ramadan fasting for patients prof. mohamad s. al-hadramy professor of medicine/consultant prof....

RAMADAN FASTING FOR PATIENTS

RAMADAN FASTING FOR PATIENTS

Prof. Mohamad S. Al-HadramyProfessor of

Medicine/Consultant

Prof. Mohamad S. Al-HadramyProfessor of

Medicine/Consultant

Ramadan Fasting for Patients

Ramadan Fasting for Patients

• A young medical student has a viral upper respiratory tract infection. His temperature was 38.9oC. Congested throat. Chest: clear. Day 1 Ramadan. What is your advice?

• A young medical student has a viral upper respiratory tract infection. His temperature was 38.9oC. Congested throat. Chest: clear. Day 1 Ramadan. What is your advice?

• Generally, patients are dispensed from fasting. The illness is the intense one that increases by fasting, or recovery is delayed. Ahmad Bin Hanbal was asked, when is the patient dispensed from fasting. “If he could not” he answered. They asked: fever, for example?. He answered: “What disease is more severe than fever?”.

• Generally, patients are dispensed from fasting. The illness is the intense one that increases by fasting, or recovery is delayed. Ahmad Bin Hanbal was asked, when is the patient dispensed from fasting. “If he could not” he answered. They asked: fever, for example?. He answered: “What disease is more severe than fever?”. Ibn Godamah. Al-Maghny

Al-Torky & Al-Helo. eds, 1408,4:403-4

1. Patients who are not harmed by fasting, and their recovery is not delayed (e.g., Type 2 DM, controlled by diet. Such patients are advised to fast.

1. Patients who are not harmed by fasting, and their recovery is not delayed (e.g., Type 2 DM, controlled by diet. Such patients are advised to fast.

Three (3) categories of patients in fasting:Three (3) categories of patients in fasting:

2. Patients who are harmed by fasting or their treatment cannot be given with fasting (e.g., IDDM pregnant lady, acute MI, advanced liver failure).

2. Patients who are harmed by fasting or their treatment cannot be given with fasting (e.g., IDDM pregnant lady, acute MI, advanced liver failure).

Three (3) categories (cont.):Three (3) categories (cont.):

3. Patients who are not harmed by fasting but their treatment could be adjusted for proper control (e.g., hypertension, epilepsy, OA).

3. Patients who are not harmed by fasting but their treatment could be adjusted for proper control (e.g., hypertension, epilepsy, OA).

Three (3) categories (cont.):Three (3) categories (cont.):

Ibn Othaymeen:

The spray used for asthma does not reach the stomach and there is no harm from using it during fasting

Ibn Othaymeen:

The spray used for asthma does not reach the stomach and there is no harm from using it during fasting

Asthma:Asthma:

Now, we have long acting inhalers (e.g., Salmetrol which could be used after sunset and before dawn.

Now, we have long acting inhalers (e.g., Salmetrol which could be used after sunset and before dawn.

Asthma (cont.):Asthma (cont.):

A 40-year-old smoker with dyspepsia. Upper GI endoscopy showed duodenal ulcer, 10 days before Ramadan. What is your advice?

A 40-year-old smoker with dyspepsia. Upper GI endoscopy showed duodenal ulcer, 10 days before Ramadan. What is your advice?

Fifty-seven (57) patients with acute duodenal ulcer. All received Lansoprazole 30 mg per day. Randomized to fasting or dispension. Endoscopy performed at end of Ramadan. Symptoms were not different. Healing rate: Fasting 90%, dispension 88.8%. Patients on Lansoprazole may fast with any risk.

Fifty-seven (57) patients with acute duodenal ulcer. All received Lansoprazole 30 mg per day. Randomized to fasting or dispension. Endoscopy performed at end of Ramadan. Symptoms were not different. Healing rate: Fasting 90%, dispension 88.8%. Patients on Lansoprazole may fast with any risk.

A study from TunisiaA study from Tunisia

Mehdi A, Ajmi S. Gastyroenterol Clin Biol 1997, (11):820-2

A 60-year-old male with long- standing hypetension who was on irregular treatment. He was on Metoprolol 50 mg BD, Frusemide 40 mg QD, Diltiazem 90 mg BD. His serum creatinine was 500 umol/L, Na 131, K 4.5. He wants to fast Ramadan. What is your advice?

A 60-year-old male with long- standing hypetension who was on irregular treatment. He was on Metoprolol 50 mg BD, Frusemide 40 mg QD, Diltiazem 90 mg BD. His serum creatinine was 500 umol/L, Na 131, K 4.5. He wants to fast Ramadan. What is your advice?

Thirty-six (36) patients with moderate to severe chronic renal failure, Creatinine >3 mg/dl; Clearance <35 ml/min

Thirty-six (36) patients with moderate to severe chronic renal failure, Creatinine >3 mg/dl; Clearance <35 ml/min

Al-Muhanna

Saudi Medical J 1998; 19:319-21

Comparison of BUN, S. Creatinine, S. Uric Acid and Caclculated Creatinine Clearance Pre, During and Post Ramadan

Comparison of BUN, S. Creatinine, S. Uric Acid and Caclculated Creatinine Clearance Pre, During and Post Ramadan

BUN (mmol/l)

S. Creatinine

(umol/l)

S. Uric Acid (umol/l)

Calculated Creatinine Clearance

(ml/m)

Pre-Ramadan

21.57 ± 2.35

550 ± 143 0.45 ± 0.03 17.2 ± 3.5

Mid-Ramadan

25.85 ± 2.64

638 ± 198 0.5 ± 0.022 14.7 ± 2.5

End Ramadan

29.7 ± 2.8 737 ± 110 0.53 ± 0.022

13.2 ± 2.2

Past Ramadan

28.37 ± 3.39

726 ± 132 0.52 ± 0.033

13.7 ± 3.2

During Ramadan, fasting patients with significant renal failure need close monitoring to offer appropriate advice.

During Ramadan, fasting patients with significant renal failure need close monitoring to offer appropriate advice.

Conclusion:Conclusion:

11 transplant recipientsNo adverse effect from fasting on alograft. K↑ during fasting.

11 transplant recipientsNo adverse effect from fasting on alograft. K↑ during fasting.

Renal transplant:Renal transplant:

Barneih, B. O. et al

Saudi K Kidney Dis Transplant 1994; 5:470-473

Forty-three (43) transplant recipients with stable renal function. Concentration of urine similar to healthy.

Forty-three (43) transplant recipients with stable renal function. Concentration of urine similar to healthy.

Renal transplant (cont.):Renal transplant (cont.):

Rashed Atl, et al.Lancet 1989, 1:1396

Cyclosporin can be taken during Ramadan at Sahoor and Fatoor.

Cyclosporin can be taken during Ramadan at Sahoor and Fatoor.

Badrah HM, et al

Saudi Kidney Dis Transplant Bull 1993, 4:596

Haemodialysis breaks fasting.Haemodialysis breaks fasting.

Fatwa No. 9944

Ibn Baz Chairman

Fatwa, Volume 10, p. 19

One-hundred six (106) patients fasting three hundred nine (309) Ramadan month, on anticoagulant; one hundred eighty-three (183) did not fast in five hundred ninety-four (594) Ramadan months. Incidence of thromboembolic events and haemorrhagic complications were not statistically significant between the two groups.

One-hundred six (106) patients fasting three hundred nine (309) Ramadan month, on anticoagulant; one hundred eighty-three (183) did not fast in five hundred ninety-four (594) Ramadan months. Incidence of thromboembolic events and haemorrhagic complications were not statistically significant between the two groups.

Saur J. N. et al.

Annals of Saudi Medicine 1989, (4):538-40

No significant differences in platelets aggregation responses between Ramadan and the non-fasting period.

No significant differences in platelets aggregation responses between Ramadan and the non-fasting period.

Kordy, M. et al

Annals of Saudi Medicine 1991, (11):23-7

Case 1:Case 1:A 55-year-old diabetic for 15 years is seen

before Sha’aban. She has polyuria and parasthesia in her feet. She has no retinopathy. She is on Glibenclamide 10 mg AM, 5 mg PM, Metformin 500 mg TDS, Atorvastatin 10 mg, and Corenitec 20/12/5 QD, Aspirin 100 mg QD. Her weight is 90 kgs. Height 155 cms. Bp 124/76 mmHg. She has diminished pain sense in her feet.

FBS 220 mg %, HbA1C – 9; LDL Cholesterol – 98 mg/dl; CPK, SGPT: normal.

A 55-year-old diabetic for 15 years is seen before Sha’aban. She has polyuria and parasthesia in her feet. She has no retinopathy. She is on Glibenclamide 10 mg AM, 5 mg PM, Metformin 500 mg TDS, Atorvastatin 10 mg, and Corenitec 20/12/5 QD, Aspirin 100 mg QD. Her weight is 90 kgs. Height 155 cms. Bp 124/76 mmHg. She has diminished pain sense in her feet.

FBS 220 mg %, HbA1C – 9; LDL Cholesterol – 98 mg/dl; CPK, SGPT: normal.

Case 1: (cont.)Case 1: (cont.)

A. What other investigations would you consider before advising her for Ramadan fasting?

B. What is your advice for her for Ramadan?

C. What is your advice for Omrah?

A. What other investigations would you consider before advising her for Ramadan fasting?

B. What is your advice for her for Ramadan?

C. What is your advice for Omrah?

No fasting for:Brittle DM:Poorly controlledSerious comorbidity (e.g., MI,

stroke)History of DKAPregnancySevere intercurrent infection (e.g.,

pneumonia)

No fasting for:Brittle DM:Poorly controlledSerious comorbidity (e.g., MI,

stroke)History of DKAPregnancySevere intercurrent infection (e.g.,

pneumonia)

No skipping of meals

Regimen of treatment

No gorging after Maghreb

No skipping of meals

Regimen of treatment

No gorging after Maghreb

Adjust dietAdjust treatment (e.g., change to

short actingExercise. When?Recognize hypo, dehydration

Adjust dietAdjust treatment (e.g., change to

short actingExercise. When?Recognize hypo, dehydration

Exercise:

Fasting does not interfere with exercise capacity

Exercise causes no harm in NIDDM

Exercise:

Fasting does not interfere with exercise capacity

Exercise causes no harm in NIDDM

Insulin:

1. R maghreb and Sahour, NPH late evening

2. R N of breakfast at Maghreb + R before dawn 0.1 – 0.2 u/kg

Insulin:

1. R maghreb and Sahour, NPH late evening

2. R N of breakfast at Maghreb + R before dawn 0.1 – 0.2 u/kg

Home glucose monitoring

PP, before Sahour and sunset

Urine ketone, weight for increase diet / decrease dehydration

Home glucose monitoring

PP, before Sahour and sunset

Urine ketone, weight for increase diet / decrease dehydration

Tabs: BMJ: switch dose of

glibenclamide

Tabs: BMJ: switch dose of

glibenclamide

RepaglinideMafauzy, Malaysia235 patientsRepag TDS versus Glibenclamide

QD or BD 6/52 before and repa in Rama 2

In Ramadan fructosamine decrease with Repag

HbA1C NO CHANGEHypo mid day < with Repag

RepaglinideMafauzy, Malaysia235 patientsRepag TDS versus Glibenclamide

QD or BD 6/52 before and repa in Rama 2

In Ramadan fructosamine decrease with Repag

HbA1C NO CHANGEHypo mid day < with Repag

LISPROLISPRO

Kadiri et al, Diab Metab 2001; 27:482-6MoroccoType 1-64 pts: BD NPH + Lispro or regular

for 2/52 each, open label, randomised, crossover. Monitoring for 3 days at end of each cycle.

2 H after Maghreb better. Doses similar compliance with time of injection better with Lispro.

Hypo Lispro 23 %, regular 48%Episodes: Lispro 0.7, Reg 2.25

episodes/pt/30 daysGlycemic control improved and hypo sig

Decreased with Lispro

Kadiri et al, Diab Metab 2001; 27:482-6MoroccoType 1-64 pts: BD NPH + Lispro or regular

for 2/52 each, open label, randomised, crossover. Monitoring for 3 days at end of each cycle.

2 H after Maghreb better. Doses similar compliance with time of injection better with Lispro.

Hypo Lispro 23 %, regular 48%Episodes: Lispro 0.7, Reg 2.25

episodes/pt/30 daysGlycemic control improved and hypo sig

Decreased with Lispro

LISPROLISPRO

Akram Diab Med 1999; 16:861-6PakistanType 2 – 70 patients:Open Label, randomized crossoverRegular versus LisproPatient self reported hypo. Glucose, FBS,

1 h, 2hpp on 3 days at end of periodResults: Before sunrise and after sunset

were similar. Rise after meal with Lispro was less. Hypo for Lispro 1.3, for regular 2.6 per patient over 14 days. Most hypos in day

Insulin Lispro may be more suitable

Akram Diab Med 1999; 16:861-6PakistanType 2 – 70 patients:Open Label, randomized crossoverRegular versus LisproPatient self reported hypo. Glucose, FBS,

1 h, 2hpp on 3 days at end of periodResults: Before sunrise and after sunset

were similar. Rise after meal with Lispro was less. Hypo for Lispro 1.3, for regular 2.6 per patient over 14 days. Most hypos in day

Insulin Lispro may be more suitable

Case 2:Case 2:

A 28-year-old married lady with type 1 DM is counseled for fasting. She has one child and she plans to have pregnancy. She is on Mixtard 70/30 36 units AM and 14 units PM. She exercises regularly and is sticking to her diet. Physical examination is negative. Sugar profile 99, 112, 116 and 102 mg%. U/Es, LFT, lipid profile, urine analysis are negative.

A. What would you tell her?

A 28-year-old married lady with type 1 DM is counseled for fasting. She has one child and she plans to have pregnancy. She is on Mixtard 70/30 36 units AM and 14 units PM. She exercises regularly and is sticking to her diet. Physical examination is negative. Sugar profile 99, 112, 116 and 102 mg%. U/Es, LFT, lipid profile, urine analysis are negative.

A. What would you tell her?