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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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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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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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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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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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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2.2 22
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2.3 23
Nutrition IS A CHALLENGE
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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
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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
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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
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