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MANAGEMENT OF DIABETES DURING RAMADAN

Dr Hanisah Arshad Family Medicine Specialist Klinik Kesihatan Bakri Muar District of Health M D fH lh

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Introduction Risk associated with fasting in Diabetics patient Diabetis PatientIs it possible to fast? H How to manage Diabetes patients who Di b i h decide to fast?

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Muslim P M li Population and DM l ti d


World wide 1.1 -1.5 billion of Muslim Diabetes prevalence 4- 6% EPIDIAR study 1422/2011 43% T1DM and 79% T2DM fasting during Ramadan 40-50 million people with DM fasting Malaysia y Prevalence of T2DM above 30 yrs old 14.9% ( NHMS 2006) Estimated 2 million Malaysian had T2DM 1.2 million are Muslim
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Ramadhan R dh
9 month of Islamic lunar calendar Duration 29 30 days y Duration of daily fast - Malaysia 14 hrs - Other countries may up to 20 hours M l consumption Meal i - 2 meals - after sunset ( Iftar) and before dawn ( Sahur)

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Puasa R P Ramadan d W J WAJIB

W h i orang-orang yang b i Wahai beriman ! K Kamu di jibk diwajibkan berpuasa sebagaimana diwajibkan atas orang-orang yang dahulu daripada kamu supaya kamu bertakwa . kamu,
(Ayat 183, Surah Al Baqarah)

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Diabetis Patient Is it possibble to fast? I ibbl t f t?

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Memang puasa itu wajib! tetapi punya kelonggaran


(Puasa yang di jibk (P diwajibkan it i l h) b b itu ialah) beberapa h i yang hari tertentu; maka sesiapa di antara kamu yang sakit, atau dalam musafir, (b l hl h i b b k ) k fi (bolehlah ia berbuka), kemudian wajiblah i di jibl h ia berpuasa sebanyak (hari yang dibuka) itu pada hari-hari yang lain; dan wajib atas orang yang tidak terdaya berpuasa (kerana tua dan sebagainya) membayar fidyah iaitu memberi makan orang miskin Maka sesiapa yang dengan sukarela miskin. memberikan fidyah, maka itu adalah satu kebaikan baginya Ayat 184 Surah Al Baqarah 184,

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Diabetes is exempted for fasting It is a chronic metabolic disorder - at risk of complication BUT. Many pt with DM insist to fast ENSURE .. A Aware the potential risk h i l ik .Appropiate advice given Appropiate

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Risks Associated With Fasting in Diabetes Patients

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Epidemiology of Diabetes and Ramadhan p gy 1422/2001 (EPIDIAR) Study


Large epidemiological study Population based p Conducted in 13 Islamic country, involved 12,243 p diabetes patients

Results: 1. Increased risk of severe hypoglycemia were more frequent during R f t d i Ramadhan dh 2. Fivefold increase of severe hyperglycemia
EPIDIARStudy,DiabetesCare27:23062311,2004
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Other risk associated with fasting 3. Diabetic ketoacidosis - esp in T1DM 4. Dehydration - d to li it ti of fl id i t k h t climate, due t limitation f fluid intake, hot li t osmotic diuresis 5. Thrombosis - due to hypercoagulable state ( increase clotting factors, reduced anticoagulant g
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Fasting not allowed:


1. 2. 3. 4. 5. 6. 7. 8. 8 9.

Poorly controlled type I or type II diabetic patients Diabetic patients known to be incompliant in terms of diet , drug regimens and daily activity Diabetic patients with serious complications such as unstable angina or uncontrolled hypertension Patients with a history of diabetic ketoacidosis Diabetic patients will inter-current infections D b ll f Elderly patients with any degree of alertness problems Two T or more episodes of hypoglycemia and/or hyperglycemia i d fh l i d/ h l i during Ramadan. Gestational DM on Insulin therapy Less than 12 years
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Allow fasting in: 1. Patients who do not have the mentioned criteria p 2. Patient who accept medical advisement. Encourage fasting in: Overweight NIDDM patients whose diabetes is stable with weight l l 20% above di b i bl i h i h levels b the ideal weight or body mass index (body weight, k /h i h meters squared) greater than i h kg/height, d) h 28.
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How to manage Diabetes patients H D b who decide to fast? h t

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1.Pre ramadan medical assessment and educational counselling


1.1 Pre Ramadan medical assessment g - look for overall well being - glucose control, BP control, lipids control - advice the potential risk 1.2 Ed 1 2 Educational counseling/ Ramadan f i l li / R d focus education d i - VERY IMPORTANT to patients and family - educate on self care, sign and sx of hypo/hyperglicemia, BG monitoring, meal planning, drug admin, management of acute complication g p
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2. R 2 Ramadan F d Focus Education Ed ti


2.1 Care must be individualized g p p Management plan differ for each patient Frequent monitoring of glucose level Before sahur, 2hrs after Sahur 2hrs b f 2h before Iftar, 2 h after If If hrs f Iftar

2.2 22

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2.3 23

Nutrition IS A CHALLENGE

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Tips Ti on nutrition/diet t iti /di t


1.

Iftar y - dont delay Iftar - limit intake of high sugar/ high fat food weight gain - break fast with dates/ tamar 1-2 seeds - take main meal later ( around Isyak prayer) complex carbo fibre salt a lot water carbo, fibre, salt,

2. Sahur - have Sahur as late as possible to avoid long fasting - eat adequate balance meal - drink a lot of water
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Sabda Rasulullah s.a.w.; Senantiasalah umatku berada dalam kebaikan selama mereka menyegerakan berbuka dan melambatkan sahur. sahur . (Riwayat Imam Ahmad dari Abu Zarr r.a.) 2.4 Exercise - maintain normal physical activity - avoid excessive physical activity 2.5 Breaking the fast immediately - when having hypoglycemia symptoms - hypoglycemia ( BG < 3.5 mmol/l) - BG reaches < 3.9 mmol/l in the first few hours of fasting - BG > 16 mmol/l
RecommendationforMxofDiabetesDuringRamadan,DiabetesCare,28:2305 2311,2005
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www.fms-malaysia.org CPGinInsulinTherapybyMOH,2010

Treatment regime adjustment.. g j

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Patient on diet control No change needed Adequate fluid intake q

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Patient on OHA P i
In general, insulin sensitizer associated with lower risk of hypoglycemia 1. 1 Sulphonylurea ( insulin secretion) - use with caution - use Chl Chlorpropamide i CI id is - SU 2x/ day eg: Glibenclamide, Gliclazide full dose at Iftar, half dose during sahur y g - SU once daily eg: Gliclazide MR dose given at Iftar
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2. Metformin ( insulin sensitizer) g , - 2/3 given at Iftar, 1/3 at sahur 3. 3 Glitazones (rosiglitazone pioglitazone) (rosiglitazone, - No change in dose required 4. Short acting insulin secretagogue g g g - Repaglinides, Nateglinides - can be taken twice during Iftar and Sahur

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Insulin adjustment

HumulinN, Insulitard

Humulin30/70, Mixtard30/70 Shortactinginsulin +intermediate

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Management of people with diabetes wanting towww.fms-malaysia.org BMJ 2010;340:c3053 fast during Ramadan,

Conclusion C l i
1. 2.

3.

Fasting during Ramadan for Diabetes patients p carries a risk discuss the risk with the patient Patients who insists on fasting should undergone assessment and receive appropriate education. The management plan should be highly p individualized and close follow up is essential

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menziarahi kita g sekeluarga bila2 masa sahaja lagi. Dia dtg bersama isterinya iaitu y REZEKI dan juga 2 anaknya ...SAHUR dan IFTAR serta 3 org cucunya iaitu RAHMAT,BARAKAH dan KEAMPUNAN.Mereka akan pulang selepas 30 hari dgn menaiki pesawat TAQ A airlines. TAQWA i li

'RAMADHAN' akan dtg RAMADHAN

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