management of diseases in ramadan
DESCRIPTION
Concern of 1.9 billion peopleTRANSCRIPT
Management manipulation of Different Medical Conditions
during Ramadan
Dr. Mansoor Khan
Resident Surgery “D”
Khyber Teaching Hospital,
Peshawar.
“Ramadan is the 9th month of Muslim
calendar”
Fasting in Ramadan is one of thefive pillars of Islam
*Estimate
“Over 1.9 billion Muslims observeRamadan each year”
The sick, travelers, pregnant andbreastfeeding women who fear for
their well being or that of thefoetus/child) may be exempted until they
are again at peace or healthy
1st Ramadan Headache
Most of the studies suggests increased frequency of headaches in Ramadan
Awada A, al Jumah M Headache. 1999 Jul-Aug;39(7):490-3.
Pathophysiology
Hypoglycemia, caffeine withdrawal, change insleep pattern and stress
of fasting itself
Neurol J Southeast Asia 2001; 6 : 13 – 17.
Bilateral, fronto‐temporal, throbbing, mild to
moderate, often lasting for 1‐2 Hours, in afternoon & evening
Neurol J Southeast Asia 2001; 6 : 13 – 17.
Characteristics of Ramadan headache
Rest, sleep, analgesia and breaking fast often relieves
the headache
Characteristics of Ramadan headache
Neurol J Southeast Asia 2001; 6 : 13 – 17.
Prevention --
Cup of coffee before fast
Subsides as the body acclimatizes with the low levels of caffeine
Awada A, al Jumah M Headache. 1999 Jul-Aug;39(7):490-3.
Peptic ulcer disease
Pathophysiology
Gastrin, pepsin and acid secretions increase.
Median pH is 2.3 prior to Ramadan, 1 at
day 10 and day 24 of Ramadan
Iraki L, Abkari A, Vallot T, Amrani N, Khlifa RH, Jellouli K et al. [Effect of Ramadan fasting on intragastric pHrecorded during 24 hours in healthy subjects]. Gastroenterol Clin Biol 1997; 21:813-819.
Irritability, non-compliance to medications &
stressM. H. Emami, H. Rahimi, Effects of Ramadan fasting on acute upper gastrointestinal bleedingdue to peptic ulcer, 175 - 0 17 ): 3 ( 11 ; 2006 JRMS
Pathophysiology
Prolonged non-neutralized
secretion of gastric acids damages the
mucosa
Diagnostic and Therapeutic Endoscopy, 1996, Vol. 2, pp. 219-221
Pathophysiology
Active acute duodenal ulcers heal with medication during Fasting
Active chronic duodenal ulcers fails to heal & are at greater risk of bleeding/perforation
Diagnostic and Therapeutic Endoscopy, 1996, Vol. 2, pp. 219-221
Duodenal ulcers--
Duodenal ulcers--
88% of chronic duodenal ulcers bled with 71% ofthese with bleeding being drug defaulters
Diagnostic and Therapeutic Endoscopy, 1996, Vol. 2, pp. 219-221
Diagnostic and Therapeutic Endoscopy, 1996, Vol. 2, pp. 219-221
Gastric ulcers--
The gastric ulceralso bled even after drug therapy and showed no signs ofhealing
Dyspeptic symptoms are considered asalarming signs
Caution in advising fasting with previous history of DU and dyspepsia
Concurrent prescription of PPI’sas prophylaxis
M. H. Emami, H. Rahimi, Effects of Ramadan fasting on acute upper gastrointestinal bleedingdue to peptic ulcer, 175 - 0 17 ): 3 ( 11 ; 2006 JRMS
Recommendations
Diabetes & fasting – A global concern
Diabetes
Normal individuals‐‐‐
Fasting > decrease glucose levels > Decreased secretion of insulin/inreased
levels of glucagon and catecholamines> Glycogenolysis/gluconeogenesis
> glycogen depletion > lipolysis > ketones for muscles > sparing glucose for brain and
erythrocytes
Trends in blood glucose during fastingDIABETES CARE, VOLUME 28, NUMBER 9, SEPTEMBER 2005 2305
Normal individuals‐‐‐Slight decrase in start of day to 3.3 mmol
to 3.9 mmol (60mg/dl to 70mg/dl)
Then gradually becomes normal due to gluconeogenesis, dec isulin, increased
glucagon
Trends in blood glucose during fasting
In diabetics --Hypoglycemia
Glucagon secretion failurein response to hypoglycemia
Defective epinephrinesecretion type 1 diabetes due to
autonomic neuropathyleading to Hypoglysemia
Hyperglycemia
Severe insulin deficiency, can lead to excessive
glycogenolysis & increasedgluconeogenesis and ketogenesis,
leading to hyperglycemia and ketoacidosis
Trends in blood glucose during fasting
DIABETES CARE, VOLUME 28, NUMBER 9, SEPTEMBER 2005 2305
Compliant patients showed euoglycemia & mostly no
episodes of acute complications
Trends in blood glucose during fasting
Assessment of glycemic status
Diet protocol
Changing drug regimens
Appropriate physical activity
Recognition of complications
Pre-Ramadan preparations
All brittle type I diabetics
Poorly controlled type I & II
Non-complaint patients in terms of diet, medicine, activity
Diabetics with complications (angina, uncontrolled HTN)
Discourage fast in ---
History of recurrent ketoacidosis
Pregnant diabetics
Inter-current infections
Elderly patients with any degree of
alertness problems
Discourage fast in ---
Patients not falling under the above exclusion criteria
Over-weight & obese diabetics
Compliant & well educated patients
Allow fasting in ---
Consume slow digesting food (fiber diet, lasting for 8hrs)
Decreased intake of refined food (lasting for 2-3 hr)
Over-weight should not gain weight
Under-weight/normal should not loose weight
Nutrition adv --
Light to moderate exercise is recommended
Physical activity & fasting ---
Insulin adjustment in IDDM ---
Three doses insulin regimenTwo doses of regular (dawn & dusk)
One dose of intermediate acting at late evening
Two doses insulin regimenCombined short acting & intermediate acting at dawn & dusk before meals
Oral anti-diabetic adjustments ---
MetforminReverse doses ( morning dose in evening &
evening dose in morning)
SulphonylureasUse short acting prandial regulators
(Rapaglinides) instead long acting SFU
Blood glucose monitoring ---
Thrice daily monitoringBefore sunset meal
Three hrs after sunset meal
Before pre-dawn meal
Psychological problems in Ramadan
Relapses in bipolar patients
Relapses observed in previously stable patients in 45%
Mostly manic attacks, despite stable lithium levels
Toda M, Morimoto K. Ramadan fasting—effect on healthy Muslims. Soc BehPers 2004;32:13–18. Kadri N, Mouchtaq N, Hakkou F, Moussaoui D. Relapses in bipolar patients: changes in social rhythm? Int J Neuropsychopharmacol 2000;3:45–9.
Relapses in bipolar patients
Fasting‐related changes in circadian rhythms and insomnia are thought
to contribute to psychiatric symptom exacerbation
Toda M, Morimoto K. Ramadan fasting—effect on healthy Muslims. Soc BehPers 2004;32:13–18. Kadri N, Mouchtaq N, Hakkou F, Moussaoui D. Relapses in bipolar patients: changes in social rhythm? Int J Neuropsychopharmacol 2000;3:45–9.
Changes in behavior
During Ramadan, even persons without mental disorders have reported irritability, decreased
sleep, difficulty concentrating, and anxiety
Toda M, Morimoto K. Ramadan fasting—effect on healthy Muslims. Soc BehPers 2004;32:13–18.
Chronic Kidney Diseases
Chronic Kidney Diseases
Decreased GFR
Tubular damage
Increased serum creatinine and urea
Increased serum potassium in CKD
Risk is multiplied in diabeticsSaudi J Kidney Dis Transplant 2007;18(3):349-354
Stroke in Ramadan
Turk J Med Sci 33 (2003) 237-241
As a whole no change in incidenceof stroke during Ramadan than
other months
Incidence of stroke
According to studies increase in a special type of stroke due to
cerebral venous sinus thrombosis (CVST), is observed (3 X) ‐‐
hemoconcentration
Increased incidence of Special type of stroke
Turk J Med Sci 33 (2003) 237-241
Increased incidence of ischemic strokes especially in uncontrolled
diabetics is observed
Ischemic stroke --
Turk J Med Sci 33 (2003) 237-241
Decreased incidence of hemorrhagic strokes in hypertensive patients is observed – good HTN control in
fasting due to depressed sympathetic system
Hemorrhagic stroke --
Ramadan & acute appendicitis
Incidence of acute appendicitis was significantly lower in Ramadan, Bowel
resting could reduce the risk of appendicitis
Iran J Med Sci March 2005; Vol 30 No 1 21
Ramadan & Immunity system--
CIC (circulating immune complex)levels were measured
before and after Ramadan bypolyethylenglycole method.
Ramadan does not have bad effecton immune system of healthy people.
A. Latifynia, M. Vojgani, T. Abofazeli, H.Jafarieh* J Ayub Med Coll Abbottabad 2007; 19(2)
Fasting and Pregnancy
Pregnant & lactating
mothers are exempted
Fasting & pregnancy --
Annals of Alquds Medicine (1426, 2005) 2:58-62
Pregnant mothers experience more stress compared with
non-pregnant ones andfasting may increase
this stress
Fasting & pregnancy --
Annals of Alquds Medicine (1426, 2005) 2:58-62
Theoretically fasting may cause hypoglycemia > leading to small size of gestational age (SGA) in fetus > Birth mortality and disabilities
among newborn babies
Fasting & pregnancy --
Annals of Alquds Medicine (1426, 2005) 2:58-62
Dehydration and decrease glomerular filtration, which may increase serum levels of renallydependent drugs such as lithium
Modifying pharmacotherapy
Aadil I, Houti I, Moussamih S. Drug intake during Ramadan. BMJ 2004;329:778–82.
Changes in gastric pH and phase II liver metabolism, altering the
pharmacokinetics of valproic acid
Aadil N, Fassi-Fihri I, Houti B, et al. Influence of Ramadan on the pharmacokinetics of a single oral dose of valproic acid administered at two different times. Methods Find Exp ClinPharmacol 2000;22(2):109–14.
Modifying pharmacotherapy
In patients taking antidepressants and antipsychotics, watch for anticholinergic side
effects —dry mouth, dehydration, and confusion—especially in the elderly
Switch before Ramadan to longer-acting medications or medications with once- or twice-
daily dosing
Modifying pharmacotherapy
Substance abstinence
Fasting mandates abstinence from alcohol, caffeine, and tobacco
Sudden abstinence can lead to withdrawal effects
Kadri N, Tilane A, Batal M, et al. Irritability during the month of Ramadan. Psychosom Med 2000;62:280–5.
Substance abstinence
Discuss a tapering approach to preempt possible withdrawal
symptoms
Kadri N, Tilane A, Batal M, et al. Irritability during the month of Ramadan. Psychosom Med 2000;62:280–5.
Number of CVS disorders deaths significantly decreased in Ramadan
No difference found in the episodes of Asthma during Ramadan
Other diseases
THANKS
Questions Please