Modern Medicine

Full text

M
07
CM
E
M
ODE
R
N
E
D
ICI
N
E
MIDDLE
E
AS
T
Like our
page
Modern
M
edicine
VOLUME
31 |
NUMBER
07 |
JULY
2014
CONTINUING MEDICAL
EDUCATION
Calf Vein
T
hr
ombosis
and
Superficial
V
enous
T
hr
ombosis
Advice on
M
anagemen
t
V
enous
thrombotic problems are common in
clinical
prac
tice
,
and
management
guidelines
for DVT
and pulmonary embolism are well
established
.
IN THE MEDICINE
Expert
Opinion
For
I
nsulin
Use
During
R
amadan
T
he
largest dataset, the
EPIDIAR
study
,
showed that fasting
dur
ing
R
amadan
increased the
r
isk
of
severe
hypoglycemia
4.7-f
old
in
patients
with type 1 diabetes and
7.5-fold
in patients with type 2
diabet
es
.
L
ong-t
erm
Daily Multivitamin
Supplement
U
se
Decreases
Cataract Risk
in
Men,
Study
F
inds
A
study of
nearly 15,000
male
ph
ysicians
.
MIDDLE EAST REVIEW
T
he
Safety and
E
fficac
y of
I
nsulin
Glargine
in
the
Management of
T
ype
1 Diabetes in
Muslim
P
a
tien
ts
during
R
amadan
in Saudi
A
r
abia
R
amadan
is the month of fast
for
Moslems w
orldwide
.
T
he
fast is
between dawn and sunset
daily for
the whole
month.
JOURNAL DIGESTS FROM
REUTERS
HEALTH
Exposure To
Smoke
I
n
Cars
May
Worsen
Asthma:
Study |
L
o
w
A
dult
Supervision
T
ied
To
I
njur
ies
Among
K
ids
| Most Doctors
W
ouldn
’
t
Want
I
nt
ensiv
e
Care
At
T
he
End
Of
Lif
e
...and
mor
e
CME Answers for the month of
May 2014
|
2014

THE MULTIDISCIPLINARY PEER-REVIEWED CONTINUING MEDICAL EDUCATION
JOURNAL

MIDDLE EAST
RE
VIE
W
MIDDLE EAST
RE
VIE
W
Modern Medicine
|
V
olume
31
|
July
2014
| 31
31
|
July 2014
|
V
olume
31
|
Modern
Medicine
ABSTR
A
C
T
OBJEC
TIVE
To
determine the
safety
and
efficacy
of glargine
insulin
in patients with
t
ype
1 diabetes
per
f
or
ming
religious
fast during
R
amadan
in
Saudi
Arabia.
ME
THODS
We studied 21 patients with type 1 diabetes who
per
f
or
med
the
religious fast during
R
amadan
in Saudi
Arabia. This
was an open
label
,
obser
vational
(prospective cohort)
study
.
T
he
patients were already on
multiple
daily
injec- tions of
insulin
with glargine as their basal
insulin.
T
he
dose of glargine was
originally
reduced by
10%.
We further adjusted this
dose during
R
amadan
to achieve an optimal fasting glucose reading at
sunset, while
still
avoiding daytime hypoglycemia
(
dur
ing the
fast). All
the
patients were observed
f
or
hypoglycemic
e
v
ents
.
HbA1c
and fructosamine
levels were assessed
bef
or
e
R
amadan,
at the end of
R
amadan,
and
3-6
months after
R
amadan.
RESUL
T
S
T
he
patients were able to
successfully
fast
for
an average of 28 out of 29
attempted
days of
fast.
T
he
number of hypoglycemic events however was
higher during
R
amadan,
both during the fasting and the
f
ed
hours
,
as
com
-
pared to the post
R
amadan
per
iod
.
C
ONCL
USION
Adult
patients with type 1 diabetes on multiple
daily injections of
insulin,
with
glargine
as their long-acting
analogue
,
and with stable metabolic
contr
ol
,
may be able to fast
safely
during
R
amadan
(with the duration of
M.
O .
AL-
D
AKER
Endocr
in ologi st at
K
in g
Abdulaziz
Medical City
in
R
iyadh
ALI
A
.
AL-
Q
ARNI
Endocr
in ologi st at
K
in g
Abdulaziz
Hospital in
Al-Ahsa
and
K
ing Abdullah
I
nt
ernational Medical
R
esear
ch
C
ent
er
,
K
in
g
Saud
Bin
Ab
d
u
l
az
iz
University
f
o
r
Healt h
S
ci
e
n
c
e
s
,
K
A
I
MR
C
,
K
S
A
U
-
H
S
,
Riyadh, Saudi
Arabia.
SALEH AL-
JASSER
Endocr
in ologi st at
K
in g
Abdulaziz
Medical City
in
R
iyadh
REEM
M AL-AMOUDI
E
nd
o
cr
i
no
lo
g
is
t
at
I
ma
m
A
b
du
l
ra
h
ma
n
Bin Faisal Hospital
in
Dammam
SALEM SUWAIDAN, PharmD
Clinical P
h
a
r
m
a
c
i
s
t
/
C
oo
r
d
i
n
a
t
o
r
a
t
K
i
ng
Abdulaziz
Medical City in
R
iy
ad
h
an d
K
ing
Ab du lla h
I
nt
er
na ti ona l
Medical
R
esear
ch
C
ent
er
,
K
ing Saud Bin
Abdulaziz University for
Health
S
ciences
,
KAIMRC, KSAU-HS,
Riyadh, Saudi
Arabia.
ABDUL
SALAM
Statistician at
K
ing
Abdulaziz
Hospital in
Al-
Ahsa
B
ADR
AL-MU
T AIR
Diabet
es
E
ducat
or
at
K
ing Abdulaziz
Medical City
in
R
iyadh
SABAH A. AL-
SHUWISH
Diab etes
E
ducat
or
at
K
ing
Abdu laziz
Hospital
in
Al-
Ahsa
REHAB
R
.
AL-HA
M
AD
Diabet
es
E
ducat
or
at
K
ing Abdulaziz
Hospital
in
Al-
Ahsa

MIDDLE EAST
RE
VIE
W
MIDDLE EAST
RE
VIE
W
Modern Medicine
|
V
olume
31
|
July
2014
| 32
32
|
July 2014
|
V
olume
31
|
Modern
Medicine
The
S
afety
and
E
/cac
y of
I
nsuli
n
G
largi
ne in
the
M
anag
eme
nt of
T
ype
1
Diabetes in Muslim
Patients during
R
amadan
in
Saudi
Arabia

Number of subjects
Age (years)
21
Mean (SD)
22.71
(6.0)
Gender (n[%])
Male 10 (47.6)
F
emale
11 (52.4)
DM Duration (years)
Median (range)
6.0
(2-18)
BMI (kg/m2)
Mean (SD)
25.10
(4.38)
Total daily insulin requirements at baseline (IU/kg)
Mean (SD)
0.97
(0.32)
BMI
= body mass
index, DM
= diabetes
mellitus
,
IU
= international unit,
SD
= standard deviation.
MIDDLE EAST
RE
VIE
W
MIDDLE EAST
RE
VIE
W
Modern Medicine
|
V
olume
31
|
July
2014
| 33
33
|
July 2014
|
V
olume
31
|
Modern
Medicine
INTROD
UCTION
Ramadan is the month of fast for Moslems worldwide. The fast is between
dawn and sunset daily for the whole month. The fasting includes abstaining
from food and drinks. It is both a religious and a cultural season and many
patients with diabetes insist on fasting even with clear religious rulings allowing
them to skip the fast.1,2 Many patients also continue to fast even with the
physician’s advice to the contrary. Prolonged fasting lasting up to 14 or more
hours daily for a whole month carries a number of risks and complications,3,4
chief among them is hypoglycemia that may be quite serious with severe
hypoglycemia requiring outside assistance.
T
her
e
have been a number of
stud
-
ies addressing fasting in
R
amadan
in
persons with
diabet
es
.
5,6
One
study
was in patients using a regimen
with ultralente and regular insulin
r
epor
t
-
ed no daytime severe
hypoglycemic
episode
,
and there
was no change in the glycosylated
hemoglobin
bef
or
e
and after
fasting
.
7
T
her
e
have been
a
f
e
w
studies addressing the safety of the
fast
in
R
amadan
in children
using
different regimen.8-11 Only the
study
by
Alwan
et al9 used glargine
as
the
basal
insulin
in a multiple
daily
injec- tion regimen in a
pediatric
popu
-
lation, and they
did not note any
compromise in the diabetes
contr
ol
.
STUDy
OBJECTIVES
Primary End
Point:
T
he
primary endpoint of the
study
was the numb er of
h
ypogly
ce
-
mic events during the month of
R
amadan
compared to the
number
of these events during the
month
f
ollo
wing
R
amadan.
Secondary
End
Point:
T
he
percentage of days of success-
ful fast out of the total number of
days of
attempted
fast; and
the
effect of the fast on the overall
TABLE 1:
BASELINE
CHAR
A
C
TERISTICS
diabetes control as determined by
the
HbA1c
and fructosamine
le
v
els
,
pre and post
R
amadan.
STUDy
PATIENTS
A
total of 21 patients were
enr
olled
in this study
(See
T
able
1)after
each
subject gave written informed
con
-
sent. Men and women at least 18
years
o
f
a
ge
,
a
l
r
e
ad
y
on a
m
ul
t
ip
l
e
daily injection of insulin
r
eg
imen
with insulin glargine as basal insu-
lin, were recruited
from
our
clinic patients with type 1
diabet
es
.
in 2004, 15 persons with type 1
di abetes treated with gl argine
in sulin sa fely tol erate d a
no n-
religious fast of 18 h
for
one day
only (as opposed to a
full
month in
R
amadan).
STUDy
RATIONAL

MIDDLE EAST
RE
VIE
W
MIDDLE EAST
RE
VIE
W
Modern Medicine
|
V
olume
31
|
July
2014
| 34
34
|
July 2014
|
V
olume
31
|
Modern
Medicine
T
he
main purpose of our study was
to determine the
safety of fasting
dur-
1
diabet
es
,
without significant
com
-
p
r
o
m
i
s
e
o
f
d
i
a
b
e
t
e
s c
o
n
t
r
o
l
, w
h
i
l
e
using glargine as the basal
insulin
in
a
multiple
daily
injection regimen.

MIDDLE EAST
RE
VIE
W
MIDDLE EAST
RE
VIE
W
Modern Medicine
|
V
olume
31
|
July
2014
| 35
35
|
July 2014
|
V
olume
31
|
Modern
Medicine
T
he
major exclusion criteria
for
the
study included: history of recent or
recurrent severe
h
y
p
og
l
y
c
e
mi
a
or
otherwise metabolicall y
unstable
d
ia
b
e
t
es
;
severe and
u
nb
a
l
a
nc
e
d
diabetic retinopathy
;
and
other
c
li
ni
ca
ll
y r
e
l
e
v
an
t
major systemic
disease
.
M
ETHODS
Open-label
,
prospective
study
,
was
carried out at two of the National
Guard Hea lt h
Affairs
centers in
Saudi Arabia:
K
i ng
Abdulaziz
Medical City
in the
Central
(R
iyadh),
and Eastern
R
eg
ion
(Al-Hassa)
after
app r
opr
iat
e ethi cs c omm itt
ee
appr
o
vals
.
Data
collec
ted included demo -
g
raphics
,
a detailed
hist
or
y
and
physical examination, as well as
laborat
or
y investigations to rule
chr onic
con diti ons
,
inc l udi n g
HbA1c
as study
measur
ement.
TREATMENT
SCHEDULE
At
enroll ment in th e
study
,
all
patients were already on a mul-
tiple daily injection of
insulin:
basal
insulin glargine taken at
22:00
hour
during
R
amadan,
with the
biggest
dose at sunset, a smaller dose
at
dawn, and a third dose to cover
the
22:00 hour snack or meal
if
ther
e
was any (the practice
var
ies
,
with
some people consumin g only 2
meals during the 24
hours
,
with
one meal at sunset and the
second
before dawn).
RES
ULTS
T
h
e
f
r
eq
ue
nc
y
o
f
hypoglycemia
was
h
i
g
h
e
r
d
u
r
i
n
g
the
d
a
y
t
i
m
e
fast as w
e
ll
as during the
night
-
time
f
eeding
hours in
R
amadan.
T
he
median number of hypogly-
cemic events during
R
amadan
(4,
range of 0 – 26) was twice that of
the
post
-R
amadan
period
(2,
range
of 0 –9) a nd the difference was
statistically significant (p=0.002)
(See
T
able
2). All
the hypoglycemic
events reported were simple reac-
tions with no instances of
se
v
er
e
h
ypogly
cemi a ;
the r
e w er e
no
hypoglycemic events during
sleep
.
While the hypo gl ycemic
e
v
ents
occurred throughout the
29 days of
R
amadan,
we noted a
higher
f
r
eq
u
e
n
c
y
du
r
i
n
g
the
first
week of
R
amadan,
and in the
early
morning
hours of the fast as opposed
t
o
later in the
da
y
.
All
the
patients
were able to fast
successfully for
a
median of 28 days out of
att
empt
-
ed 29 days (range 19-29 days),
a
93%
success rat
e
.
One patient had recurrent symp-
tomatic hypoglycemic
r
eac
tions
and was withdrawn
from
the
study
.
This
patient however desired to
con
-
tinue the daily fast and had a final
total of 26 hypoglycemic
r
eac
tions
throughout
R
amadan.
We
f
ollo
w
ed
this patient closely with
ongoing
counseling and adjustment of insu-
lin
dose
.
This
patient could fast suc-
cessfully for
19 out of an
att
empt
ed
29
da
ys
,
having to break the fast
f
or
10 days due to hypoglycemia.
Another patient broke the fast
f
or
one day because of hyperglycemia
and excessive thirst.
This
patient
had significant deterioration of dia-
betes control during the
first w
e
ek
of
R
amadan
and was withdra
wn
from
the
study
,
but the patient still
desired to continue the fast
and
again close
f
oll
o
w
-up
and
o
ngo
-
ing counseling were
per
f
or
med
.
and aspart
i
ns
u
l
i
n
taken w
i
t
h
t
h
e
meals
.
T
he
dose of glargine was
initially
reduced by 10%,
f
ollo
w
ed
by
a
d
j
u
s
t
m
e
n
t
s
d
u
r
i
n
g
R
a
m
a
d
a
n
to achieve optimal fasting
glucose
levels
at sunset.
This
optimal fasting
glucose was defined as higher
than
80
m
g/dl
,
to avoid hypoglycemia
during the fast. During
R
amadan,
the patients continued to take their
basal insulin glargine at 22:00
hour
.
T
he
pre-meal insulin in all
patients
wa s the shor
t
-a c
ti ng
analogue
aspar t.
T
he
do se o f aspar t was tailored to the new meal
schedule

Number of events (Median [range])
During
Ramadan
After
Ramadan
p-value
T
otal hypoglycemic
e
v
ents
4 (0-26) 2
(0-9)
0.002
Symptomatic
non-
severe hypoglycemic
e
v
ents
4(2-21)
1(0-5)
0.049
A
sympt
omatic
hypoglycemic
e
v
ents
0.5(0-10)
0(0-5)
0.197
Breakfast
days due
t
o
high blood
sugar
0
(0
– 1) Not applicable
MIDDLE EAST
RE
VIE
W
MIDDLE EAST
RE
VIE
W
Modern Medicine
|
V
olume
31
|
July
2014
| 36
36
|
July 2014
|
V
olume
31
|
Modern
Medicine
TABLE 2.
HYPOGLYCEMIC EVENTS
AND INSULIN
DOSING

Before
Ramadan
During/End of
Ramadan
p-value
F
ruc
t
osamine
370.0
± 77.68
402.71
± 55.92 0.363
HbA1c
07.92
± 01.13
08.36
± 01.13 0.385
MIDDLE EAST
RE
VIE
W
MIDDLE EAST
RE
VIE
W
Modern Medicine
|
V
olume
31
|
July
2014
| 37
37
|
July 2014
|
V
olume
31
|
Modern
Medicine
TABLE 3.
FRUCTOSAMINE
AND HBA1C
LEVELS
w
ITH
RESPECT
T
O
RAMADAN
F
AST
Diab etes duri ng
R
amadan.
Diab etes Care
2005;28:2305-11.
4
.
Al-Arouj M , Assaa d-Khali l S,
Buse
J,
et
al
.
R
ec ommen datio ns
for
management
of
diabete s during
R
amadan.
Diabete s Care
2010;33(8)1895-902.
5
.
Laing
SP,
Swerdlow
AJ,
Slater
SD
,
et
al
.
T
he
II.
Cause-specific
mortality in patients with
insulin-treated diabetes
mellitus
.
Diabet Med
1999;16:466–71.
T
he
data of both of these
patients
are included in the final statistical
analysis
.
T
here was a sm all inc rea se i n
fr uc
tos am ine and
H
bA1c
le ve ls
from
pr
e
-R
amadan
to the
end of
R
amadan
readings; the
difference however was not
statistically
sig-
nificant (See
T
able
3).
DISCUSSI
ON
As
expec
t
ed
,
there was a
sig
nifi
-
cant increase in the
frequency
of
hypoglycemia in our study
dur
ing
R
amadan,
both during the fasting
and
f
ed
hours
.
Ho
w
e
v
er
,
these wer
e
exclusively
simple reactions with
no
instances of severe hypoglycemia.
T
he
patients were able to
successful-
ly
fast
for
a median of
28 of 29 days
att
empt
ed
.
Although
hypoglycemia occurred throughout
the fasting month, it was more
common in
the
early
part in
R
amadan.
This
could
be
because
the participants were
still
selected patients with type 1 DM
on insulin glargine as basal insu-
li n in comb ination wi th as par
t
as prandial insulin in our
study
.
Although the number of hypogly-
cemic reaction was higher
dur
ing
R
ama da n, none of th es e
h
ypo
-
glycemic events was severe
and
none required outside assistance
.
F
ur
th er
more t here w as no
si g- nificant effect on glycemic
contr
ol
during the period of the
study
.
A
l
t
h
ou
g
h
t
h
i
s
study was
p
r
o
s
p
e
c
-
tiv
e
,
it has the limitations of small
nu mber of
su bjec
ts and
being
o
b
s
e
r
v
a
t
i
o
n
a
l
.
To
make these
f
i
n
d
-
ings generalizable
,
larger
studies
are
needed
.
I
ndividualiz
ed
approach to
patients
with type 1 diabetes who are plan-
ning to fast is a key element of
diabetes care in combination with
suf
fi
ci
e
nt
p
r
e
-
R
a
mad
an
(
m
on
th
o
f
fast)
preparation and
education.
6
.
Sal ti
I,
B
ena r
d
E,
Detour nay
B,
et
al
,
the
EPIDI AR
Study Group:
A
popul ation-based
stu dy of diabetes and it s cha rac ter ist ics
d
ur
i
ng
the f asting mon th of
R
a
ma
d
a
n
i
n
13 countries: results of the Epidemiology of
Diabetes and
R
amadan
1422/2001
(EPIDIAR)
study
.
Diabetes
Care
2004;27:2306–11.
7
.
K
as sem
HS
,
Z antout
MS
,
Azar S T.
I
n
sul in
thera py
dur
ing
R
ama da n fast
for
T
ype
1 diabet es
patients
.
J Endo cri nol
I
n
v
est
2005;28(9):802-5.
8
.
Sal man
H,
Abda llah
MA,
Aban amy
MA,
Al
Howasi
M.
R
amada n fas ting in
diabetic
child ren in
R
iya dh. D iabet es
M
ed
ic ine
.
1992;9(6):583-4
9
.
I
brahim
Al Alwan,
Abdulhameed
Al
Banyan. of
R
amadan
fasting on children
with type 1
diab
et
es
.
I
nt
ernational Journal
of Diabetes
M
ellitus
.
2010;2:
127–129
10
.
Al-K hawari M, Al-Ruwayeh A,
Al-D oub
K
,
Allgro ve
J. A
dolescents
on ba sal -bo lus
insulin can fast during
R
amadan.
Pediatr
Diabetes 2010;11(2):96-100.
11
.
Fasting
and
I
nsulin
Glargine in
I
ndividuals
With
T
ype
1 Diabetes
Bin-Abbas BS.
I
nsulin
pump therapy during
R
amadan
fasting in
T
ype
1 diabetic
adolescents
.
Ann
Saudi
Med
2008;28(4):305-6.
12
.
Mucha
GT,
M
e
r
k
e
l
S,
T
ho
m
as
W,
B
an
tl
e
J
P
.
Fasting
and
I
nsulin
Glargine in
I
ndividuals
a
d
a
p
t
i
n
g
t
o
t
h
e
f
a
s
t
,
t
o
g
e
t
h
e
r
w
i
t
h
Wi th
T
yp e
1
Di ab et
es
.
D ia be te s
ca r
e
the ongoing active adjustment of
the
insulin
dose
.
One limitation of the study is
the
small number of the patients
f
ol
-
lo
w
ed
.
Larger
studies are
needed
.
C
ONCLUSI
ON
Successful
fasting during
R
amadan
was
p o s s i b l e
in
major
it
y
of
REFERENCES
1
.
Sulim ani
RA, Famu yiwa
FO
,
Laaja m
M
A.
Diabete s
mellitu s and
R
amadam
fasting : the need
for
a
critical
appraisal
.
Diabet Med
1988;5:589-91.

MIDDLE EAST
RE
VIE
W
MIDDLE EAST
RE
VIE
W
Modern Medicine
|
V
olume
31
|
July
2014
| 38
38
|
July 2014
|
V
olume
31
|
Modern
Medicine
2
.
R
ashe d
AH .
T
he fas t o f
R
amad an. No
p
r
o
b
l
e
m
s
for
the w
e
ll
:
the
sick
s
h
ou
l
d
a
v
o
i
d
fasting
.
Br
Med J 1992;304:521-2.
3
.
Al -Ar ou j M,
B
ouguer
ra
R,
Buse
J,
et
al
.
R
ecomm endat ions
for
management
of
2004;27:1209-10