People with diabetes will listen more to Religious scholars rather than doctors, hence we need to educate them-Dr.Hassanein

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Diabetes and Ramadan Conference by BIDE-BMU-III
People with diabetes will listen more to
Religious scholars rather than doctors,
hence we need to educate them-Dr.Hassanein
These patients must be educated to break the Fast if
their blood glucose falls below 70

Karachi: Prof. Jamal Zafar alongwith Prof. Jahangir chaired the second session during the Diabetes & Ramadan Conference organized by Baqai Institute of Diabetology and Endocrinology in collaboration with IDF and Baqai Medical University from 23-24 March 2019. Dr. Muhammad Husnain was the first speaker who shared the salient features of recent studies on the subject. EPIDIAR, he said, was a landmark study done many years ago but now there have been lot of changes and improvement in technology. Data shared by other speakers has shown that not everybody with diabetes was able to fast. CREED study done in 2010 showed that Hypoglycemia was a major problem in patients on oral therapy alone. Those patients who experience hypo episodes before Ramadan, will have more hypo episodes during Ramadan as well. 

 

Dr. Muhammad Hassanein

People with diabetes will listen more to Imams, Religious scholars rather than doctors, hence it is important to educate the Mosque Imams and religious scholars. This will take over lot of burden from the doctors. There are risks. Some patients must not fast otherwise they will harm themselves. There is a high risk of hypo in chronic kidney disease. Studies have also shown that patients with stable cardiovascular diseases had 50% hypo episodes during Ramadan and 19% of patients with diabetes had hypo episodes. These patients must be educated to break the fast if their blood glucose falls below 70 (seventy) but studies have showed that 31% of patients who developed hypoglycemia did not break fast. Education of the patients does reduce the episodes of hypoglycemia during Ramadan. The patients should be advised to monitor their blood glucose as they might have to change the dosage of medications. During Ramadan, one should reduce the dose of Sulphonylureas. He concluded his presentation by stating that now IDF-DAR has developed effective guidelines for management of diabetes during Ramadan.


Dr. Qamar Masood

Dr. Qamar Masood spoke about Safe Fasting with oral ant hyperglycemic drugs during Ramadan. He pointed out that different drugs have varying level of hypo risk hence dose and time adjustment should be done for each patient. EPIDIAR and CREED studies have also showed that many people with diabetes are fasting and they are allowed to fast but it is essential to make the fasting safe. He also referred to Ramadan Feasting as we tend to eat too much. Patients with diabetes should reduce their number of meals. Hypo is a genuine concern and this incidence is now decreasing. The risks include Hypo and Hyperglycemia besides DKA. He was of the view that the patient must be ready to break the fast if symptoms of hypoglycemia occur, only then these patients should be allowed to fast. Only metformin has a very low risk of hypoglycemia. Pioglitazone is safe but one must take it with Sehar or Iftar. Those using DPP4 inhibitors need modification during Ramadan. Those taking Sulphonylureas once daily should take it with Iftar. Those taking twice daily Iftar dose will remain same. Gliclazide is safe for management of diabetes during Ramadan. All Sulphonylureas, he stated, are not the same. In case of Gliclazide dose reduction may be required. SGLT2 dose may also need to be reduced during Ramadan. Prof. Jamil Ahmad remarked that some patients come to us, they have no change in their drugs but they do not develop any hypo episodes but we do not know the reason. However, we do need to adjust the dose, he added.


Dr. Sobia Sabir

Dr. Sobia Sabir from Lady Reading Hospital Peshawar in his presentation discussed whether it was safe to use GLP-I analogue during Ramadan. She pointed out that almost 80% of people with diabetes fast. It means two meals per day though we recommend the patients with diabetes to have frequent meals with small quantity. They can take third meal late at night. Time between meals is shrinking while volume of meal is increasing. Use of fatty foods and sugary drinks make people too lazy. Exercise is ignored. SMBG is not done. Dose adjustment is also not done. Their sleep cycle is disturbed. They may suffer from mood irritability. All this results in hypo or hyper glycaemia. In such circumstances we need good quality Antidiabetic which should be effective and also control episodes of hypoglycemia. Other desired goal of treatment include simple regimen of once daily or BD dose should be preferred. The drugs should not make the patient more hungry and it should also not result in dehydration and should have no side effects as well. She then shared the information regarding safety with GLP-I analogue as shown in LIRA Ramadan trial. LIRA was more safe and effective. Most patients taking this drug were satisfied. The side effects were not severe as it included nausea and vomiting. It also offers the advantage of once daily dose, is safe and effective with no dehydration while nausea and vomiting are not serious. Hence they can be used a monotherapy or combined with other oral drugs or with insulin.

During the discussion it was pointed out that most patients with diabetes are poor hence this being very costly, many patients may not be able to afford it as the drug has to be taken lifelong. Responding to a question regarding contra indications, Dr. Sobia Sabir said that do not use it in patients who have GIT side effects. It is injectable but it is allowed during Ramadan.


Prof. Jamil Ahmad from BMU chaired the next session. Dr. Tarik Elhadd was the first speaker who discussed combination of multiple and complex therapy during Ramadan and shared the highlights from the PROFAST Ramadan Study. At present there are seven class of oral drugs. Most studies have add on metformin affect. Small number of patients are included in most studies. There are GLP-RA, various insulin, alpha glucoses and multiple therapies are used. Most patients with diabetes do fast. No study has included patients on three or multiple drugs. In this study patients suffering from Type-2 diabetes between the age of 18-79 years who were on three or more anti Diabetic agents were included. Their HbA1C was 9.9. Patients undergoing cancer treatment, active CAD were also included. Dose of metformin if used was reduced by 60%. The patients included were four weeks pre-Ramadan and they were evaluated two to six weeks after Ramadan. There were 238 patients with diverse ethnic background. We observed how many days they fasted, how many of them had to visit the Emergency Room for admission. One hundred eighty nine patients completed the study. Their duration of diabetes was over ten years. Seventy two were Arab, fifty eight wee Asian and 52 were from Qatar and other countries. Twenty two patients were taking four drugs, 50% were on SGLT2I, 6% were on Sulphonylureas, and one hundred fifty patients were on DPP4 with insulin metformin and other medications. Six patients went to the Emergency Room, most of the patients fasted for twenty eight days. Many patients did not break fast despite hypoglycemia episodes. Many of the patient were not aware of hypo or hyperglycemia symptoms. In PROFAS-IT study the dose of sulphonylurea was reduced by 50%, they were included in the study 2-4 week’s pre-Ramadan. Out of eighty five patients included, sixty completed the study and used IT successfully. The preliminary data is now available. The study showed that Hypoglycemia episodes did not change during fasting. More than 60% of patients met their blood glucose targets. Dose adjustment of Sulphonylureas and decrease in dose of insulin might have been effective in preventing hypoglycemia episodes. Patients taking more than one drug during Ramadan need special consideration. Insulin and Sulphonylureas are at greater risk of causing hypoglycemia. Dose adjustment was needed in these patients including that of Sulphonylureas and insulin. Combination of metformin, insulin and DPP4 had more hypo episodes.


Dr. Asma Deep

Dr. Asma Deep’s presentation was entitled “People with diabetes on Insulin can fast”. She pointed out that they can fast but to fast or not to fast is an individual decision. It is advisable to take medical opinion. Those fasting against medical advice have more complications. The risks include DKA, dehydration and hypoglycemia. Some people say why we should blame Ramadan as hypoglycemia is a complication of diabetes and not fasting. Hypo is a fact of life for people with diabetes. She opined that let us improve the guidelines and do not blame Ramadan. Patients are more stable on basal bolus. Fasting is safe on BD dose and insulin pump offer better control. Another study showed no severe hypo or DKA and no ER visits. The patients had wide blood glucose fluctuations and unreported Hypos. Admissions due to DKA is not very high in Ramadan.

Dr. M. Hassanein said that most of the patients on insulin can fast. Patients need multiple injections and there is no randomized trials. Patients have passion for fasting, smoking. We have to give them the right opinion. In most studies high risk patients are not included. Conclusions from some small studies should not be generalized. How I can convince patient to take insulin and fast for sixteen to eighteen hours, he asked? In another study 58% of patients did not fast despite passion, 41% had more than ten episodes of Hypo. It is not blaming Ramadan. Generally Type-1 and Type-2 with MDI are high risk to fast, they may be advised to use the permission of not fasting. Those not willing to break the fast with Hypo, are not following the diabetes guidelines. Prof. Jamil Ahmad remarked that as long as we are in touch with the patients with diabetes, they can fast. Prof. Abdul Basit remarked that there are certain grey areas and we must provide some take home messages to ensure safe fasting.

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