Management of type 2 diabetes in Ramadan fasting Ukandu Igwe Senior Registrar Endocrinology, Diabetes and Metabolism Unit Lagos University Teaching Hospital

Management of type 2 diabetes in Ramadan

fastingUkandu Igwe

Senior RegistrarEndocrinology, Diabetes and Metabolism Unit

Lagos University Teaching Hospital

Outline

• Introduction• Pathophysiology of fasting• Risks associated with fasting in

diabetes• Risk assessment• Management• Summary

Introduction

• ~1.57 billion Muslims worldwide• 23% of world population of 6.86

billion• Ramadan is holy month in Islam• All healthy Muslims fast

Introduction

• Type 2 DM 6.6% worldwide (20-79 years)

• 43% of type 1 and 79% of type 2 fast during Ramadan

• > 50 million with DM fast during Ramadan

Introduction

• In Ramadan, abstain from eating, drinking, use of oral medications, smoking

• From pre-dawn to after sunset• No restriction to food and drink

between sunset and dawn• Most people take 2 meals

Introduction

• Fasting not meant to add hardship• But many insist on it



Pathophysiology of fasting

• During fasting, blood glucose reduces, causing reduced insulin secretion

• Catecholamines and glucagon increase, with more glycogenolysis and gluconeogenesis


With more fasting• Depletion of glycogen stores• Reduced insulin causes increased

free fatty acids (FFA) from adipocytes• FFA oxidized to ketones


• Ketones are used as fuel by skeletal muscles, cardiac muscles, adipocytes, kidneys, liver…

• Glucose spared for erythrocytes and brain

• Liver glycogen stores (70-80g) last about 12h


• These processes are well coordinated in non-DM individuals

• But in DM these are perturbed by the underlying pathophysiology and by pharmacological agents


• In type 1, glucagon may fail to rise appropriately in response to dropping glucose

• Some type 1 also have defective epinephrine secretion (autonomic neuropathy and recurrent hypoglycaemia)


• In severe insulin deficiency, prolonged fasting leads to glycogenolysis, gluconeogenesis and excessive ketogenesis

• Resultant hyperglycaemia and ketoacidosis


• May have similar findings in type 2• Ketoacidosis uncommon and

hyperglycaemia not so severe



Risks associated with fasting in diabetes

• Hypoglycaemia – more in type 1• Hyperglycaemia • Diabetes ketoacidosis (DKA)• Dehydration and thrombosis


Hyperglycaemia • Increased incidence x5 of severe

hyperglycaemia requiring hospital admission• Glycaemic control improves, deteriorates or

remains same• Hyperglycaemia may be due to excessive

reduction of dose to prevent hypoglycaemia• Also increased food consumption, especially

sugary drinks


DKA• Increased risk, especially if

glycaemia is poor• Also from excessive reduction in

insulin dose on assumption of reduced food intake


Dehydration, thrombosis• Limited fluid• Hyperglycaemia also causes osmotic

diuresis• May have orthostatic hypotension,

especially in autonomic neuropathy• Contracted intravascular space leads to

increased hypercoagulable state, with more risks of thrombosis and stroke



Risk assessment

Very high risk• Severe hypoglycaemia within 3 months prior to Ramadan• History of recurrent hypoglycaemia• Hypoglycaemia unawareness• Sustained poor glycaemic control• DKA within 3 months prior to Ramadan• Type 1 DM• Acute illness• Hyperosmolar hyperglycaemic coma within 3 months prior

to Ramadan• Performing intense physical labour• Pregnancy• Chronic dialysis

Risk assessment

High risk• Moderate hyperglycaemia (150-300mg/dl or HbA1C

7.5-9.0%)• Renal insufficiency• Advanced macrovascular complications• Living alone and treated with insulin or

sulphonylurea• Pre-morbid conditions that present additional risk

factors• Old age with ill health• Treatment with drugs that may affect mentation

Risk assessment

Moderate risk• Well-controlled DM treated with

short-acting insulin secretagogue

Risk assessment

Low risk• Well-controlled DM treated with

lifestyle, metformin, acarbose, thiazolodinedione, and/or incretin-based, in otherwise healthy patients



Management

• Decision to fast personal• Careful assessment of risks• Medical recommendations most

times is ‘don’t fast’• But if patients insist, they should be

aware of risks

General considerations

• Individualization: most crucial issue• Frequent glycaemic monitoring• Nutrition – Avoid large carbohydrates and fats at Iftar– Complex carbohydrates at Suhur and eat

as late as possible– Increase water during non-fasting hours

• Exercise – normal, not excessive. Kneeling and bending

Breaking the fast

• Must break immediately if:– Blood glucose < 60mg/dl– Blood glucose < 70mg/dl in the first few

hours, especially if on insulin, sulphonylureas or meglitinides

– Blood glucose > 300mg/dl

• Avoid fasting on sick days

Pre-Ramadan medical assessment

• Should be 1-2 months before fast• Diet plan• Good control of BP, glucose, lipids

Ramadan-focused structured diabetes education

• Structured education very important in management of DM

• Opportunity to empower patient, not only about Ramadan

• But usually lack of harmony between medical and religious advice


3 components• Awareness campaign: people living

with diabetes, health care professionals, public

• Ramadan-focused structured education for health care professionals

• Ramadan-focused structured education for people living with diabetes


Health care professionals should be trained to deliver structured patient education

• Understanding of fasting and DM• Risk stratification• Options to achieve safer fasting


Education delivered• Individually or in group sessions• DM centres• Primary health care centres• Mosques…

• Simple, structured method• In patient’s own language


• Study in the UK, 111 patients • At end of Ramadan, those in

Ramadan-structured diabetes education had 50% reduction in hypoglycaemia than those without education

• Also lost small amount of weight

Management of type 1

• Very high risk • Intensive insulin recommended• Close monitoring and frequent dose

adjustment• Basal-bolus best• May also use pre-meal rapid acting +

once/twice daily intermediate/long-acting• Continuous subcutaneous insulin infusion

is good but costly


Diet-controlled• Low risk• Distribute calories over 2-3 smaller

meals


Patients on oral antidiabetic• Metformin safe, but may modify

dosing (⅓:⅔)• Glitazones– Low risk of hypoglycaemia– But maximum effects 2-4 weeks, so

cannot be quickly substituted


• Sulphonylureas– Individualize– Chlorpropamide: relative

contraindication–Maybe glibenclamide too– 2nd generation better– But use with caution


• Short-acting insulin secretagogues– Repaglinide and meglitinide twice daily– Lower risk of hypoglycaemia

• Alpha-glucosidase inhibitors– Usually no effects on fasting blood

glucose– So usually used in combination


• Incretin-based– Not independently associated with

hypoglycaemia– Exenatide can be given before meal.

Reduced appetite, weight loss– Liraglutide once daily– DPP4 inhibitors are among best

tolerated antidiabetic– Do not require titration


• VIRTUE– Vildagliptin experience compared with

sulphonylureas observed– >1300 patients– Vildagliptin vs sulphonylureas– Less incidence of hypoglycaemia in vildagliptin

• VERDI– Vildagliptin experience during Ramadan in patients

with diabetes– Multicentre in France– Also lower episodes of hypoglycaemia in vildagliptin– More fasting completion too


Insulin• Aim is to maintain basal insulin level• Intermediate- or long-acting insulin +

short-acting• Some will require only basal• Analogue said to be better


Insulin pump• Provides continuous delivery• Patient self-administers bolus with

meal or in hyperglycaemia• Hypoglycaemia can be prevented by

rapid adjustment of dosing• Most patients will need to reduce

rate of basal and increase bolus doses

Recommended changes to treatment regimen in patients with type 2 diabetes whofast during Ramadan

Before Ramadan During Ramadan

Patients on diet and exercisecontrol

Consider modifying the time and intensity of physicalactivity; ensure adequate fluid intake

Patients on oral hypoglycemicagents

Ensure adequate fluid intake

Biguanide, metformin 500 mg,three times daily

Metformin, 1,000 mg at the sunset meal, 500 mg atthe predawn meal

TZDs, AGIs, or incretin-basedtherapies

No change needed

Recommended changes to treatment regimen in patients with type 2 diabetes

whofast during Ramadan

Before Ramadan During Ramadan

Sulfonylureas once a day Dose should be given before the sunset meal; adjustthe dose based on the glycemic control and the riskof hypoglycemia

Sulfonylureas twice a day Use half the usual morning dose at the predawn mealand the usual dose at sunset meal

Patients on insulin Ensure adequate fluid intake

Premixed or intermediate-actinginsulin twice daily

Consider changing to long-acting or intermediateinsulin in the evening and short or rapid-actinginsulin with meals; take usual dose at sunset mealand half usual dose at predawn

Pregnancy

• Increased risk for mother and fetus• If patient insists, intensive care• Pre-gestational care, with emphasis

on achieving near-normal HbA1C

• Appropriate diet and insulin• More frequent monitoring and insulin

adjustment

Hypertension and dyslipidaemia

• May need to adjust dose of antihypertensives

• Diuretics may not be OK• Continue agents for dyslipidaemia

Summary

• Fasting carries risks• Type 1 very high risk• Decision to fast should be made after

appropriate discussion• Those who insist should have pre-

Ramadan assessment, education, instructions

• Some pharmacological agents may cause less hypoglycaemia

References

• Al-Arouj M, Asaad-Khalil S, Buse J, Fahdil I, Fahmy I, Hafez S, et al. Recommendations for management of diabetes during Ramadan. Diabetes Care 2010 (33): 1895-1902

• Hui E, Bravis V, Hanif W, Malik R, Chowdhury TA, Suliman M, et al. Management of people with diabetes wanting to fast during Ramadan. BMJ 2010 (340): 1407-11

• Halimi S, Levy M, Huet D. Experience with vildagliptin in type 2 diabetic patients fasting during Ramadan in France: Insights from the VERDI Study. Diabetes Ther (2013): 4:385-398

References

• Al-Arouj M, Hassoun AK, Medlej R, Pathan MF, Shaltout I, Chawla MS, et al. The effect of vildagliptin relative to sulphonylureas in Muslim patients with type 2 diabetes fasting during Ramadan: the VIRTUE study. Int J Clin Pract 2013; 67: 933–4.

Thank You

Documents

Management of type 2 diabetes in Ramadan fasting Ukandu Igwe Senior Registrar Endocrinology, Diabetes and Metabolism Unit Lagos University Teaching Hospital