or without Metformin)
 Randomized just before Ramadan to:
 Sitagliptin Vs SU
 Hypoglycemia:
 4.8 %: Sitagliptin group
 14.3 %: SU group
 Had to break fast:
 6.3 %: Sitagliptin group
 10.3 %: SU group
Al Sifiri S, et al. Int J Clin Pract. 2011;65:1132

Incidence of symptomatic hypoglycemia in Muslim
patients with Type 2 DM (Ramadan)
The International Journal of Clinical Practice ,November 2011,65,11,1132-1143
Sitagliptin Gliclazide MR

Conclusions:
Among > 1000 patients
The incidence of Hypoglycemia
was lower with Gliclazide relative to the other
sulphonylurea agents and similar to that observed
with Sitagliptin

Before Ramadan During Ramadan
Patients on
“Diet and Exercise”
- No change
- Modify time /intensity of
exercise
- Ensure adequate fluid intake
Metformin -Iftar: 1,000 mg
-Sohour: 500 -1000 mg
DPP4 inhibitor As usual at night
Glitazone As usual at night
Glinide As usual at night
Treatment Recommendations

Sulfonylurea Once Daily:
Morning dose.
e.g., Gliclazide MR
Iftar: Full Morning Dose
May cut down by 20-30%
SulfonylureaTwice Daily:
Morning & Evening dose.
e.g., Gliclazide 80-160 mg BD
-Iftar: Full Morning Dose
-Sohour: ½ Evening Dose
(or skip ?)
Majority of our type 2 diabetic patients are treated
with Sulfonylurea & Metformin

-RAI analog Vs. Regular Insulin
Less hypoglycemia and smaller postprandial
glucose excursions
-Long acting Basal insulin (Glargine ) with RAI
analog at Iftar and RAI analog at Sohour

Premixed insulin 30
Morning: (ex: 30 U)
Dinner: (ex :20 U)
Iftar: Full Morning Dose (30 U)
Sohour: ½ Dinner Dose (10 U)
(? 50% reduction at Sohour ?)
Consider switching patients
who are on either:
Mixed or intermediate-acting insulins to
basal insulin
Split Mixed (R+N)
R+0+R
N+0+N
R+0+50 % of R
N+0+50% of N
(50% reduction at Sohour)
R+R+R
0+0+N
R+R+50% of R
0+0+50% of N (50% reduction at Sohour)

Rapid-acting insulin;
Ex: Aspart
Usual dose of should be taken with sunset meal
RAA insulin can work immediately after meals.
Decrease predawn dose in half (?omit )
Basal Analogue
Ex: Glargine
At the same time
Up to 20-40 % dose reduction

CONCLUSIONS
Fasting carries a risk for many patients
(DM 1 > DM 2)
Commonest concerns :
Hypoglycemic and Hyperglycemic
Risk assessment = Advice who should be
exempted /shouldn’t fast

CONCLUSIONS
Fasting Can Be Accomplished, but Care Must Be Taken
-Majority of DM patients can fast safely
-If patients insist on fasting ;Work with them
-Adjusting medications is an Art >> Science
-Certain agents provide safer control
( ex: Incretins; GLP-1 R agonists and DPPr i ,MFN, Acarbose ,Glinides)

DM and Fasting
CONCLUSIONS
Education
Diet control
Daily activity
Drug regimen adjustment

Conclusion
Until guidelines are available, the most
important management strategy for health-
care providers is
Individualized
Structured education
Before and during Ramadan

References
1-Recommendations for Management of Diabetes During Ramadan
, DIABETES CARE,VOLUME 33, NUMBER 8, AUGUST 2010
2-Recommendations for Management of Diabetes During Ramadan
DIABETES CARE,VOLUME 28, NUMBER 9, SEPTEMBER 2005 2305
3-Dietary Patterns and Glycemic Control and Compliance to DietaryAdvice
Among Fasting PatientsWith Diabetes During Ramadan
DiabetesCare 2014;37:e47–e48 | DOI: 10.2337/dc13-2063
4-Incidence if hypoglycemia among Muslims fasting Ramadan : SU vs
Sitagliptin ,Al Sifiri S, et al. Int J Clin Pract. 2011;65:1132
5- Long-acting oral hypoglycemic agents (OHA) must be used more caution
Hassan Chamsi-Pasha and Khalid S.Aljabri. Avicenna J Med. 2014 Apr-
Jun; 4(2): 29–33

References
6- Salti I, Bénard E, Detournay B, Bianchi-Biscay M, Le Brigand C,Voinet C,
et al.
A population-based study of diabetes and its characteristics during the
fasting month of Ramadan in 13 countries: Results of the epidemiology of
diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care
2004;27:2306–11
7- Karamat MA, SyedA, HanifW. Review of diabetes management and
guidelines during Ramadan. J R Soc Med. 2010;103:139–47
8- Management ofType 2 diabetes in Ramadan: Low-ratio premix insulin
working group practical advice ,
Indian J Endocrinol Metab. 2014 Nov-Dec; 18(6): 794–799.
Mohamed Hassanein, Mohamed Belhadj,1 Khalifa Abdallah,2 Arpan D.
Bhattacharya,3 Awadhesh K. Singh,4 KhaledTayeb,5 Monira Al-Arouj,6 Awad
Elghweiry,7 Hinde Iraqi,8 Mohamed Nazeer,9 Henda Jamoussi,10 Mouna
Mnif,11AbdulrazzaqAl-Madani,12 Hossam Al-Ali,13 and Robert Ligthelm

Diabetes Mellitus and Fasting Ramadan may 2015

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