Fasting Ramadan carry many hazards to diabetic need to fast. Uncontrolled patients have a liability to some dangerous complications like DKA,HYPOGLYCEMIA,HHS AND thromboembolism
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Diabetes & ramadan (2)
1. ALAA WAFA. MD
Associate Professor of Internal Medicine
PGDIP DM Cardiff University UK
Diabetes and Endocrine unit
Mansoura university
Diabetes and Ramadan
(Challenges and Recommendations)
2.
3. Blood glucose
Insulin and Glucagon Regulate Normal Glucose Homeostasis
Glucose output Glucose uptake
Glucagon (α cell)
Insulin
(β cell)
Pancreas
Liv
er
Muscle
Adipose
tissue
Fasting state Fed state
Porte D Jr, Kahn SE. Clin Invest Med. 1995;18:247–254.
Adapted with permission from Kahn CR, Saltiel AR. In: Kahn CR et al,
eds. Joslin’s Diabetes Mellitus. 14th ed. Lippincott Williams & Wilkins; 2005:145–168. 4
4. Islet dysfunction
Adapted from Buse JB et al. In Williams Textbook of Endocrinology. 10th ed. Philadelphia, Saunders, 2003:1427–1483; Buchanan TA Clin
Ther 2003;25(suppl B):B32–B46; Powers AC. In: Harrison’s Principles of Internal Medicine. 16th ed. New York: McGraw-Hill, 2005:2152–2180;
Rhodes CJ Science 2005;307:380–384.
The Pathophysiology of Type 2 Diabetes Includes
Multiple Defects
Pancreas
Insulin deficiency
Liver
Muscle & Fat
Excess
glucagon Diminished
insulin
Beta cell
produces
less insulin
Alpha cell
produces
excess
glucagon
Insulin resistance
(decreased glucose
uptake)
Excess Glucose
Output
HYPERGLYCEMI
A
6. The Core Defects in type 2 diabetes:
Insulin
resistance in
peripheral tissues
Excess Hepatic Glucose
Production
due to
1)increased glucagon
2)insulin insufficiency
3)insulin resistance
Insulin deficiency
due to insufficient
pancreatic insulin
release
12. Adapted from Riddle MC. Endocrinol Metab Clin North Am. 2005;34:77–98.
Diet and Exercise
Oral Monotherapy
Standard Approach to the Management
of T2DM: Treatment Intensification
Oral Combination +
+
Oral + Injectable
Incretin Mimetics
Oral + Insulin + +
Insulin
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23. Management of Hyperglycemia in
Type 2 Diabetes, 2015:
A Patient-Centered Approach
Update toa Position Statement of theAmericanDiabetesAssociation(ADA) and the
EuropeanAssociationfor the Study of Diabetes (EASD)
Diabetes Care 2015;38:140–149
Diabetologia 2015;58:429–442
24. Glycemic targets
- HbA1c < 7.0% (mean PG 150-160 mg/dl [8.3-8.9 mmol/l])
- Pre-prandial PG <130 mg/dl (7.2 mmol/l)
- Post-prandial PG <180 mg/dl (10.0 mmol/l)
- Individualization is key:
Tighter targets (6.0 - 6.5%) - younger, healthier
Looser targets (7.5 - 8.0%+) - older, comorbidities,
hypoglycemia prone, etc.
- Avoidance of hypoglycemia
PG = plasma glucose
ADA-EASD Position Statement Update:
Management of Hyperglycemia in T2DM, 2015
Diabetes Care 2012;35:1364–1379; Diabetologia 2012;55:1577–1596
Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
25. more
stringent
less
stringent
Patient attitude and
expected treatment efforts highly motivated, adherent,
excellent self-care capacities
less motivated, non-adherent,
poor self-care capacities
Risks potentially associated
with hypoglycemia and
other drug adverse effects
low high
Disease duration
newly diagnosed long-standing
Life expectancy
long short
Important comorbidities
absent severefew / mild
Established vascular
complications absent severefew / mild
Readily available limited
Usually not
modifiable
Potentially
modifiable
HbA1c
7%
PATIENT / DISEASE FEATURES
Approach to the management
of hyperglycemia
Resources and support
system
Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
Figure 1. Modulation of the
intensiveness of glucose
lowering therapy in T2DM
27. Oral Class Mechanism Advantages Disadvantages Cost
a-Glucosidase
inhibitors
• Inhibits a-glucosidase
• Slows carbohydrate
digestion / absorption
• No hypoglycemia
• Nonsystemic
• Postprandial glucose
• ? CVD events
• Gastrointestinal
• Dosing frequency
• Modest A1c
Mod.
DPP-4
inhibitors
• Inhibits DPP-4
• Increases incretin
(GLP-1, GIP) levels
• No hypoglycemia
• Well tolerated
• Angioedema /
urticaria
• ? Pancreatitis
• ? Heart failure
High
Bile acid
sequestrants
• Bind bile acids
• ? Hepatic glucose
production
• No hypoglycemia
• LDL-C
• Gastrointestinal
• Modest A1c
• Dosing frequency
High
Dopamine-2
agonists
• Activates DA receptor
• Alters hypothalamic
control of metabolism
• insulin sensitivity
• No hypoglyemia
• ? CVD events
• Modest A1c
• Dizziness, fatigue
• Nausea
• Rhinitis
High
SGLT2
inhibitors
• Inhibits SGLT2 in
proximal nephron
• Increases glucosuria
• Weight
• No hypoglycemia
• BP
• Effective at all stages
• GU infections
• Polyuria
• Volume depletion
• LDL-C
• Cr (transient)
High
Table 1. Properties of anti-hyperglycemic agents
Diabetes Care 2015;38:140-149;
Diabetologia 2015;10.1077/s00125-014-3460-0
28. Injectabl
e
Class
Mechanism Advantages Disadvantages Cost
Amylin
mimetics
• Activates amylin
receptor
• glucagon
• gastric emptying
• satiety
• Weight
• Postprandial glucose
• Gastrointestinal
• Modest A1c
• Injectable
• Hypo if insulin dose
not reduced
• Dosing frequency
• Training requirements
High
GLP-1
receptor
agonists
• Activates GLP-1 R
• Insulin, glucagon
• gastric emptying
• satiety
• Weight
• No hypoglycemia
• Postprandial glucose
• Some CV risk factors
• Gastrointestinal
• ? Pancreatitis
• Heart rate
• Medullary ca (rodents)
• Injectable
• Training requirements
High
Insulin • Activates insulin
receptor
• Myriad
• Universally effective
• Unlimited efficacy
• Microvascular risk
• Hypoglycemia
• Weight gain
• ? Mitogenicity
• Injectable
• Patient reluctance
• Training requirements
Variable
Table 1. Properties of anti-hyperglycemic agents
Diabetes Care 2015;38:140-149;
Diabetologia 2015;10.1077/s00125-014-3460-0
29. Healthy eating, weight control, increased physical activity & diabetes education
Metformin
high
low risk
neutral/loss
GI / lactic acidosis
low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
high
low risk
gain
edema, HF, fxs
low
Thiazolidine-
dione
intermediate
low risk
neutral
rare
high
DPP-4
inhibitor
highest
high risk
gain
hypoglycemia
variable
Insulin (basal)
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Basal Insulin +
Sulfonylurea
+
TZD
DPP-4-i
GLP-1-RA
Insulin§
or
or
or
or
Thiazolidine-
dione
+
SU
DPP-4-i
GLP-1-RA
Insulin§
TZD
DPP-4-ior
or
or GLP-1-RA
high
low risk
loss
GI
high
GLP-1 receptor
agonist
Sulfonylurea
high
moderate risk
gain
hypoglycemia
low
SGLT2
inhibitor
intermediate
low risk
loss
GU, dehydration
high
SU
TZD
Insulin§
GLP-1 receptor
agonist
+
SGLT-2
Inhibitor
+
SU
TZD
Insulin§
Metformin
+
Metformin
+
or
or
or
or
SGLT2-i
or
or
or
SGLT2-i
Mono-
therapy
Efficacy*
Hypo risk
Weight
Side effects
Costs
Dual
therapy†
Efficacy*
Hypo risk
Weight
Side effects
Costs
Triple
therapy
or
or
DPP-4
Inhibitor
+
SU
TZD
Insulin§
SGLT2-i
or
or
or
SGLT2-i
or
DPP-4-i
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add
basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin
+
Combination
injectable
therapy‡
GLP-1-RAMealtime Insulin
Insulin (basal)
+
Figure 2. Anti-hyperglycemic therapy
in T2DM: General recommendations Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
30. Healthy eating, weight control, increased physical activity & diabetes education
Metformin
high
low risk
neutral/loss
GI / lactic acidosis
low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
high
low risk
gain
edema, HF, fxs
low
Thiazolidine-
dione
intermediate
low risk
neutral
rare
high
DPP-4
inhibitor
highest
high risk
gain
hypoglycemia
variable
Insulin (basal)
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Basal Insulin +
Sulfonylurea
+
TZD
DPP-4-i
GLP-1-RA
Insulin§
or
or
or
or
Thiazolidine-
dione
+
SU
DPP-4-i
GLP-1-RA
Insulin§
TZD
DPP-4-ior
or
or GLP-1-RA
high
low risk
loss
GI
high
GLP-1 receptor
agonist
Sulfonylurea
high
moderate risk
gain
hypoglycemia
low
SGLT2
inhibitor
intermediate
low risk
loss
GU, dehydration
high
SU
TZD
Insulin§
GLP-1 receptor
agonist
+
SGLT-2
Inhibitor
+
SU
TZD
Insulin§
Metformin
+
Metformin
+
or
or
or
or
SGLT2-i
or
or
or
SGLT2-i
Mono-
therapy
Efficacy*
Hypo risk
Weight
Side effects
Costs
Dual
therapy†
Efficacy*
Hypo risk
Weight
Side effects
Costs
Triple
therapy
or
or
DPP-4
Inhibitor
+
SU
TZD
Insulin§
SGLT2-i
or
or
or
SGLT2-i
or
DPP-4-i
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add
basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin
+
Combination
injectable
therapy‡
GLP-1-RAMealtime Insulin
Insulin (basal)
+
Figure 2. Anti-hyperglycemic therapy
in T2DM: General recommendations Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
31. Healthy eating, weight control, increased physical activity & diabetes education
Metformin
high
low risk
neutral/loss
GI / lactic acidosis
low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
high
low risk
gain
edema, HF, fxs
low
Thiazolidine-
dione
intermediate
low risk
neutral
rare
high
DPP-4
inhibitor
highest
high risk
gain
hypoglycemia
variable
Insulin (basal)
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Basal Insulin +
Sulfonylurea
+
TZD
DPP-4-i
GLP-1-RA
Insulin§
or
or
or
or
Thiazolidine-
dione
+
SU
DPP-4-i
GLP-1-RA
Insulin§
TZD
DPP-4-ior
or
or GLP-1-RA
high
low risk
loss
GI
high
GLP-1 receptor
agonist
Sulfonylurea
high
moderate risk
gain
hypoglycemia
low
SGLT2
inhibitor
intermediate
low risk
loss
GU, dehydration
high
SU
TZD
Insulin§
GLP-1 receptor
agonist
+
SGLT-2
Inhibitor
+
SU
TZD
Insulin§
Metformin
+
Metformin
+
or
or
or
or
SGLT2-i
or
or
or
SGLT2-i
Mono-
therapy
Efficacy*
Hypo risk
Weight
Side effects
Costs
Dual
therapy†
Efficacy*
Hypo risk
Weight
Side effects
Costs
Triple
therapy
or
or
DPP-4
Inhibitor
+
SU
TZD
Insulin§
SGLT2-i
or
or
or
SGLT2-i
or
DPP-4-i
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add
basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin
+
Combination
injectable
therapy‡
GLP-1-RAMealtime Insulin
Insulin (basal)
+
Figure 2. Anti-hyperglycemic therapy
in T2DM: General recommendations Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
32. Healthy eating, weight control, increased physical activity & diabetes education
Metformin
high
low risk
neutral/loss
GI / lactic acidosis
low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
high
low risk
gain
edema, HF, fxs
low
Thiazolidine-
dione
intermediate
low risk
neutral
rare
high
DPP-4
inhibitor
highest
high risk
gain
hypoglycemia
variable
Insulin (basal)
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Basal Insulin +
Sulfonylurea
+
TZD
DPP-4-i
GLP-1-RA
Insulin§
or
or
or
or
Thiazolidine-
dione
+
SU
DPP-4-i
GLP-1-RA
Insulin§
TZD
DPP-4-ior
or
or GLP-1-RA
high
low risk
loss
GI
high
GLP-1 receptor
agonist
Sulfonylurea
high
moderate risk
gain
hypoglycemia
low
SGLT2
inhibitor
intermediate
low risk
loss
GU, dehydration
high
SU
TZD
Insulin§
GLP-1 receptor
agonist
+
SGLT-2
Inhibitor
+
SU
TZD
Insulin§
Metformin
+
Metformin
+
or
or
or
or
SGLT2-i
or
or
or
SGLT2-i
Mono-
therapy
Efficacy*
Hypo risk
Weight
Side effects
Costs
Dual
therapy†
Efficacy*
Hypo risk
Weight
Side effects
Costs
Triple
therapy
or
or
DPP-4
Inhibitor
+
SU
TZD
Insulin§
SGLT2-i
or
or
or
SGLT2-i
or
DPP-4-i
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add
basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin
+
Combination
injectable
therapy‡
GLP-1-RAMealtime Insulin
Insulin (basal)
+
Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
33. Healthy eating, weight control, increased physical activity & diabetes education
Metformin
high
low risk
neutral/loss
GI / lactic acidosis
low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
high
low risk
gain
edema, HF, fxs
low
Thiazolidine-
dione
intermediate
low risk
neutral
rare
high
DPP-4
inhibitor
highest
high risk
gain
hypoglycemia
variable
Insulin (basal)
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Basal Insulin +
Sulfonylurea
+
TZD
DPP-4-i
GLP-1-RA
Insulin§
or
or
or
or
Thiazolidine-
dione
+
SU
DPP-4-i
GLP-1-RA
Insulin§
TZD
DPP-4-ior
or
or GLP-1-RA
high
low risk
loss
GI
high
GLP-1 receptor
agonist
Sulfonylurea
high
moderate risk
gain
hypoglycemia
low
SGLT2
inhibitor
intermediate
low risk
loss
GU, dehydration
high
SU
TZD
Insulin§
GLP-1 receptor
agonist
+
SGLT-2
Inhibitor
+
SU
TZD
Insulin§
Metformin
+
Metformin
+
or
or
or
or
SGLT2-i
or
or
or
SGLT2-i
Mono-
therapy
Efficacy*
Hypo risk
Weight
Side effects
Costs
Dual
therapy†
Efficacy*
Hypo risk
Weight
Side effects
Costs
Triple
therapy
or
or
DPP-4
Inhibitor
+
SU
TZD
Insulin§
SGLT2-i
or
or
or
SGLT2-i
or
DPP-4-i
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add
basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin
+
Combination
injectable
therapy‡
GLP-1-RAMealtime Insulin
Insulin (basal)
+
Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
HbA1c
≥9%
Metformin
intolerance or
contraindication
Uncontrolled
hyperglycemia
(catabolic features,
BG ≥300-350 mg/dl,
HbA1c ≥10-12%)
34. Healthy eating, weight control, increased physical activity & diabetes education
Metformin
high
low risk
neutral/loss
GI / lactic acidosis
low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
high
low risk
gain
edema, HF, fxs
low
Thiazolidine-
dione
intermediate
low risk
neutral
rare
high
DPP-4
inhibitor
highest
high risk
gain
hypoglycemia
variable
Insulin (basal)
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Basal Insulin +
Sulfonylurea
+
TZD
DPP-4-i
GLP-1-RA
Insulin§
or
or
or
or
Thiazolidine-
dione
+
SU
DPP-4-i
GLP-1-RA
Insulin§
TZD
DPP-4-i
GLP-1-RA
high
low risk
loss
GI
high
GLP-1 receptor
agonist
Sulfonylurea
high
moderate risk
gain
hypoglycemia
low
SGLT2
inhibitor
intermediate
low risk
loss
GU, dehydration
high
SU
TZD
Insulin§
GLP-1 receptor
agonist
+
SGLT-2
Inhibitor
+
SU
TZD
Insulin§
Metformin
+
Metformin
+
or
or
or
or
SGLT2-i
or
or
or
SGLT2-i
Mono-
therapy
Efficacy*
Hypo risk
Weight
Side effects
Costs
Dual
therapy†
Efficacy*
Hypo risk
Weight
Side effects
Costs
Triple
therapy
or
or
DPP-4
Inhibitor
+
SU
TZD
Insulin§
SGLT2-i
or
or
or
SGLT2-i
or
DPP-4-i
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add
basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin
+
Combination
injectable
therapy‡
GLP-1-RAMealtime Insulin
Figure 2A. An -hyperglycemic
therapy in T2DM:
Avoidance of hypoglycemia
or
or
or
Insulin (basal)
+
Diabetes Care 2015;38:140-149; Diabetologia 2015;10.1077/s00125-014-3460-0
35. Healthy eating, weight control, increased physical activity & diabetes education
Metformin
high
low risk
neutral/loss
GI / lactic acidosis
low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
high
low risk
gain
edema, HF, fxs
low
Thiazolidine-
dione
intermediate
low risk
neutral
rare
high
DPP-4
inhibitor
highest
high risk
gain
hypoglycemia
variable
Insulin (basal)
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Basal Insulin +
Sulfonylurea
+
TZD
DPP-4-i
GLP-1-RA
Insulin§
or
or
or
or
Thiazolidine-
dione
+
SU
DPP-4-i
GLP-1-RA
Insulin§
TZD
DPP-4-i
GLP-1-RA
high
low risk
loss
GI
high
GLP-1 receptor
agonist
Sulfonylurea
high
moderate risk
gain
hypoglycemia
low
SGLT2
inhibitor
intermediate
low risk
loss
GU, dehydration
high
SU
TZD
Insulin§
GLP-1 receptor
agonist
+
SGLT-2
Inhibitor
+
SU
TZD
Insulin§
Metformin
+
Metformin
+
or
or
or
or
SGLT2-i
or
or
or
SGLT2-i
Mono-
therapy
Efficacy*
Hypo risk
Weight
Side effects
Costs
Dual
therapy†
Efficacy*
Hypo risk
Weight
Side effects
Costs
Triple
therapy
or
or
DPP-4
Inhibitor
+
SU
TZD
Insulin§
SGLT2-i
or
or
or
SGLT2-i
or
DPP-4-i
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add
basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin
+
Combination
injectable
therapy‡
GLP-1-RAMealtime Insulin
Insulin (basal)
+
or
or
or
Diabetes Care 2015;38:140-149; Diabetologia 2015;10.1077/s00125-014-3460-0
Figure 2B. An -hyperglycemic
therapy in T2DM:
Avoidance of weight gain
36. Healthy eating, weight control, increased physical activity & diabetes education
Metformin
high
low risk
neutral/loss
GI / lactic acidosis
low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
high
low risk
gain
edema, HF, fxs
low
Thiazolidine-
dione
intermediate
low risk
neutral
rare
high
DPP-4
inhibitor
highest
high risk
gain
hypoglycemia
variable
Insulin (basal)
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Basal Insulin +
Sulfonylurea
+
TZD
DPP-4-i
GLP-1-RA
Insulin§
or
or
or
or
Thiazolidine-
dione
+
SU
DPP-4-i
GLP-1-RA
Insulin§
TZD
DPP-4-ior
or
or GLP-1-RA
high
low risk
loss
GI
high
GLP-1 receptor
agonist
Sulfonylurea
high
moderate risk
gain
hypoglycemia
low
SGLT2
inhibitor
intermediate
low risk
loss
GU, dehydration
high
SU
TZD
Insulin§
GLP-1 receptor
agonist
+
SGLT-2
Inhibitor
+
SU
TZD
Insulin§
Metformin
+
Metformin
+
or
or
or
or
SGLT2-i
or
or
or
SGLT2-i
Mono-
therapy
Efficacy*
Hypo risk
Weight
Side effects
Costs
Dual
therapy†
Efficacy*
Hypo risk
Weight
Side effects
Costs
Triple
therapy
or
or
DPP-4
Inhibitor
+
SU
TZD
Insulin§
SGLT2-i
or
or
or
SGLT2-i
or
DPP-4-i
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add
basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin
+
Combination
injectable
therapy‡
GLP-1-RAMealtime Insulin
Insulin (basal)
+
Diabetes Care 2015;38:140-149; Diabetologia 2015;10.1077/s00125-014-3460-0
Figure 2C. An -hyperglycemic
therapy in T2DM:
Minimiza on of costs
37. • Start: 10U/day or 0.1-0.2 U/kg/day
• Adjust: 10-15% or 2-4 U once-twice weekly to
reach FBG target.
• For hypo: Determine & address cause;
ê dose by 4 units or 10-20%.
Basal Insulin
(usually with metformin +/-
other non-insulin agent)
Figure 3.
Approach
to starting
& adjusting
insulin in
T2DM
Diabetes Care 2015;38:140-149;
Diabetologia 2015;58:429-442
38. Add ≥2 rapid insulin* injections
before meals ('basal-bolus’†
)
Change to
premixed insulin* twice daily
Add 1 rapid insulin* injections
before largest meal
• Start: Divide current basal dose into 2/3 AM,
1/3 PM or 1/2 AM, 1/2 PM.
• Adjust: é dose by 1-2 U or 10-15% once-
twice weekly until SMBG target reached.
• For hypo: Determine and address cause;
ê corresponding dose by 2-4 U or 10-20%.
• Start: 10U/day or 0.1-0.2 U/kg/day
• Adjust: 10-15% or 2-4 U once-twice weekly to
reach FBG target.
• For hypo: Determine & address cause;
ê dose by 4 units or 10-20%.
Basal Insulin
(usually with metformin +/-
other non-insulin agent)
If not
controlled after
FBG target is reached
(or if dose > 0.5 U/kg/day),
treat PPG excursions with
meal-time insulin.
(Consider initial
GLP-1-RA
trial.)
If not
controlled,
consider basal-
bolus.
If not
controlled,
consider basal-
bolus.
• Start: 4U, 0.1 U/kg, or 10% basal dose. If
A1c<8%, consider ê basal by same amount.
• Adjust: é dose by 1-2 U or 10-15% once-
twice weekly until SMBG target reached.
• For hypo: Determine and address cause;
ê corresponding dose by 2-4 U or 10-20%.
• Start: 4U, 0.1 U/kg, or 10% basal dose/meal.‡
If
A1c<8%, consider ê basal by same amount.
• Adjust: é dose by 1-2 U or 10-15% once-twice
weekly to achieve SMBG target.
• For hypo: Determine and address cause;
ê corresponding dose by 2-4 U or 10-20%.
Figure 3.
Approach
to starting
& adjusting
insulin in
T2DM
Diabetes Care 2015;38:140-149;
Diabetologia 2015;58:429-442
39. Add ≥2 rapid insulin* injections
before meals ('basal-bolus’†
)
Change to
premixed insulin* twice daily
Add 1 rapid insulin* injections
before largest meal
• Start: Divide current basal dose into 2/3 AM,
1/3 PM or 1/2 AM, 1/2 PM.
• Adjust: é dose by 1-2 U or 10-15% once-
twice weekly until SMBG target reached.
• For hypo: Determine and address cause;
ê corresponding dose by 2-4 U or 10-20%.
• Start: 10U/day or 0.1-0.2 U/kg/day
• Adjust: 10-15% or 2-4 U once-twice weekly to
reach FBG target.
• For hypo: Determine & address cause;
ê dose by 4 units or 10-20%.
Basal Insulin
(usually with metformin +/-
other non-insulin agent)
If not
controlled after
FBG target is reached
(or if dose > 0.5 U/kg/day),
treat PPG excursions with
meal-time insulin.
(Consider initial
GLP-1-RA
trial.)
low
mod.
high
more flexible less flexible
Complexity
#
Injections
Flexibility
1
2
3+
If not
controlled,
consider basal-
bolus.
If not
controlled,
consider basal-
bolus.
• Start: 4U, 0.1 U/kg, or 10% basal dose. If
A1c<8%, consider ê basal by same amount.
• Adjust: é dose by 1-2 U or 10-15% once-
twice weekly until SMBG target reached.
• For hypo: Determine and address cause;
ê corresponding dose by 2-4 U or 10-20%.
• Start: 4U, 0.1 U/kg, or 10% basal dose/meal.‡
If
A1c<8%, consider ê basal by same amount.
• Adjust: é dose by 1-2 U or 10-15% once-twice
weekly to achieve SMBG target.
• For hypo: Determine and address cause;
ê corresponding dose by 2-4 U or 10-20%.
Figure 3.
Approach
to starting
& adjusting
insulin in
T2DM
Diabetes Care 2015;38:140-149;
Diabetologia 2015;58:429-442
41. ADA-EASD Position Statement Update:
Management of Hyperglycemia in T2DM, 2015
Long (Detemir)
Rapid (Lispro, Aspart, Glulisine)
Hours
Long (Glargine)
0 2 4 6 8 10 12 14 16 18 20 22 24
Short (Regular)
Hours after injection
Insulinlevel
(Degludec)
3. ANTI-HYPERGLYCEMIC THERAPY
• Therapeutic options: Insulins
42. Lifestyle changes plus metformin (± other agents)
Basal
Add basal insulin
Basal Plus
Add prandial insulin at main meal
Basal Bolus
Add prandial insulin before each meal
Progressive deterioration of -cell function
Basal Plus: once-daily basal insulin
plus once-daily* rapid-acting insulin
Matching treatment to disease progression using a
stepwise approach
*As the disease progresses, a second daily injection of glulisine may be added
Adapted from Raccah D, et al. Diabetes Metab Res Rev 2007;23:257–64
Proper Basal titration
Titrate insulin
43. Clinical challenge:
Selecting the appropriate treatment for your patient
Adapted from Nathan DM. N Engl J Med. 2007;356:437-40
and Nathan et al. Diabetes Care. 2009;32:193-203
0.5-1.01.5 1.5 1.0-1.5 0.5-1.0 0.8-1.0
≥2.5
Sulfonylureas
Biguanides
(metformin) Glinides
DPP-IV
inhibitors TZDs Insulin
0.0
0.5
1.0
1.5
2.0
2.5
3.0
HbA1creduction
(%)
Efficacy as
mono
therapy
Anti
diabetic
agents
GLP-1
agonist
s
Insulin is the most effective
glucose-lowering agent
46. 46
The Current decade…
Over the current decade, the number of
fasting hours will progressively increase
in the northern hemisphere as Ramadan
falls in the summer months.
This will have important implications for
Muslims with diabetes who wish to fast.
48. Ramadan Between Diabetes
and Fasting
Although the Koran exempts
sick people from the duty of
fasting, many Muslims with
diabetes may not perceive
themselves as sick and are
keen to fast.
43% of patients with type 1
and 86% of those with type 2
diabetes fasted during
Ramadan.
1-IBRAHIM SALTI, et al . Diabetes Care 27:2306–2311, 2004
2-E Hui et al , BMJ, 26 june 2010 , Volume 340
49. 49
During Ramadan about 60% of patients change
their antidiabetic drug intake:
35% stop treatment
8% change the dosage schedule
25% decrease the drug dose.
Importantly, this is done at the patients’
own initiative without medical supervision.
Salti I, Benard E, Detournay B et al. A population-based study of diabetes and its characteristics during the fasting
month of Ramadan in 13 countries. Diabetes Care 2004; 27: 2306–11.
Aslam M, Healey MA. Compliance and drug therapy in Moslem patients. J Clin Hosp Pharm 1986; 11: 321–5.
Aslam M, Assad A. Drug regimens and fasting during Ramadan: a survey in Kuwait. Public Health 1986; 100: 49–53.
50. The Risks of Fasting Include:
Hypoglycemia
Hyperglycemia
Diabetic ketoacidosis
Dehydration and thrombosis
M. al-Arouj et al, “Recommendations for management of diabetes during Ramadan,” Diabetes Care, 28(2005), 2305-2311.
51. 12,243 subjects, in 13 countries including Egypt 1
Almost 90% was T2DM
The important finding was:
5 folds Increase in severe hyperglycemia with Ketoacidosis that required
hospital admission
7.5 folds increase in the risk of severe hypoglycemia during Ramadan
2% Of fasting patients experienced at least one episode of sever hypoglycemia
requiring hospitalization
1-IBRAHIM SALTI, et al . Diabetes Care 27:2306–2311, 2004
2- E Hui et al , BMJ 2010;340:c3053;
52. Classification of hypoglycemia according to
severity: American Diabetes Association
1- Documented
symptomatic
hypoglycemia.
An event during which typical symptoms of hypoglycemia
are accompanied by a measured plasma glucose
concentration ≤ 70 mg/dl (3.9 mmol/l).
2- Asymptomatic
hypoglycemia.
An event not accompanied by typical symptoms of
hypoglycemia but with a measured plasma glucose
concentration ≤ 70 mg/dl (3.9 mmol/l).
3- Probable symptomatic
hypoglycemia.
An event during which symptoms of hypoglycemia are not
accompanied by a plasma glucose determination.
4- Relative
hypoglycemia.
An event during which the person with diabetes reports any
of the typical symptoms of hypoglycemia, and interprets
those as indicative of hypoglycemia, but with a measured
plasma glucose concentration >70 mg/dl (3.9 mmol/l).
5- Severe An event requiring assistance of another person to actively
administer carbohydrate, glucagons, or other resuscitative
actions.
52
American Diabetes Association Workgroup on Hypoglycemia. Defining and Reporting Hypoglycemia in Diabetes. Diabetes Care . 2005;28 (5):1245–
1249.This material can only be shown reactively to answer specific questions from physicians.
53. Hypoglycemic Events Increased
by 84% During Ramadan
Significant increasing in hypoglycemic events during Ramadan
mainly with patients >60 years old
Fatima J et al , Indian J Endocrinol Metab. 2012 Mar;16(2):323-4.
164
NumberofHypoglycemicevents
302
147
N= 179
84%
55. Health and economical consequences of hypoglycemia
55
This material can only be shown reactively to answer specific questions from physicians.
Hypoglycemia
CV complications2
Weight gain by defensive eating3
Coma2
Car accident4
Hospitalization costs1
Dizzy turn unconsciousness2
Seizures2
Death6
Increased risk of dementia5
Quality of Life7
1. Jönsson L, et al. Cost of Hypoglycemia in Patients with Type 2 Diabetes in Sweden. Value In Health. 2006;9:193–198
2. Barnett AH. CMRO. 2010;26:1333–1342
3. Foley J & Jordan. J. Vasc Health Risk Manag. 2010;6:541–548
4. Canadian Diabetes Association’s Clinical Practice Guidelines for Diabetes and Private and Commercial Driving. CanJ Diabetes. 2003;27(2):128 –140.
5. Whitmer RA, et al. JAMA. 2009;301:15655–1572
6. Zammitt NN, et al. Diabetes Care. 2005;28:2948–2961
7. McEwan P, et al. Diabetes Obes Metab. 2010;12:431–436
56. Hypoglycemia and Treatment
Adherence
Patients’ reports of
hypoglycemic symptoms
are associated with
significantly lower
treatment satisfaction and
with barriers to adherence.
Alvarez Guisasola F, et al. Diabetes Obes Metab. 2008 Jun;10 Suppl 1:25-32.
57. Diabetic Ketoacidosis
Patients with type 1 diabetes and severe insulin deficiency may have
excessive glycogenolysis, gluconeogenesis and ketogenesis. All of
this may lead to hyperglycemia and ketoacidosis that may be life-
threatening.
Karamat et al, J R Soc Med 2010: 103: 139–147.
64. Dehydration and Thrombosis
Limitation of
fluid intake
Hot and
humid
climates
Hard physical
labor
Excessive
perspiration.
Hyperglycemia
•Osmotic
diuresis
&
•Volume and
electrolyte
depletion.
Adapted from : M. al-Arouj et al, “Recommendations for management of diabetes during Ramadan,” Diabetes Care,
65. Dehydration and Thrombosis
• Patients with diabetes exhibit a hypercoagulable state
due to an increase in clotting factors, a decrease in
endogenous anticoagulants, and impaired fibrinolysis.
• Increased blood viscosity secondary to dehydration may
enhance the risk of thrombosis.
• A report from Saudi Arabia suggested an increased
incidence of retinal vein occlusion in patients who fasted
during Ramadan
M. al-Arouj et al, “Recommendations for management of diabetes during Ramadan,” Diabetes Care, 28(2005),
66. Patients who insist on fasting need to
be aware of the associated risks and
be ready to adhere to the
recommendations of their health care
providers to achieve a safer fasting
experience.
Al-Arouj M, et al. Diabetes Care. 2005;28(9):2305-11.
For Safer Fasting
69. High
Moderate
Low risk of
adverse events
Categories of risks for patients
fasting Ramadan
E Hui et al , BMJ 2010;340:c3053; Al-Arouj M. et al, Recommendations for management of diabetes during Ramadan. Diabetes Care. 2010;33: 1895-
70. High
Moderate
Low risk of
adverse events
•Poor glycemic control, Severe and recurrent
episodes of hypoglycemia.
• Experience ketoacidosis three months
before Ramadan.
• Elderly and Pregnant women
• Advanced complications
• Well controlled patients treated with short
acting insulin secretogogue,
sulphonylurea, insulin, or taking
combination oral or oral plus insulin
• Well controlled patients treated with
Metformin, Dipeptidyl peptidase-4
inhibitors, or thiazolidinediones who are
otherwise healthy
E Hui et al , BMJ 2010;340:c3053; Al-Arouj M. et al, Recommendations for management of diabetes during Ramadan. Diabetes Care. 2010;33: 1895-1902.
Categories of risks for patients fasting
Ramadan
71. Diabetic patients at risks during fasting:
Acute Peptic Ulcer
Pulmonary Tuberculosis
Bronchial Asthma
Cancer
Diabetes –Type 1 and 2
who have poor glycemic control (HbA1c >12%), non compliant with diet or
drug/oral regimes, four OR more episodes of hypoglycemia AND/OR
hyperglycemia during preceding month, on 2 and MORE insulin injection/day.
ESRD
Cardiovascular disease
Psychiatry
Liver disorder, hepatic dysfunction where the liver enzyme is >> 2 x Upper
Normal Limit.
Intercurrent infections
73. Management of Diabetic Patients
During Ramadan
Patients Education
T2DM Pharmaceutical
Management in
Ramadan
74. Four key areas in Ramadan
focused education
1-Meal planning and dietary advice
2-Exercise
3-Blood glucose monitoring
4-Recognizing and managing
complications
E Hui et al , BMJ 2010;340:c3053;
75. Breaking the Fast
All patients must always and immediately end their
fast if:
1. Hypoglycaemia (blood glucose of <60mg/dl).
2. Blood glucose reaches <70 mg in the first few
hours after the start of the fast, especially if insulin,
sulfonylurea drugs, or neglitinide are taken at predawn.
3. Blood glucose exceeds 300 mg with symptoms of
hyperglycaemia.
Recommendations for Diabetic Individuals during Ramadan, Diabetes Care , vol 33, num. 8, August2010
76. Oral hypoglycaemic agents
Short acting
insulin Sus
Take twice
daily at suhur
and iftar
TZDs
No treatment adjustment
required 2–4 weeks to
exert substantial
antihyperglycemic
effects
DPP4 inhibitors
The best tolerated
drugs,
Consider DPP4i if
the risk of
hypoglycemia is high.
SUs
. Consider dose adjustment.
Metformin
Modify timing
of doses:
• Two thirds of
dose at iftar
• One third at
suhur.
T2DM Pharmaceutical
Management in Ramadan
E Hui et al , BMJ 2010;340:c3053; Al-Arouj M. et al, Recommendations for management of diabetes during Ramadan. Diabetes Care. 2010;33: 1895-
1902.
82. 82
Time of day
20
40
60
80
100
B L D
Split-Mixed Regimen
Human Insulins
B=breakfast; L=lunch; D=dinner
0600 06000800 18001200 2400
NPH
Regular
NPH
Regular
Normal pattern
U/mL
84. 84
Time of day
20
40
60
80
100
B L D
Multiple Daily Injections MDI
Human Insulins
B=breakfast; L=lunch; D=dinner
0600 06000800 18001200 2400
Regular NPH
NPH
Regular
Normal pattern
U/mL
Regular
85. 85
0600 0800 18001200 2400 0600
Time of day
20
40
60
80
100
B L D
Basal-Bolus Insulin Treatment
With Insulin Analogues
B=breakfast; L=lunch; D=dinner
Glargine/ detemir
Lispro, glulisine, or aspart
Normal pattern
U/mL
86. 86
Recommendations for Management of Diabetes
During Ramadan for Patients on Insulin
The major objective of insulin therapy during
Ramadan is to provide adequate insulin to prevent
the post meal hyperglycemia and also prevent
hypoglycemia during the period of fasting
The choice of insulin therapy is decided by the
previous therapy that the patient is taking and also
the blood glucose profiles.
Ensure adequate fluid intake
89. 89
Plasmainsulin(µU/ml)
Aly A. Abdel-Rahim.
4:00
25
50
8:00 12:00 16:00 20:00 24:00 4:00
Time
8:00
Oral agents
Can NPH be used in Ramadan
•Peak at a time which is not needed. NPH at breakfast
•Will not cover breakfast.
•Poor coverage of day time
91. 91
Plasmainsulin(µU/ml)
Aly A. Abdel-Rahim.
4:00 8:00 12:00 16:00 20:00 24:00 4:00
Time
8:00
Can peakless insulin replace NPH in Ramadan ??
•No peak, no hypoglycaemia.
•Control meals with oral
•Free time of injection
50
Oral agents
25
basal
insulin
93. 93
4:00
25
50
75
8:00 12:00 16:00 18:00 22:00 4:0
0
PlasmaInsulinµU/ml)
Time
8:0
0
One peakless Insulin + One Oral
OAD e.g DPP-4inhibitors Glargine
Detemir
8-12PM
•No Peak
•No Hypoglycemia
•Control Iftar meal with OAD
94. 94
Plasmainsulin(µU/ml)
Aly A. Abdel-Rahim.
4:00
50
25
8:00 12:00 16:00 20:00 24:00 4:00
Time
8:00
Peakless insulin+ premeal short acting oral
secretagogue
•Glinides offers ideal combination
•Similar to intensive insulin therapy
when there is beta cell reserve
•Adjust the dose according to the time
and size of meal
Short acting secretagogues basal insulin
8-12 pm
95. 95
Plasmainsulin(µU/ml)
Aly A. Abdel-Rahim.
4:00
25
50
8:00 12:00 16:00 20:00 24:00 4:00
Time
8:00
Short acting
Oral agents
Once daily premixed in Ramadan:
once daily+ oral
•50/50 is better to control breakgast.
•Short acting secretagogues additional
control on sohour
•Not suitable for exhausted beta cells
100. 100100
Ensure adequate fluid intake.
70/30 premixed insulin twice daily, e.g., 30 units
in morning and 20 units in evening……
In Ramadan,,,,,Use the usual morning dose
at the sunset meal (Iftar) and half the usual
evening dose at predawn (Suhur), e.g., 70/30
premixed insulin, 30 units at Iftar and 10 units at
suhur.
Diabetes Care
September 2005 , pages 2305-11
Premixed insulin :
101. 101
Premixed insulins
Mix insulin 50/50 at iftar instead of Mix30
reduced postprandial glucose excursions
and reduced hypoglycemia
Consider changing premixed insulin
preparations to glargine or detemir plus
lispro or aspart .
Mattoo V, Diabetes Res Clin Pract 2003;59:137-43
102. 102
Time of day
20
40
60
80
100
B L D
Multiple Daily Injections MDI
Human Insulins
B=breakfast; L=lunch; D=dinner
0600 06000800 18001200 2400
Regular NPH
NPH
Regular
Normal pattern
U/mL
Regular
104. 104104
MOST patients will require short-acting
insulin administered in combination
with the intermediate, or long-acting
insulin at the sunset meal to cover
the large caloric load of Iftar & an
additional dose of short-acting insulin
at predawn.
1. ADA. Diabetes Care 2006;29(suppl 1):S4–S42.
105. 105
Patients on Basal insulin analogue
glargine or detemir
It is advised that patients who take long
acting basal insulin, such as glargine, to
reduce the dose by 20% to avoid
hypoglycemia.
Continue taking the same doses of
repaglinide or short acting insulin
108. 108Aly A. Abdel-Rahim.
Patient education regarding fasting during the
holy month of Ramadan is badly needed.
Diabetic patients with established renal disease
are high-risk category.
Fasting for prolonged periods, especially in hot
climates, may impose negative impacts on renal
function from hypovolemia and dehydration.
The mainstay of management of those patients is
targeted toward arresting the progression of their
underlying renal disease, and fasting during
Ramadan should not be recommended.
110. 110
Remember
Careful use of intermediate- or long-acting
insulin preparations plus a short-acting
insulin administered before meals would be
an effective strategy.
Adjustment to treatment necessary: e.g.
Reduce the dose of Basal insulin by 20%
Use Mix 50 in the evening instead of Mix 30
to avoid post prandial hyperglycemia
Diabetes Care 28.9 (Sept 2005): p2305(7).
112. 112
Some Parting Thoughts
“Fasting is for Me and I (Allah) only will
reward it” (Hadith Qudsi)
“While fasting , if one does not give up
falsehood in words and actions , then
Allah has no need of him giving up food
and drink (saying of Prophet
Muhammad-pbuh)”
HAVE A BLESSED RAMADAN
113. How to Help Patients Fast Safely ??
Patient Education Program.
Individualization of anti diabetic drugs
Select more safe drugs.
Adjust dose if needed
Ensure good non – sugar fluid intake.
Avoid heavy physical exercise at afternoon.
Ensure good calorie distribution.
Summary