Diabetes Mellitus in Ramadhan CME Presentation

Diabetes Mellitus in Ramadhan CME Presentation

1. CME MO KK KANGAR 12/3/2024 Diabetes in Ramadhan

2. Normal fed, increase in glucose  stimulate insulin secretion  which in turn trigger liver & muscle to store glucose as glycogen Energy sources : CHO (glycogen)  Lipid (fat)  Protein (AA) During fasting  circulating glucose level fall, insulin secretion is suppressed Glucagon & cathecolamines secretion is increased  stimulating glycogenolysis and gluconeogenesis then lead to increase glucose level In early morning of fasting, there is dominance of CHO usage as main source of fuel, whereas lipid become more important toward afternoon and at time of approaching Iftar Who take sahur are in state of glycogen depletion by late afternoon, at which point ketogenesis occur Who omit Sahur lead to early glycogen store depletion, result in ketotic state much earlier in fasting days 2

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4. Pre-Ramadhan review Should be performed 1-2 months prior Overall general wellbeing Comorbidities Glycaemic / BP/ Lipid control Medication Diabetes-related complication Aim : 1. To categorized patient in term of risk of fasting 2. Optimize management 4

5. Very High Risk High Risk Moderate Low History of severe diabetes complication 3 month prior fasting - Severe hypoglycemia - Ketoacidosis - Hyperosmolar Hyperglycemic coma - Recurrent hypoglycemia Hypoglycemia unawareness Acute illness Sustained poor sugar control (Hba1c >9%) Pregnancy Advanced renal failure/ chronic dialysis Moderate Hyperglycemia (HbA1c 7.5-9.0%) Moderate renal failure Advanced macrovascular complication Living alone and treated with insulin or SU Patient with comorbid that present additional risk factors Old age with ill health Treatment with drugs that may affect mentation Well-controlled diabetes treated with short acting insulin Well controlled diabetes treated with lifestyle therapy, MTF, Acarbose, TZD, and/or incretin-based therapies in otherwise healthy patient Those in Very high & High risk group should be abstain from fasting 5

6. Structured Education Risk of adverse effect fasting Blood glucose monitoring - Fasting & non-fasting hours - Emphasize that administration/prick not cause break fasting When to stop fasting Hydration/ fluid intake Meal planning & food choices Exercise & Physical activity – timing & intensity Medication modification Management of acute complication 6

7. Risk/ Adverse effect of fasting Hypoglycemia (Esp during late period of fasting) Hyperglycemia (After each of main meals) Dehydration : Orthostatic hypotension  Falls, syncope, injury, fracture, AKI Thrombosis Diabetes-related risk can be minimised through education, appropriate food choice and SMBG 7

8. SMBG – Timing & Frequency OGLD – When symptomatic Insulin - Pre-meal & 2H post Sahur - Mid-day - Pre-meal & 2H post Iftar - Bedtime Risk & suggestion : - Moderate/ low : 1-2x per day - High/ very high : Several times - on insulin +/- SU : Frequent 8

9. Indication termination of fasting - BG < 3.3 anytime during fasting - BG < 3.9 in 1 st few hours (Esp for taking SU, Meglitinides, Insulin) - BG > 16.7 anytime during fasting (No/ lack of adequate insulin  excessive glycogen breakdown  increased gluconeogenesis & ketogenesis - Symptoms of hypoglycemia (Without SMBG) - Symptoms of severe dehydration (Syncope/ Confusion) 9

10. Diet adjustment Sahur - Never skip, taken as late as possible Iftar - Don’t delay, Limit high sugary food, encourage after maghrib prayer Supper after Taraweh ( Prebed snack) Include fruits, vegetable, high fibre carbohydrate at all meals Limit fried/ fatty foods Limit high salted food 8 glass fluid per day (pick sugar free) Physical activity Regular basis – Light & moderate intensity exercise Avoid rigorous exercise during fasting Timing : 1-2H post Iftar Taraweh : A form of physical activity 10

11. www.daralliance.org Diabetes & Ramadhan International Alliances Ramadhan Nutrition Plan (RNP) 11

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13. OGLD that proven to be safe in Ramadhan - MTF, Gliclazide, Glimepiride, Sitagliptin, Vildagliptin SGLTi - Lower risk hypoglycemia - Safety concern, which is dehydration, cautious in DKD 3 and above Principles OGLD modification - non fasting morning dose should be taken during Iftar - non fasting evening dose should be taken during Sahur - dose may be maintained or reduced depending on risk of hypoglycemia 13

14. REGIME Sahur Iftar Examples Biguanides (Metformin) **No change in total daily dose BD TDS No changes Morning dose No changes Lunch + Evening dose Pre : MTF HCL 500mg BD R : MTF HCL 500mg at Sahur & MTF HCL 500mg at Iftar Pre : MTF HCL 1000mg TDS R : MTF HCL 1000mg at Sahur & MTF HCL 2000mg at Iftar XR None Full dose Pre : MTF XR 500mg OD R : MTF XR 500mg at Iftar SU Gliclazide, Glibenclamide Reduced/ omit No changes Pre : Gliclazide 80mg BD R : Gliclazide 80mg at Iftar & 40mg at Sahur (50% reduction) Gliclazide MR,Glimepiride Switch dosing to Iftar No changes Pre : Gliclazide MR 60mg OD R : Gliclazide MR 60mg at Iftar SGLT2-I Switch dosing to Iftar No changes Pre : Empagliflozin 10mg OD R : Empagliflozin 10mg at Iftar - Ensure adequate hydration - Not recommended as new initiation prior/during Ramadhan 14

15. REGIME Sahur Iftar Examples DPP4-I Vildagliptin No changes No changes Pre : Vildagliptin 50mg OD/ BD R : Vildagliptin 50mg at Iftar To consider reduce/ stop concomitant SU Meglitinides No changes No changes A-glucosidase inhibitor No changes No changes TZD None No changes Can be taken at Sahur or Iftar To consider reduce/ stop concomitant SU GLP1-RA (Injectable) Liraglutide & Exenatide are safe as add-on to MTF, effective in reduced weight & HbA1c in Ramadhan - Preferred administration **No need dose adjustment If not tolerated (nausea/vomit), to reduce/stop medication Pre : Liraglutide 1.2mg OD R : Liraglutide 1.2mg OD at Iftar (Any time without regard of meals) 15

16. INSULIN REGIME Type 1 DM Type 2 DM EXAMPLES Basal insulin only Not applicable Taken at bedtime/ after Iftar **May need dose reduction Pre : SC Insulatard 16u ON R : SC Insulatard 12u (Reduced 15-30%) Premixed insulin OD Not applicable Usual dose at Iftar Premixed insulin BD Reverse dose : - Morning dose at Iftar - Evening dose at sahur Dose at sahur reduced by 20-50% Reverse dose : - Morning dose at Iftar - Evening dose at sahur Dose at sahur reduced by 20-50% Or Change to short/rapid acting Pre : SC Mixtard 20u BD R : SC Mixtard 20u Iftar, SC Mixtard 12u Sahur (Reduced 20-50% at sahur ) Basal bolus - Basal - Bolus As mentioned above - Sahur : Usual breakfast dose (**May need dose reduction) -Lunch : Omit -Iftar : Usual dinner dose (**May need dose increment) Pre : SC Actrapid 8u TDS R : SC Actrapid 8u Iftar, SC Actrapid 4u Sahur (Reduced 15-30% at sahur ) 16

17. Other medication Dose & timing of anti-HPT may need to be adjusted to prevent hypotension Diuretic should be use with caution to avoid volume depletion Antilipid should be continued without dose adjustment 17

18. References Practical Guide to Diabetes Management in Ramadan (MEMS) CPG Management of Type 2 DM (6 th Edition)