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The MERIT™ Programme

The MERIT™ Programme. M eeting E ducational R equirements, I mproving T reatment. The management of diabetes during Ramadan. MERIT is an educational resource for UK diabetes health professionals, developed and funded by Novo Nordisk. Religious populations in UK.

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The MERIT™ Programme

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  1. The MERIT™ Programme Meeting Educational Requirements, Improving Treatment The management of diabetes during Ramadan MERIT is an educational resource for UK diabetes health professionals, developed and funded by Novo Nordisk.

  2. Religious populations in UK Distribution of non-Christian religions More than 20% of the Muslim population in the UK suffers from diabetes Office for National Statistics. Religious populations. April 2001. Available at: http://www.statistics.gov.uk/cci/nugget.asp?id=954 (accessed January 2010) Shaikhet al. Br J Diabetes VascDis2001;1:65-67

  3. Ramadan • Ramadan is the Islamic holy month where fasting is compulsory for all healthy Muslims • Absolute fast between sunrise and sunset • Muslims refrain from: • Food • Liquids • Medication • No restrictions on food or fluid intake between sunset and sunrise Diabetes and Ramadan. Leicestershirediabetes. Available at: http://www.leicestershirediabetes.org.uk/display/templatedisplay1.asp?sectionid=243 (accessed May 2010); Benaji et al. Diabetes Res Clin Pract 2006;73:117–25; Al-Arouj et al. Diabetes Care 2005;28:2305–11

  4. Ramadan • Ramadan is a lunar-based month • Occurs 11 days earlier each year • Not fixed to any season • Duration of the fast can vary from a few hours to more than 20 hours, depending on geographical location and season Benaji et al. Diabetes Res Clin Pract 2006;73:117–25; Al-Arouj et al. Diabetes Care 2005;28:2305–11

  5. Who observes the fast during Ramadan? • Mandatory for healthy Muslims • Exemption for: • Children • Elderly • Sick • Pregnant or nursing mothers • Menstruating women • People with chronic illness (e.g. diabetes, chronic kidney disease, cardiovascular disease) Diabetes and Ramadan. Leicestershirediabetes. Available at: http://www.leicestershirediabetes.org.uk/display/templatedisplay1.asp?sectionid=243 (accessed May 2010); Al-Arouj et al. Diabetes Care 2005;28:2305–11

  6. The Koran specifically exempts sick people from fasting (Al-Bakarah, 183–185) • Patients with diabetes are exempt from fasting during Ramadan • High risk of complications if daily food and fluid intake are markedly altered • More than a permission not to fast • “God likes his permission to be fulfilled, as he likes his will to be executed” • ‘Fidyah’: compensation for not fasting • Fast at later date if possible • Feed the hungry and poor Many Muslims with diabetes insist on fasting during Ramadan. This creates a medical challenges for both patients and physicians. Diabetes and Ramadan. Leicestershirediabetes. Available at: http://www.leicestershirediabetes.org.uk/display/templatedisplay1.asp?sectionid=243 (accessed May 2010); Al-Arouj et al. Diabetes Care 2005;28:2305–11; Salti et al. Diabetes Care 2004;27:2306–11; Ramadan health guide, NHS. Available at http://www.communitiesinaction.org/Ramadan%20Health%20and%20Spirituality%20Guide.pdf (accessed Feb 2010)

  7. Pathophysiology of fasting in healthy individuals Plasma glucose Glucagon and catecholamines Depleted glycogen stores Insulin secretion Glycogenolysis Gluconeogenesis Low plasma insulin levels Liver Muscle Fatty acid release from adipocytes Generation of ketones Energy Adipose tissue Al-Aroujet al. Diabetes Care 2005;28:2305–11

  8. Risks associated with fasting in patients with diabetes • Glucagon secretion may fail to increase appropriately in response to hypoglycaemia • Severe insulin deficiency may lead to excessive glycogenolysis and increased gluconeogenesis and ketogenesis • Fasting can lead to several complications: • Hypoglycaemia • Hyperglycaemia • Diabetic ketoacidosis • Dehydration and thrombosis Al-Aroujet al. Diabetes Care 2005;28:2305–11

  9. Ramadan affects diet of patients with diabetes Change in frequency of meals • Two meals per day: • Sehri (before dawn) • Iftari (at sunset) Change in dietary patterns • Increase in intake of: • Sugary drinks • Fried foods • Carbohydrate-rich meals • Sweets Diabetes and Ramadan. Leicestershirediabetes. Available at: http://www.leicestershirediabetes.org.uk/display/templatedisplay1.asp?sectionid=243 (accessed May 2010); Benaji et al. Diabetes Res Clin Pract 2006;73:117–25

  10. Patients at high risk of developing complications during Ramadan Very high risk High risk • Type 1 diabetes • Severe hypoglycaemia or ketoacidosis within last three months prior to Ramadan • Recurrent hypoglycaemia • Sustained poor glycaemic control • Acute illness • Pregnancy • Moderate hyperglycaemia • Renal insufficiency • Advanced macrovascular complications • Living alone and treated with sulphonylurea or insulin • Comorbid conditions that present additional risk factors Al-Aroujet al. Diabetes Care 2005;28:2305–11

  11. General consideration for the management of diabetes during Ramadan • Individualisation • Patient specific recommendations • Frequent monitoring of glycaemia • Crucial for patients with type 1 diabetes and patients with type 2 diabetes who require insulin treatment • This will not break the fast • Nutrition • Healthy and balanced diet • Exercise • Maintain normal levels of physical activity • Breaking the fast • Blood glucose <3.3 mmol/L or >16.7 mmol/L Al-Arouj et al. Diabetes Care 2005;28:2305–11; Dietary advice during Ramadan. Leicestershirediabetes. Available at: http://www.leicestershirediabetes.org.uk//display/templatedisplay1.asp?sectionid=245 (accessed May 2010)

  12. Medical assessment and educational counseling prior to Ramadan • Medical assessment • 1–2 months prior to Ramadan • Assess overall well-being of patients • Check glycaemic control, blood pressure and lipids • Make patient aware of potential risks • Make necessary changes to diet and treatment regimen • Educational counselling • Self-care • Symptoms of hyper- and hypoglycaemia • Blood glucose monitoring • Meal planning • Physical activity • Medication administration • Management of acute complications Al-Aroujet al. Diabetes Care 2005;28:2305–11

  13. Management of patients with type 1 diabetes during Ramadan Poorly controlled Unable to monitor blood glucose levels Very high risk of severe complications Patients should be strongly advised not to fast If patients with type 1 diabetes insist on fasting during Ramadan, their insulin treatment regimen may need to be adjusted Al-Aroujet al. Diabetes Care 2005;28:2305–11

  14. Insulin treatment regimens for patients with type 1 diabetes during Ramadan • Two daily injections of NPH insulin (intermediate-acting) in combination with pre-meal short-acting insulin1 • Before predawn and sunset meals • Increased risk of hypoglycaemia around midday • Long-acting insulin in combination with pre-meal rapid-acting insulin analogues • Once-daily injection of insulin glargine1 or insulin detemir2 • or • Twice-daily injections of insulin detemir2 NPH, neutral protein Hagedorn 1. Al-Arouj et al. Diabetes Care 2005;28:2305–11 2. Levemir Summary of Product Characteristics 2011

  15. Management of patients with type 2 diabetes during Ramadan • Diet-controlled patients • Risk associated with fasting is low in patients who are adequately controlled with diet alone • Potential risk of postprandial hyperglycaemia • Daily exercise programme may need to be modified to avoid hypoglycaemia • Fluid restrictions and dehydration may increase the risk of thrombosis Al-Aroujet al. Diabetes Care 2005;28:2305–11

  16. Management of patients with type 2 diabetes during Ramadan • Patients treated with oral agents • Metformin • Minimal possibility of hypoglycaemia • Timing of doses should be modified • Glitazones • Low risk of hypoglycaemia • No change in dose required • Short-acting insulin secretagogues • Short duration of action • Twice-daily dosing • Sulphonylurea • Increased risk of hypoglycaemia Suitable for use during Ramadan Use with caution during Ramadan Al-Aroujet al. Diabetes Care 2005;28:2305–11

  17. Management of patients with type 2 diabetes during Ramadan • Patients treated with incretin-based therapies Incretin-based therapies GLP-1 receptor agonists DPP-4 inhibitors • Glucose dependent • Low risk of hypoglycaemia • Suitable for use during Ramadan? Devendra et al. Int J Clin Pract 2009;63:1446–50; Beshyah et al. Libyan J Med 2007;2:16–20; Barnett. Clin Endocrinol 2009;70:343–53; To fast or not to fast? Leicestershirediabetes. Available at http://www.leicestershirediabetes.org.uk//display/templatedisplay1.asp?sectionid=244 (accessed May 2010) GLP-1, glucagon-like peptide-1; DPP-4, dipeptidyl peptidase-4

  18. Management of patients with type 2 diabetes during Ramadan • Patients treated with insulin • Aim is to maintain adequate basal insulin levels • Intermediate- or long-acting insulin can be used in combination with pre-meal short-acting insulin • Once-daily injection of insulin glargine • Twice-daily injections of NPH insulin or insulin detemir • Dosage of each injection needs to be individualised • Frequent monitoring of blood glucose is required • Overall dose may need to be adjusted depending on weight changes during Ramadan • Potential risk of hypoglycaemia • Patients who have needed insulin therapy for several years • Very elderly patients Al-Arouj et al. Diabetes Care 2005;28:2305–11

  19. The importance of self-monitoring blood glucose • Monitoring glucose is important for successful insulin treatment: • It guides dose adjustment • It allows patients to see the impact of behaviours and diet on glucose • Patients should be encouraged to monitor blood glucose at appropriate intervals • The most important aspect of self-monitoring is that patients use the results Diabetes UK http://www.diabetes.org.uk/Documents/Professionals/primary_recs.pdf (accessed May 2010); NCC-CC http://www.nice.org.uk/Guidance/CG66/Guidance/pdf/English (accessed May 2010); Owens et al. Diabetes Prim Care 2004;6:8–16

  20. Epidemiology of Diabetes and Ramadan (EPIDIAR) study • Aim: to study diabetes during Ramadan and investigate the effects of fasting • Population: 12,243 Muslim patients with diabetes in 13 countries • Demographics: *Data are mean (SD) Salti et al. Diabetes Care 2004;27:2306–11

  21. EPIDIAR study - Results Lifestyle changes during Ramadan Type 1 diabetes Type 2 diabetes Physical activity Food intake Fluid intake Sugar intake Physical activity Food intake Fluid intake Sugar intake Adapted from Salti et al. Diabetes Care 2004;27:2306–11

  22. EPIDIAR study - Results Body weight changes during Ramadan Proportion of patients (%) Type 1 diabetes (n=899) Type 2 diabetes (n=9775) Adapted from Salti et al. Diabetes Care 2004;27:2306–11

  23. EPIDIAR study - Results Changes in medication during Ramadan Type 1 diabetes Type 2 diabetes Proportion of patients (%) Insulin dose (n=980) OAD dose (n=94) Insulin dose (n=1831) OAD dose (n=9476) Adapted from Salti et al. Diabetes Care 2004;27:2306–11 OAD, oral antidiabetic drug

  24. EPIDIAR study - Results Severe hyperglycaemia with or without ketoacidosis in patients who fasted ≥15 days p=0.0015 Number of events per month Type 1 diabetes Type 2 diabetes Adapted from Salti et al. Diabetes Care 2004;27:2306–11

  25. EPIDIAR study - Results Number of severe hypoglycaemic events during Ramadan (number per month) Data (except p values) are mean (SD) Adapted from Salti et al. Diabetes Care 2004;27:2306–11

  26. Case study – Mr Ali • 45-year old male • Type 2 diabetes • Diabetes duration: 4 years • Treatment regimen: • Metformin 850 mg TID • Biphasic insulin lispro 25–60 units morning • Biphasic insulin lispro 50–65 units evening TID, three times a day

  27. Your turn! • What advice should you give him? • What factors need to be taken into consideration before offering advice? • What evidence is available to guide management? • Are there any circumstances in which you should modify your advice?

  28. Case study – Mrs Begum • 55-year old female • Type 2 diabetes • Diabetes duration: 7 years • HbA1c: 6.9% • BMI: 40 kg/m2 • Treatment regimen: • Gliclazide 80 mg morning / 160 mg evening • Metformin 850 mg TID • Pioglitazone 45 mg morning BMI, body mass index

  29. Your turn! • What advice should you give her? • What factors need to be taken into consideration before offering advice? • What evidence is available to guide management? • Are there any circumstances in which you should modify your advice?

  30. Key summary points • Many patients with diabetes insist on fasting during Ramadan • Patients need to be aware of the potential risks associated with fasting • Patients with type 1 diabetes are at a very high risk of developing complications • Well-controlled patients with type 2 diabetes are at a low risk of developing complications • Patients need to be educated on meal planning and glucose monitoring • Physicians should recommend necessary changes to diet and exercise programmes and treatment regimens

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