1
|
Comprehensive Care for Patients with Diabetes in Ramadan: A Module for Pharmacy Students and Pharmacists. Saudi Pharm J 2022; 30:619-628. [PMID: 35693434 PMCID: PMC9177447 DOI: 10.1016/j.jsps.2022.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/10/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Prior studies show that many patients with diabetes whose health maybe impacted by fasting, choose to fast during Ramadan. This study describes the implementation and evaluation of an online module targeting bachelor of pharmacy (BPharm) and doctor of pharmacy (PharmD) students that aims to improve participants' knowledge, communication, and self-efficacy concerning proper care for patients with diabetes in Ramadan. Methods An online module consisting of two phases targeting both BPharm and PharmD students was implemented over two semesters in fall 2020 and spring 2021. Participants were directed to fill pre-module and post-module assessments to evaluate the change in their knowledge and self-efficacy using two scales. Pre- and post-survey data for participants’ knowledge and self-efficacy were analyzed for significance using paired sample t-tests. Qualitative data analysis was performed to assess participants’ responses to the open-ended question concerning what they liked and disliked about the module. Results All BPharm and PharmD students taking the lesson responded to both the baseline survey and the follow-up one resulting in 92 responses (participation rate of 100%). The average score for participants in the pre-module self-efficacy section was 1.5 (SD = 1) and increased post-module to 3.5 (SD = 0.7), t (91) = 20.2, p < 0.001. Further, the average score for participants in the pre-module knowledge section was 14 (SD = 3), which similarly increased to 22 (SD = 3) post-module t (91) = 19.7, p < 0.001. Qualitative analysis provided insights on how participants perceived the module design, content, and its impact on practice. Participants described the module as an informative one that addresses a much-needed issue they haven’t been exposed to before. They emphasized how the module addresses the cultural needs of patients in their communities. They particularly appreciated seeing instructor videos depicting real-life scenarios and the focus on their communication skills, but some preferred learning about this topic through live sessions. Conclusion An online module positively impacted both self-efficacy and knowledge in relation to caring for patients with diabetes considering fasting in Ramadan. Future studies should explore how different versions of this module can be integrated into educational activities for pharmacy students, pharmacists in different settings, and for other health care professionals.
Collapse
|
2
|
Nassar M, Ahmed TM, AbdAllah NH, El Sayed El Hadidy K, Sheir RES. The impact of structured diabetes education on glycemic control during Ramadan fasting in diabetic patients in Beni Suef, Egypt. Diabetes Metab Syndr 2021; 15:102249. [PMID: 34418633 DOI: 10.1016/j.dsx.2021.102249] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 11/25/2022]
Abstract
AIMS Ramadan is a holy month for the Muslim community. Fasting Ramadan is directed by a systematic alteration in eating habits, sleeping times, and daily physical activities that optimize blood glucose levels. This study aims to evaluate the effects of structured education on safe fasting among diabetic patients. METHODS This study included diabetic patients with eligibility for the Ramadan fast. The control group included 494 patients who received standard diabetes education, while the intervention group included 407 patients who attained structured diabetes education. The patients were required to register their responses following the written, structured questionnaires before and after Ramadan fasts. In addition, patients were advised to keep a log of their hypoglycemic episodes. RESULT This study showed that structured diabetes education improved the blood glucose levels/glycemic control and outcomes of patients during their Ramadan fasting. The structured diabetes education helped reduce the incidence of hypoglycemic events and hyperglycemic crises. It also increased the acceptance and frequency of blood sugar level measurements among patients during Ramadan. CONCLUSION The standard diabetes management plan should include structured diabetes education measures to improve outcomes effectively. The providers should screen the patients with diabetes before Ramadan and educate them to improve their safe fasting practices.
Collapse
Affiliation(s)
- Mahmoud Nassar
- Medicine Department, Icahn School of Medicine at Mount Sinai / NYC Health + Hospitals / Queens, New York, USA.
| | | | - Nilly Helmy AbdAllah
- Medicine Department, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt.
| | | | - Rania El-Sayed Sheir
- Medicine Department, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt.
| |
Collapse
|
3
|
Ramadan Intermittent Fasting Affects Adipokines and Leptin/Adiponectin Ratio in Type 2 Diabetes Mellitus and Their First-Degree Relatives. BIOMED RESEARCH INTERNATIONAL 2020; 2020:1281792. [PMID: 32775407 PMCID: PMC7407010 DOI: 10.1155/2020/1281792] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/07/2020] [Accepted: 07/20/2020] [Indexed: 12/02/2022]
Abstract
Background In view of the association of Ramadan intermittent fasting with profound changes in lifestyle both in nondiabetic and diabetic patients, the aim of this study was to investigate the effect of Ramadan fasting on adiponectin, leptin and leptin to adiponectin ratio (LAR), growth hormone (GH), human-sensitive C-reactive protein (hs-CRP), and diabetic and metabolic syndrome factors in patients with Type 2 Diabetes Mellitus (Type 2 DM), their first-degree relatives (FDRs), and healthy controls. Methods This cohort study involved 98 Yemeni male subjects aged 30-70 years old: 30 Type 2 DM, 37 FDRs of Type 2 diabetic patients, and 31 healthy control subjects. Subjects' body mass index (BMI), waist circumference (WC), and blood pressure (BP) were measured, and venous blood samples were collected twice: the first samples were collected a couple of days prior to Ramadan fasting (baseline) and the second samples after 3 weeks of fasting. Results Ramadan fasting did not affect BMI, WC, and BP in Type 2 DM and their FDRs with respect to the baseline levels prior to Ramadan, whereas triglyceride and cholesterol were borderline significantly decreased in Type 2 DM with no effect in FDRs. Fasting blood glucose was not affected in Type 2 DM but was significantly increased in FDRs and control groups, whereas glycated haemoglobin (HbA1c) was slightly decreased in Type 2 DM, FDRs, and healthy controls. C-peptide, insulin, and insulin resistance (HOMA-IR) were significantly increased in Type 2 DM and FDRs, with no effect in the control group, whereas β-cell function (HOMA-β) was significantly decreased in FDRs and controls with no change in Type 2 DM. Ramadan fasting significantly decreased GH in both FDRs and control groups, and significantly increased hs-CRP in the control with no effect in Type 2 DM and FDRs. Adiponectin was significantly decreased, and leptin and LAR were significantly increased in Type 2 DM, FDRs, and control groups. Conclusion Ramadan intermittent fasting decreased adiponectin and increased leptin, LAR, insulin, and insulin resistance in both Type 2 DM and FDRs as well as decreased GH in both FDRs and healthy controls and increased hs-CRP in healthy controls. Moreover, Ramadan intermittent fasting neither worsens a patient's glycemic parameters nor improves it, with the exception of a slight improvement in HbA1c in Type 2 DM, FDRs, and healthy controls.
Collapse
|
4
|
Theodore-Oklota C, Bonner N, Spencer H, Arbuckle R, Chen CY, Skrinar A. Qualitative Research to Explore the Patient Experience of X-Linked Hypophosphatemia and Evaluate the Suitability of the BPI-SF and WOMAC® as Clinical Trial End Points. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:973-983. [PMID: 30098676 DOI: 10.1016/j.jval.2018.01.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 12/14/2017] [Accepted: 01/22/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND X-linked hypophosphatemia (XLH) is a rare genetic disorder characterized by renal phosphate wasting and defective bone mineralization. Symptoms include bone pain, joint pain, stiffness, and fatigue. Published evidence regarding the patient experience of XLH is sparse and no XLH-specific outcome measures have been validated. OBJECTIVES To understand the symptoms, impacts, and patient experience of XLH and to evaluate the face and content validity of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC®) and the Brief Pain Inventory Short Form (BPI-SF) for use as end points in XLH clinical trials. METHODS Face-to-face, qualitative, semistructured interviews were conducted with 18 adults with XLH in the United States using concept elicitation and cognitive debriefing techniques. Open-ended questioning elicited spontaneous concepts focusing on XLH-associated symptoms and functional limitations. Cognitive debriefing of the WOMAC® and BPI-SF assessed the relevance and patient understanding of item wording, recall period, and response options. RESULTS Various distinct symptom concepts were elicited including pain symptoms, dental symptoms, sensory symptoms, tiredness/fatigue symptoms, and musculoskeletal symptoms. Participants reported experiencing significant bone and joint pain, stiffness, mobility limitations, and an impact on their ability to work. Cognitive interviewing found both instruments to be relevant and well understood by most patients. CONCLUSIONS The interviews generated rich, qualitative insights into the patient experience of XLH. Cognitive debriefing of the BPI-SF and WOMAC® supported their value as XLH clinical trial end points. Future research will assess the psychometric properties of these instruments for use in the XLH population.
Collapse
|
5
|
Hassanein M, Echtay A, Hassoun A, Alarouj M, Afandi B, Poladian R, Bennakhi A, Nazar M, Bergmans P, Keim S, Hamilton G, Azar ST. Tolerability of canagliflozin in patients with type 2 diabetes mellitus fasting during Ramadan: Results of the Canagliflozin in Ramadan Tolerance Observational Study (CRATOS). Int J Clin Pract 2017; 71:e12991. [PMID: 28851109 PMCID: PMC5656913 DOI: 10.1111/ijcp.12991] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 07/14/2017] [Indexed: 12/19/2022] Open
Abstract
AIMS There is a large population of people with type 2 diabetes mellitus (T2DM) who are Muslim and fast during Ramadan. Changes in the pattern and amount of meal and fluid intake during Ramadan, in addition to the long fasting hours, may increase the risk of hypoglycaemia, hyperglycaemia, and dehydration. The Canagliflozin in Ramadan Tolerance Observational Study (CRATOS) evaluated the tolerability of canagliflozin, a sodium glucose co-transporter 2 inhibitor, compared with sulphonylureas among patients with T2DM who fast during Ramadan. METHODS This non-randomised, parallel-cohort, prospective, comparative, observational study was conducted in the Middle East during Ramadan and enrolled patients who were taking canagliflozin (n=162) or any sulphonylurea (n=159) added to metformin±dipeptidyl peptidase-4 inhibitor. The proportion of patients who experienced hypoglycaemia events was assessed as the primary end-point. Between-cohort comparisons were adjusted using propensity score analysis. RESULTS During Ramadan, fewer patients experienced symptomatic hypoglycaemia with canagliflozin vs sulphonylurea (adjusted odds ratio: 0.273 [95% CI: 0.104, 0.719]). Of hypoglycaemia events for which blood glucose was measured, two of six with canagliflozin and 27 of 37 with sulphonylurea were confirmed by blood glucose <3.9 mmol/L. More patients treated with canagliflozin experienced volume depletion events compared with sulphonylurea (adjusted odds ratio: 3.5 [95% CI: 1.3, 9.2]). Missed fasting days were few and medication adherence was high in both groups. No patients treated with canagliflozin and 9.4% treated with sulphonylurea adjusted their medication dose near the beginning of Ramadan. Both treatments were generally well tolerated, with low rates of adverse events and no serious adverse events in either group. CONCLUSIONS Overall, these findings support the use of canagliflozin for the treatment of adults with T2DM who fast during Ramadan. CLINICALTRIALS. GOV IDENTIFIER NCT02737657.
Collapse
Affiliation(s)
- Mohamed Hassanein
- Endocrine DepartmentDubai HospitalDubai Health AuthorityDubaiUnited Arab Emirates
- Cardiff UniversityCardiffUK
| | - Akram Echtay
- Division of EndocrinologyLebanese University Medical SchoolRafik Hariri University HospitalBeirutLebanon
| | | | | | - Bachar Afandi
- Diabetes CenterTawam HospitalAl AinUnited Arab Emirates
| | | | | | | | | | | | | | - Sami T. Azar
- Department of Internal MedicineAmerican University of Beirut Medical CentreBeirutLebanon
| |
Collapse
|
6
|
Beano AM, Zmaili MA, Gheith ZH, Naser AM, Momani MS, Yousef AMF, Zayed AA. Predetermined Anti-Diabetic Drug Regimen Adjustments during Ramadan Fasting: An Observational Study of Safety. Endocrinol Metab (Seoul) 2017; 32:265-273. [PMID: 28685515 PMCID: PMC5503872 DOI: 10.3803/enm.2017.32.2.265] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/28/2017] [Accepted: 04/06/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Many Muslim type 2 diabetes mellitus (T2DM) patients choose to fast the month of Ramadan despite the possible adverse health effects brought about by the change in dietary habits, among other things. Clinical data regarding the safety of multi-drug regimens during fasting are particularly scarce. The aim of the study was to evaluate the safety of a drug protocol devised by the authors to accommodate Ramadan's dietary changes, involving dose adjustments of four anti-diabetic drug regimens in T2DM patients fasting Ramadan. METHODS In this prospective, observational, open-label study, 301 T2DM patients who wished to fast Ramadan were followed during Ramadan and the preceding month. The incidence of hypoglycemia, diabetic ketoacidosis (DKA) and non-ketotic hyperosmolar state (NKHS) was monitored. Patients were classified into four groups: A group (those taking metformin, sulfonylurea and insulin [n=33]); B group (metformin and sulfonylurea [n=89]); C group (metformin and insulin [n=96]); and D group (premixed 70/30, glargine or regular insulin [n=82]). During Ramadan, drug doses were adjusted as percentages of their pre-Ramadan values: 75% for sulfonylureas, 75% for glargine, 75% for premixed insulin 70/30 in two doses, and 75% for regular insulin. Metformin was adjusted to a twice-daily regimen. RESULTS No cases of DKA or NKHS were reported. Hypoglycemia occurred at a lower rate than pre-Ramadan values in groups C, and D; and a similar rate in groups A, and B. CONCLUSION The data suggested that using the above protocol to adjust the doses of anti-diabetic drugs is safe in T2DM patients in regards to hypoglycemia, DKA, and NKHS.
Collapse
Affiliation(s)
- Abdallah M Beano
- Department of Internal Medicine, The University of Jordan School of Medicine, Amman, Jordan
| | - Mohammad A Zmaili
- Department of Internal Medicine, The University of Jordan School of Medicine, Amman, Jordan
| | - Zaid H Gheith
- Department of Internal Medicine, King Hussein Cancer Center (KHCC), Amman, Jordan
| | - Ahmad M Naser
- Department of Internal Medicine, The University of Jordan School of Medicine, Amman, Jordan
| | - Munther S Momani
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Jordan University Hospital, The University of Jordan School of Medicine, Amman, Jordan
| | | | - Ayman A Zayed
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Jordan University Hospital, The University of Jordan School of Medicine, Amman, Jordan.
| |
Collapse
|
7
|
Kiyani MM, Memon AR, Amjad MI, Ameer MR, Sadiq M, Mahmood T. Study of Human Biochemical Parameters During and After Ramadan. JOURNAL OF RELIGION AND HEALTH 2017; 56:55-62. [PMID: 26149778 DOI: 10.1007/s10943-015-0084-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Ramadan fasting is obligatory for Muslims each year. They abstain from drinking, eating and intimate relationship between dawn and dusk during this month. Dietary restriction during Ramadan has various biochemical and physiological effects. It is shown to decrease the body weight, glucose and lipid profile. This study aims to analyze the changes in body weight, glucose and lipid profile during Ramadan in physiotherapy students in Pakistan. The study was conducted during June-July 2013 (Hijri year 1434). There were 80 students (50 males and 30 females) recruited in the experiment. They all were healthy adults between the age group of 18-24 (mean age 20.5) years. All subjects underwent a general physical examination and interview, and non-healthy subjects were excluded. On statistical analysis, quantitative data were expressed in terms of mean ± SD and a p value of ≤0.05 was believed statically significant. Paired t test was used to compare the variables. There was a little reduction in body weight (62.7 ± 8.8 vs. 62.3 ± 9.0; p value = 0.009) but a significant decline in glucose level (72.6 ± 12.5 vs. 57.9 ± 10.7; p value = 0.000), low-density lipoprotein level (2.9 ± 0.3 vs. 2.5 ± 0.3; p value = 0.000), total cholesterol (4.6 ± 0.4 vs. 4.2 ± 0.5; p value = 0.000) and triglycerides (1.4 ± 0.5 vs. 1.2 ± 0.5; p value = 0.000) was observed. Moreover, there was some reduction in high-density lipoprotein cholesterol level (1.2 ± 0.3 vs. 1.1 ± 0.3; p value = 0.045). This study shows that Ramadan fasting, a religious obligation for purification of body and soul, resulted in reduced body weight and a positive effect on glucose level and lipid profile.
Collapse
Affiliation(s)
- Mubin Mustafa Kiyani
- Faculty of Health and Medical Sciences, Riphah College of Rehabilitation Sciences, Riphah International University, Islamabad, Pakistan
| | - Aamir Raoof Memon
- Institute of Physiotherapy and Rehabilitation Sciences, Peoples University of Medical and Health Sciences, Nawabashah, Pakistan.
| | - Mian Imran Amjad
- Faculty of Health and Medical Sciences, Riphah College of Rehabilitation Sciences, Riphah International University, Islamabad, Pakistan
| | | | | | - Tariq Mahmood
- Nano Sciences and Catalysis Division, National Center for Physics, Quaid-i-Azam University, Islamabad, Pakistan
| |
Collapse
|
8
|
Khattab M, Mahmoud K, Shaltout I. Effect of Vildagliptin Versus Sulfonylurea in Muslim Patients with Type 2 Diabetes Fasting During Ramadan in Egypt: Results from VIRTUE Study. Diabetes Ther 2016; 7:551-60. [PMID: 27550549 PMCID: PMC5014796 DOI: 10.1007/s13300-016-0190-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Fasting in patients with type 2 diabetes mellitus (T2DM) is associated with high risk of hypoglycemia. The aim of this study was to compare the effectiveness and safety of vildagliptin in T2DM patients fasting during Ramadan in a real-life setting in Egypt. METHODS In this 16-week prospective and noninterventional study, data were collected up to 6 weeks before and after Ramadan fasting. Patients who had received vildagliptin or sulfonylurea (SU) either as dual therapy with metformin or as monotherapy were enrolled into the study. RESULTS Two hundred fifty four patients were enrolled in the study, out of which 246 [121 (97.6%) treated with vildagliptin and 125 (99.2%) with SU] were included in the safety analysis set. A significantly lower proportion of patients experienced ≥1 hypoglycemic event (HE) with vildagliptin as compared to those receiving SUs (1.7% vs. 19.2%, respectively; p < 0.001). No patient in either group reported a grade 2 HE. At week 16, mean change in HbA1c from baseline for vildagliptin and SU were -0.1% and +0.3%, respectively, with a between-treatment difference of -0.4% (p < 0.001). Mean change in body weight from baseline for vildagliptin and SU were -0.8 and -0.1 kg, with a between-treatment difference of -0.7 kg (p = 0.011). A higher proportion of SU-treated patients experienced adverse events compared to those treated with vildagliptin (23.2% vs. 5.8%, respectively), the primary reason being the high incidence of hypoglycemia in the SU group (n = 24, 19.2%). CONCLUSIONS Treatment with vildagliptin was associated with lower incidence of hypoglycemia compared with SU and showed good glycemic and weight control in patients with T2DM fasting during Ramadan in a real-life setting in Egypt. FUNDING Novartis Pharma AG.
Collapse
Affiliation(s)
- Mohamed Khattab
- Internal Medicine and Diabetes, Cairo University, Giza, Egypt.
| | - Khalifa Mahmoud
- Internal Medicine and Diabetes, Alexandria University, Alexandria, Egypt
| | - Inass Shaltout
- Internal Medicine and Diabetes, Cairo University, Giza, Egypt
| |
Collapse
|
9
|
Al Sifri S, Rizvi K. Filling the Knowledge Gap in Diabetes Management During Ramadan: the Evolving Role of Trial Evidence. Diabetes Ther 2016; 7:221-40. [PMID: 27091198 PMCID: PMC4900978 DOI: 10.1007/s13300-016-0168-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Indexed: 12/14/2022] Open
Abstract
UNLABELLED Muslim patients with type 2 diabetes (T2D) who fast during Ramadan face challenges in diabetes management due to substantial alterations in lifestyle and treatment that frequently accompany the decision to fast. International guidelines for treating T2D do not fully address the clinical issues unique to fasting, and other guidance documents lack the large and high-quality evidence base available for non-fasting conditions. We reviewed 10 randomized controlled trials and 20 observational studies in T2D during Ramadan to assess the quality of evidence and identify issues in trial design that should be addressed in future studies. Results indicated that heterogeneity in key aspects of trial design precluded meaningful comparisons across studies. These included patients' baseline treatment at entry; use of a cutoff for glycemic control [glycated hemoglobin (HbA1c)] for eligibility; exclusion of patients with a history of recurrent hypoglycemia or hypoglycemia unawareness, or with other serious systemic diseases; duration of treatment and follow-up, selection of safety versus efficacy as primary end point; and definition and measurement of those end points. Fructosamine was rarely used as an efficacy end point, despite the advantage of reflecting glycemic control over a period more closely aligned with the duration of Ramadan fasting than HbA1c. Adherence to treatment, definition and adherence to fasting, and changes in diet and exercise were reported inconsistently, and when reported, not in a fashion that would allow adequate control of confounding due to these variables. Despite a large body of evidence demonstrating their safety and efficacy in non-fasting populations, only two trials reported data for glucagon-like peptide-1 analogs, and neither involved a head-to-head comparison against dipeptidyl peptidase-4 inhibitors. More rigorous studies using trial designs suited to the unique conditions of a fasting population and capturing both standardized efficacy and safety end points are needed to provide better guidance to optimal treatment of T2D during Ramadan fasting. FUNDING Novo Nordisk AG.
Collapse
Affiliation(s)
- Saud Al Sifri
- Endocrinology Department, Alhada Military Hospital, Taif, Saudi Arabia.
| | - Kashif Rizvi
- Specialized British Medical Unit, Mazaya Clover Centre, Jabriya, Kuwait
| |
Collapse
|
10
|
Monnier L, El Azrak A, Lessan N, Rochd D, Colette C, Bonnet F. Ramadan and diabetes: What we see, learn and understand from continuous glucose monitoring. DIABETES & METABOLISM 2015; 41:456-62. [PMID: 26476619 DOI: 10.1016/j.diabet.2015.09.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 09/08/2015] [Accepted: 09/09/2015] [Indexed: 11/29/2022]
Abstract
Abstinence from eating and drinking from dawn to sunset characterizes the holy month of Ramadan. For the 50 million Muslims worldwide with diabetes who adhere to this religious fast, the practice results in marked changes in glucose homoeostasis. The sunset meal (Iftar) that breaks the fasting state is followed by exaggerated surges in blood glucose and sustained overnight hyperglycaemia in cases of nocturnal overfeeding. The predawn meal (Suhoor) frequently results in prolonged glucose decay over the daylight hours. These glycaemic disturbances are particularly marked in insulin-treated patients, in those with unsatisfactory diabetes control during the pre-Ramadan period and in patients who are poorly compliant with lifestyle recommendations. Whether such patients should be exempt from the Islamic fast remains an open debate, which might be partially resolved by long-term controlled studies using the technology of continuous glucose monitoring in large populations of patients with diabetes.
Collapse
Affiliation(s)
- L Monnier
- Institute of Clinical Research, University of Montpellier, 641, avenue du Doyen-Giraud, 34093 Montpellier cedex 5, France.
| | - A El Azrak
- Association for Medical Formation G11, 89, boulevard Anfa, 20000 Casablanca, Morocco
| | - N Lessan
- Imperial College London Diabetes Centre, PO Box 48338, Abu Dhabi, United Arab Emirates
| | - D Rochd
- Association for Medical Formation G11, 89, boulevard Anfa, 20000 Casablanca, Morocco
| | - C Colette
- Institute of Clinical Research, University of Montpellier, 641, avenue du Doyen-Giraud, 34093 Montpellier cedex 5, France
| | - F Bonnet
- Department of Endocrinology, University Hospital, 16, boulevard de Bulgarie, 35200 Rennes, France
| |
Collapse
|
11
|
Gray LJ, Dales J, Brady EM, Khunti K, Hanif W, Davies MJ. Safety and effectiveness of non-insulin glucose-lowering agents in the treatment of people with type 2 diabetes who observe Ramadan: a systematic review and meta-analysis. Diabetes Obes Metab 2015; 17:639-48. [PMID: 25777247 DOI: 10.1111/dom.12462] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 03/04/2015] [Accepted: 03/12/2015] [Indexed: 01/07/2023]
Abstract
AIM To determine which non-insulin glucose-lowering treatment regimens are most appropriate in people with type 2 diabetes who choose to fast during Ramadan. METHODS Electronic databases were searched for randomized controlled trials (RCTs) and observational studies that compared non-insulin glucose-lowering agents in people with type 2 diabetes fasting during Ramadan. Those studies which reported hypoglycaemia, weight and glycated haemoglobin (HbA1c) change were included. Data were pooled using random effects models. RESULTS A total of 16 studies were included: 9 RCTs and 7 observational studies. There was evidence that dipeptidyl peptidase-4 (DPP-4) inhibitors led to fewer hypoglycaemic events compared with sulphonylureas. Sitagliptin significantly reduced the number of patients with ≥1 hypoglycaemic episodes during Ramadan [risk ratio (RR) 0.48, 95% confidence interval (CI) 0.36, 0.64; p > 0.0001]. This was not replicated in the RCTs of vildagliptin, but a significant reduction was found in the observational studies (RR 0.28, 95% CI 0.10, 0.75; p = 0.01) with high heterogeneity (I(2) = 86.7%). Significant reductions in HbA1c and weight were seen in the observational studies of vildagliptin versus sulphonylureas. The use of liraglutide led to significant weight loss (-1.81 kg, 95% CI -2.91, -0.71; p = 0.001) compared with sulphonylureas. Pioglitazone significantly increased weight compared with placebo (3.48 kg, 95% CI 2.82, 4.14; p < 0.0001). CONCLUSIONS The analysis supports the use of DPP-4 inhibitors during Ramadan rather than sulphonylureas for reduction in hypoglycaemia without a cost to diabetes control and weight. The glucagon-like peptide (GLP)-1 agonist liraglutide provides clinical benefits, but more studies are required. RCTs of DPP-4 inhibitors compared with GLP-1 agonists and novel therapies including the sodium-glucose co-transporter 2 and α-glucosidase inhibitors are needed to inform evidence-based guidelines.
Collapse
Affiliation(s)
- L J Gray
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - J Dales
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - E M Brady
- Leicester Diabetes Centre, University Hospitals of Leicester, Leicester, UK
| | - K Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Leicester Diabetes Centre, University Hospitals of Leicester, Leicester, UK
| | - W Hanif
- Department of Diabetes & Endocrinology, University Hospital Birmingham, NHS Trust, Birmingham, UK
| | - M J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Leicester Diabetes Centre, University Hospitals of Leicester, Leicester, UK
| |
Collapse
|
12
|
Héliniak É, Sari H, Chambin O, Michiels Y, Pillon F. Diabète et ramadan, une pratique à risque. ACTUALITES PHARMACEUTIQUES 2015. [DOI: 10.1016/j.actpha.2015.03.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
13
|
Rouhani MH, Azadbakht L. Is Ramadan fasting related to health outcomes? A review on the related evidence. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2014; 19:987-92. [PMID: 25538785 PMCID: PMC4274578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Revised: 03/09/2014] [Accepted: 10/16/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND Fasting during Ramadan is an Islamic rule. Although previous review studies have assessed the impact of Ramadan on cardiovascular risk factors, athlete performance, diabetes and transplantation, in this study we have appraised some on these reviews by focusing on limitations and also, we have reviewed more recently published study and several recent studies, which are not reviewed till now. MATERIALS AND METHODS In this article, we reviewed recently conducted studies in regarding the impact of Ramadan fasting on weight, lipid profile, diabetes, immune system and gestation. MEDLINE (http://www.pubmed.com) was searched by using "Ramadan" as keyword and the most recent articles in mentioned topics since 2009 until February 2014 were selected. RESULTS Although weight has been decreased during Ramadan in the most studies, weight regain is prevalent during the following months. Meta-analysis of pre-Ramadan lipid profile in comparison to post-Ramadan values had been showed that total cholesterol and triglyceride were decreased in men and high-density lipoprotein was increased among women. In regarding diabetes and fasting, diabetic patients should be aware that medical, nutritional and physical activity consulting is necessary for individuals with diabetes who want to fast during Ramadan. Although published studies show that Ramadan fasting had no serious adverse effect on offspring, it is strongly recommended that pregnant women avoid fasting because of the limitations of studies. The effect of fasting during Ramadan on the immune system is favorable. Ramadan fasting has no impact on kidney function and urine component. CONCLUSION Studies showed that Ramadan fasting has health protective effects. More precise studies should be conducted for more reliable conclusion.
Collapse
Affiliation(s)
- Mohammad Hossein Rouhani
- Food Security Research Center and Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Leila Azadbakht
- Food Security Research Center and Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran,Address for correspondence: Dr. Leila Azadbakht, Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, PO Box 81745, Isfahan, Iran. E-mail:
| |
Collapse
|
14
|
Community pharmacists’ knowledge of diabetes management during Ramadan in Egypt. Int J Clin Pharm 2014; 36:1213-21. [DOI: 10.1007/s11096-014-0019-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 09/17/2014] [Indexed: 11/25/2022]
|
15
|
Brady EM, Davies MJ, Gray LJ, Saeed MA, Smith D, Hanif W, Khunti K. A randomized controlled trial comparing the GLP-1 receptor agonist liraglutide to a sulphonylurea as add on to metformin in patients with established type 2 diabetes during Ramadan: the Treat 4 Ramadan Trial. Diabetes Obes Metab 2014; 16:527-36. [PMID: 24373063 DOI: 10.1111/dom.12249] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 11/18/2013] [Accepted: 12/12/2013] [Indexed: 11/28/2022]
Abstract
AIMS To compare a sulphonylurea with the glucagon like peptide-1 (GLP-1) receptor agonist liraglutide in combination with metformin in patients on mono/dual oral therapy with established type 2 diabetes fasting during Ramadan. METHODS Ninety-nine adults intending to fast during Ramadan [50% male, mean age 52 years, body mass index (BMI) 32 kg/m(2)] were randomized from two UK sites. Baseline data were collected ≥14 days prior to Ramadan and at 3 and 12 weeks after Ramadan. RESULTS At 12 weeks, more patients in the liraglutide compared with the sulphonylurea group achieved a composite endpoint of haemoglobin A1c (HbA1c) < 7%, no weight gain and no severe hypoglycaemia but this did not reach statistical significance [odds ratio (OR) 4.08, 95% confidence interval (CI) 0.97, 17.22, p = 0.06]. From a baseline of 7.7% there was no change in HbA1c at 12 weeks in the sulphonylurea (+0.02%) compared with a 0.3% reduction in the liraglutide group (adjusted coefficient -0.41, 95% CI -0.83, 0.01, p = 0.05). Significant reductions were also observed in weight and diastolic blood pressure (BP) in the liraglutide compared with the sulphonylurea group. Treatment satisfaction was comparable across the treatment groups. There were no episodes of severe hypoglycaemia in either group, however, self-recorded episodes of blood glucose ≤3.9 mmol/l were significantly lower with liraglutide (incidence rate ratio 0.29, 95% CI 0.19, 0.41, p < 0.0001). CONCLUSIONS Liraglutide compared with sulphonylurea is well tolerated and maybe an effective therapy in combination with metformin during Ramadan with more patients able to achieve target HbA1c, lose or maintain weight with no severe hypoglycaemia. This was achieved with a high level of treatment satisfaction.
Collapse
Affiliation(s)
- E M Brady
- Leicester Diabetes Centre, University Hospitals of Leicester, NHS Trust, Leicester, UK
| | | | | | | | | | | | | |
Collapse
|
16
|
Almaatouq MA, Al-Arouj M, Amod A, Assaad-Khalil SH, Assaad SN, Azar ST, Esmat K, Hassoun AAK, Jarrah N, Zatari S. Barriers to the delivery of optimal antidiabetic therapy in the Middle East and Africa. Int J Clin Pract 2014; 68:503-11. [PMID: 24471972 DOI: 10.1111/ijcp.12342] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The prevalence of type 2 diabetes is increasing worldwide, but developing nations will bear a disproportionate share of this burden. Countries in the Middle East and Africa are in a state of transition, where marked disparities of income and access to education and healthcare exist, and where the relatively young populations are being exposed increasingly to processes of urbanisation and adverse changes in diet that are fuelling the diabetes epidemic. Optimising diabetes care in these nations is crucial, to minimise the future burden of complications of diabetes. METHODS We have reviewed the barriers to effective diabetes care with special relevance to countries in this region. RESULTS The effects of antidiabetic treatments themselves are unlikely to differ importantly in the region compared with elsewhere, but economic inequalities within countries restrict access to newer treatments, in particular. Values relating to family life and religion are important modifiers of the physician-patient interaction. Also, a lack of understanding of diabetes and its treatments by both physicians and patients requires more and better diabetes education, delivered by suitably qualified health educators. Finally, sub-optimal processes for delivery of care have contributed to a lack of proper provision of testing and follow-up of patients in many countries. CONCLUSION Important barriers to the delivery of optimal diabetes care exist in the Middle East and Africa.
Collapse
Affiliation(s)
- M A Almaatouq
- King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Wilbur K, Al Tawengi K, Remoden E. Diabetes patient management by pharmacists during Ramadan. BMC Health Serv Res 2014; 14:117. [PMID: 24606885 PMCID: PMC3975299 DOI: 10.1186/1472-6963-14-117] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Accepted: 02/21/2014] [Indexed: 11/30/2022] Open
Abstract
Background Many Muslim diabetes patients choose to participate in Ramadan despite medical advice to the contrary. This study aims to describe Qatar pharmacists’ practice, knowledge, and attitudes towards guiding diabetes medication management during Ramadan. Methods A cross-sectional descriptive study was performed among a convenience sample of 580 Qatar pharmacists. A web-based questionnaire was systematically developed following comprehensive literature review and structured according to 4 main domains: subject demographics; diabetes patient care experiences; knowledge of appropriate patient care during Ramadan fasting; and attitudes towards potential pharmacist responsibilities in this regard. Results In the 3 months prior to Ramadan (July 2012), 178 (31%) pharmacists responded to the survey. Ambulatory (103, 58%) and inpatient practices (72, 41%) were similarly represented. One-third of pharmacists reported at least weekly interaction with diabetes patients during Ramadan. The most popular resources for management advice were the internet (94, 53%) and practice guidelines (80, 45%); however only 20% were aware of and had read the American Diabetes Association Ramadan consensus document. Pharmacist knowledge scores of appropriate care was overall fair (99, 57%). Pharmacists identified several barriers to participating in diabetes management including workload and lack of private counseling areas, but expressed attitudes consistent with a desire to assume greater roles in advising fasting diabetes patients. Conclusion Qatar pharmacists face several practical barriers to guiding diabetes patient self-management during Ramadan, but are motivated to assume a greater role in such care. Educational programs are necessary to improve pharmacist knowledge in the provision of accurate patient advice.
Collapse
Affiliation(s)
- Kerry Wilbur
- College of Pharmacy, Qatar University, PO Box 2713 Doha, Qatar.
| | | | | |
Collapse
|
18
|
Siaw MYL, Chew DEK, Dalan R, Abdul Shakoor SAKK, Othman N, Choo CH, Shamsuri NH, Abdul Karim SN, Chan SY, Lee JYC. Evaluating the Effect of Ramadan Fasting on Muslim Patients with Diabetes in relation to Use of Medication and Lifestyle Patterns: A Prospective Study. Int J Endocrinol 2014; 2014:308546. [PMID: 25435876 PMCID: PMC4244681 DOI: 10.1155/2014/308546] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 10/22/2014] [Indexed: 12/20/2022] Open
Abstract
Objectives. This study aimed to examine the effect of Ramadan fasting on HbA1c in Muslim patients with type 2 diabetes. The incidence of hypoglycemia and glycemic changes in relation to the adjustment of doses of antidiabetic agents, diet, and physical activity during Ramadan was also evaluated. Methods. This was a prospective study conducted in an outpatient endocrine clinic. A set of questionnaires was administered to Muslim patients with diabetes who fasted for ≥10 days. Those who were hospitalized for diabetic ketoacidosis or severe hypoglycemia a month prior to Ramadan or were given short-term corticosteroid therapy were excluded. The patients' responses and clinical outcomes from the clinic database were collected before, during, and after Ramadan. Results. A total of 153 participants completed the study. The mean HbA1c improved from 8.9% before Ramadan to 8.6% during Ramadan (P < 0.05). Although diet and physical activity did not contribute to changes in glycemia, a significant improvement in HbA1c was observed in patients who had adjustments made to their doses of antidiabetic agents during Ramadan (P < 0.001). In addition, their rate of hypoglycemia was minimal. Conclusions. Ramadan fasting appeared to improve glycemic control, especially in those whose doses of antidiabetic agents were adjusted during Ramadan.
Collapse
Affiliation(s)
- Melanie Yee Lee Siaw
- Department of Pharmacy, Faculty of Science, National University of Singapore, Block S4, 18 Science Drive 4, Singapore 117543
| | - Daniel Ek Kwang Chew
- Department of Endocrine and Diabetes, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433
| | - Rinkoo Dalan
- Department of Endocrine and Diabetes, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433
| | | | - Noorani Othman
- Department of Endocrine and Diabetes, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433
| | - Chor Hui Choo
- Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433
| | - Nur Hidayah Shamsuri
- Department of Pharmacy, Faculty of Science, National University of Singapore, Block S4, 18 Science Drive 4, Singapore 117543
| | | | - Sui Yung Chan
- Department of Pharmacy, Faculty of Science, National University of Singapore, Block S4, 18 Science Drive 4, Singapore 117543
| | - Joyce Yu-Chia Lee
- Department of Pharmacy, Faculty of Science, National University of Singapore, Block S4, 18 Science Drive 4, Singapore 117543
- *Joyce Yu-Chia Lee:
| |
Collapse
|
19
|
Schweizer A, Halimi S, Dejager S. Experience with DPP-4 inhibitors in the management of patients with type 2 diabetes fasting during Ramadan. Vasc Health Risk Manag 2013; 10:15-24. [PMID: 24391442 PMCID: PMC3878957 DOI: 10.2147/vhrm.s54585] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A large proportion of Muslim patients with type 2 diabetes mellitus (T2DM) elect to fast during the holy month of Ramadan. For these patients hypo- and hyperglycemia constitute two major complications associated with the profound changes in food pattern during the Ramadan fast, and efficacious treatment options with a low risk of hypoglycemia are therefore needed to manage their T2DM as effectively and safely as possible. Dipeptidyl peptidase-4 (DPP-4) inhibitors modulate insulin and glucagon secretion in a glucose-dependent manner, and consequently a low propensity of hypoglycemia has consistently been reported across different patient populations with these agents. Promising data with DPP-4 inhibitors have now also started to emerge in patients with T2DM fasting during Ramadan. The objective of this review is to provide a comprehensive overview of the currently available evidence and potential role of DPP-4 inhibitors in the management of patients with T2DM fasting during Ramadan whose diabetes is treated with oral antidiabetic drugs, and to discuss the mechanistic basis for their beneficial effects in this setting.
Collapse
Affiliation(s)
| | - Serge Halimi
- Department of Diabetology, Endocrinology and Nutrition, University Hospital of Grenoble, France
- Joseph Fourier University, Grenoble, France
| | | |
Collapse
|
20
|
Halimi S, Levy M, Huet D, Quéré S, Dejager S. Experience with Vildagliptin in Type 2 Diabetic Patients Fasting During Ramadan in France: Insights from the VERDI Study. Diabetes Ther 2013; 4:385-98. [PMID: 23996548 PMCID: PMC3889327 DOI: 10.1007/s13300-013-0038-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Indexed: 02/07/2023] Open
Abstract
AIM To assess in real life the rate of hypoglycemia during Ramadan in patients with type 2 diabetes (T2DM) in France, according to their ongoing dual therapy of metformin-vildagliptin or metformin-sulfonylurea/glinide (IS). METHODS Prospective, non-interventional study with 2 visits (within 8 weeks before and 6 weeks after the end of Ramadan 2012). Study diaries were not used to collect events or record values of glucose monitoring. One hundred and ninety-eight patients on stable oral dual therapy for ≥2 months and with glycosylated hemoglobin (HbA1c) ≤8.0% were recruited by 62 centers: 83 in the IS cohort and 115 in the vildagliptin cohort. RESULTS Approximately 90% of patients were from Maghreb. The two cohorts were well balanced: 60% men, mean age 59 years, BMI 28 kg/m(2), metformin dose ~2,000 mg/day, and HbA1c 7.2%. Distinct therapeutic management was planned in view of Ramadan with drug-adaptation intended in 61.4% of IS and 18.3% of vildagliptin patients. Hypoglycemia was reported in 37% of IS and 34% of vildagliptin patients; episodes declared as confirmed in 30.8% and 23.5%, respectively, and episodes documented as adverse event (AE) in 17.9% (22 episodes) and 7.5% (13 episodes), respectively (P = 0.025). Severe episodes were reported in 3.9% of IS and 1.7% of vildagliptin patients. 10.4% of IS and 2.6% of vildagliptin patients reported severe episodes and/or unscheduled medical visits due to hypoglycemia (P = 0.029). Glycemic control remained stable in both cohorts. Compliance with fasting was high, as well as adherence to drug with ≥5 missed-dose for 15.4% of IS and 8.5% of vildagliptin patients. CONCLUSION Although the overall frequency of malaise suggestive of hypoglycemia was high, which would be expected with prolonged fasting in a well-controlled T2DM population during hot summer days, the incidence of more severe and better-documented episodes (AE, severe event, event leading to unscheduled medical visit) were much lower, with consistently less events with vildagliptin therapy.
Collapse
Affiliation(s)
- Serge Halimi
- Department of Diabetology, Endocrinology and Nutrition, CHU Hospital Grenoble, and University Joseph Fourier, Grenoble, France
| | - Marc Levy
- Department of Diabetology and Endocrinology, Max Fourestier Hospital, Nanterre, France
| | - Dominique Huet
- Department of Diabetology and Endocrinology, Saint-Joseph Hospital, Paris, France
| | - Stéphane Quéré
- Biostatistics, Novartis Pharma SAS, Rueil Malmaison, France
| | - Sylvie Dejager
- Medical Affairs, Novartis Pharma SAS, 2-4 rue Lionel Terray, 92 506 Rueil Malmaison, France
| |
Collapse
|
21
|
Al Sifri S. Pharmacological approaches to the management of type 2 diabetes in fasting adults during Ramadan. Diabetes Metab Syndr Obes 2012; 5:293-4. [PMID: 22924005 PMCID: PMC3422908 DOI: 10.2147/dmso.s36505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Saud Al Sifri
- Correspondence: Saud Al Sifri, Chairman, Endocrinology Department, Alhada Armed Forces Hospital, PO Box 1347, Taif, 21944, Saudi Arabia, Fax +966 7541610 x2096, Email
| |
Collapse
|