ramadan & insulin

2. DR./ADEL ELNAGGAR
Endocrinologist
Ain Shams University, EGYPT.
Postgraduate Diabetes, UK.
Dr.Erfan & Bagedo Hospital

4. diabetes
&
Ramadan

5. DIABETES SPOT LIGHTS
RAMDAN & DIABETES
NOVEL PREMIX INSULIN
TOPICS

8. Risk Factors
• Obesity
• Race
• History of CVD
• HTN
• Physical inactivity
• Familial history
• Polycystic Ovary Syndrome
• Gestational Diabetes
? ? ? ? ? ? ?

11. (LACK OF DIABETES PYRAMID
STRATEGIES):
BASE: Early detection; diagnosis &
prevention Programs (Health
Education).
BODY: Proper scientific socio-economic
Management (Qualified Health Care
Providers).
TOP: Delay or prevent Diabetic
Complications (Reduce Morbidity &
Mortality).

14. SAUDI ARABIA
1 IN 4

15. PANCREAS
HORMONES:
INSULIN BY BETA CELLS
GLUCAGON BY ALPHA CELLS
Review of Anatomy and Physiology

16. • Pancreas secretes 40-50
units of insulin daily in two
steps:
• Secreted at low levels
during fasting ( basal
insulin secretion)
• Increased levels after
eating (prandial)
• An early burst of insulin
occurs within 10 minutes of
eating
• Then proceeds with
increasing release as long
as hyperglycemia is present

17. Insulin
• Insulin allows glucose to
move into cells to make
energy
• Inhibits glucagon activity

18. Action of Insulin on Carbohydrate,
Protein and Fat Metabolism
•Carbohydrate
• Facilitates the transport of glucose into
muscle and adipose cells
• Facilitates the conversion of glucose to
glycogen for storage in the liver and muscle.
• Decreases the breakdown and release of
glucose from glycogen by the liver

19. Action of Insulin on Carbohydrate,
Protein and Fat Metabolism
•Fat
• Stimulates lipogenesis- the transport of
triglycerides to adipose tissue
• Inhibits lipolysis – prevents excessive
production of ketones or ketoacidosis

20. Action of Insulin on Carbohydrate,
Protein and Fat Metabolism
•Protein
• Stimulates protein synthesis
• Inhibits protein breakdown; diminishes
gluconeogenesis

21. What goes wrong in diabetes?
• Multitude of mechanisms
• Insulin
• Regulation
• Secretion
• Uptake or breakdown
• Beta cells
• damage

25. Pre-Diabetes
•Impaired fasting glucose (IFG)
•FPG- 100-125mg/dL
•Impaired glucose tolerance (IGT)
•OGTT 140-199mg/dL
•HbA1c 6-6.5%

27. Insulin resistance
metabolic syndrome
adults obese
Central obesity (waist circumference)
IGT or IFG
High lipid profile
LDL-HDL/CHOLESTEROL/TRIGLYCERIDES
HIGH BP more than 130/90

31. MANAGEMENT OF DIABETES
Life style modification
Diet
Exrcise
Psychological support

34. MANAGEMENT OF DIABETES
METFORMIN
DPP4
PIOGLTAZONES
GLP1 ANALOUGES
SGLT2 INHIBITORS
SUs
INSULINs
PANCREATIC TRANSPLANTION
STEM CELLS
METABOLIC SURGERIES

36. LETHAL
WEAPON

40. • Islamic holy month
where fasting is compulsory for all healthy
Muslims
• Absolute fast
between sunrise and sunset.
• Muslims fast from:
• Food
• Liquids
• Medication
Ramadan

41. • Children
• Elderly
• Sick
• Pregnant or nursing mothers
• Menstruating women
• People with chronic illness
(e.g. DM, CKD, CVD)

42. • Which Patients with
DIABETES
are Exempt from Fasting during
RAMADAN???
Patients With High Risk Of Complications.
Many Muslims with diabetes
insist on fasting during Ramadan.
This creates a medical challenges for both
patients and physicians.
Al-Arouj et al. Diabetes Care 2005;28:2305–11
Salti et al. Diabetes Care 2004;27:2306–11

44. CNS, central nervous system; GI, gastrointestinal; T2DM, type 2 diabetes mellitus
Cernea S & Raz I. Diabetes Care 2011;34(suppl 2):S264–S271
Adipocyte
CNS
Incretin
deficiency
GI tract
Altered fat
metabolism
INSULIN
RESISTANCE
INADEQUATE
INSULIN
SECRETION
↑ HEPATIC
GLUCOSE
PRODUCTION
↑ BLOOD GLUCOSE
Hyperglucagonaemia
↑ hepatic sensitivity
to glucagon
 cells
α cells
Skeletal
Muscle
Pancreas
Muscle
Kidney
Enhanced glucose
reabsorption
Pathophysiology Of Type 2 DIABETES

45. body glucose, which is stored in the liver and muscles, is
the body’s main source of energy.
Early In The Fast ; this store of glucose is used up first
to provide energy.
Later In The Fast ; once the stores of glucose run out,
fat becomes the next store source of energy for the
body.Mahroof,Ramadan Health Guide : a guide to healthy fasting ,Department of Health ,Sept,2007
Physiological Changes
That Occur During A Fast
In The Normal State
During A Fast

48.  Type 1 Diabetes
 Severe Hypoglycaemia Or
Ketoacidosis Within Last
Three Months Prior To
Ramadan
 Recurrent Hypoglycaemia
 Sustained Poor Glycaemic
Control
 Acute Illness
 Pregnancy
 Type 2 diabetes
 Moderate hyperglycaemia
 Renal insufficiency
 Advanced macro vascular
complications
 Living alone and treated with
sulphonylurea or insulin
 Comorbid conditions that
present additional risk factors
Al-Arouj et al. Diabetes Care 2005;28:2305–11
Patients at HIGH RISK
of developing COMPLICATIONS during Ramadan
VERY HIGH RISK HIGH RISK

51. Salti et al. Diabetes Care 2004;27:2306–11
• AIM:
to study diabetes during Ramadan and investigate the
effects of fasting
• Population:
12,243 Muslim patients with diabetes in 13 countries
• Demographics:
Demographics
Type 1
diabetes
Type 2
diabetes
Number 1070 11,173
Male/Female (%) 50/50 49/51
Age (years)* 31 (12.7) 54 (11.0)
Duration of diabetes (years)* 10 (7.6) 7.6 (5.8)
*Data are mean (SD)
Percentage of patients
reported fasting at
least 15 days:
type 1 – 42.8%
type 2 – 78.7%
Epidemiology of DIABETES and Ramadan
(EPI-DIA-R) study

54. Proportionofpatients(%)
Type 1 diabetes
(n=899)
Type 2 diabetes
(n=9775)
Body weight changes during Ramadan
Adapted from Salti et al. Diabetes Care 2004;27:2306–11
EPIDIAR study - Results

55. Proportionofpatients(%)
Changes in medication during
Ramadan
Type 1 diabetes Type 2 diabetes
Insulin dose
(n=980)
OAD dose
(n=94)
Insulin dose
(n=1831)
OAD dose
(n=9476)
Adapted from Salti et al. Diabetes Care 2004;27:2306–11
EPIDIAR study - Results
OAD, oral anti-diabetic drug

56. Numberofeventspermonth
Type 1 diabetes Type 2 diabetes
Severe hyperglycaemia with or without
ketoacidosis in patients who fasted ≥15 days
0.00
0.04
0.08
0.12
0.16
0.20
Before Ramadan During Ramadan
p=0.0015
Adapted from Salti et al. Diabetes Care 2004;27:2306–11
p=0.67
EPIDIAR study - Results

57. Type 1 diabetes Type 2 diabetes
Before
Ramadan
During
Ramadan
p-value
Before
Ramadan
During
Ramadan
p-value
Overall population 0.03 0.14 0.0174 0.004 0.03 <0.0001
Patients who fasted
≥15 days
0.02 0.12 0.9896 0.003 0.02 0.0015
Number of severe hypoglycaemic events during
Ramadan (number per month)
Data (except p values) are mean
Adapted from Salti et al. Diabetes Care 2004;27:2306–11
4.5 Folds 7.5 Folds
6 Folds 6.5 Folds
EPIDIAR study - Results

58. Al-Arouj et al. Diabetes Care 2005;28:2305–11
E Hui et al. BMJ 2010;340:1407–11
RECOMMENDATIONS

59. • Individualisation
• Patient specific recommendations
• Frequent monitoring of glycaemia
• Crucial for patients with type 1 diabetes and patients with
type 2 diabetes who require insulin treatment
• This will not break the fast
• Nutrition
• Healthy and balanced diet
• Ingesting large amount of foods rich in carbohydrate and
fat should be avoided
• Exercise
• Maintain normal levels of physical activity
• Breaking the fast
• Blood glucose <3.3 mmol/L or >16.7 mmol/L
Al-Arouj et al. Diabetes Care 2005;28:2305–11;
GENERAL CONSIDERATION & RULES
for
the management of DIABETES during RAMADAN

60. DIET-CONTROLLED PATIENTS
• Risk associated with fasting is low in patients who
are adequately controlled with diet alone
• Potential risk of postprandial hyperglycaemia if
patients overindulge in eating
• Daily exercise programme
may need to be modified to
avoid hypoglycaemia
• Fluid restrictions and
dehydration may increase
the risk of thrombosis
Al-Arouj et al. Diabetes Care 2005;28:2305–11
Management of patients
with TYPE 2 DIABETES during RAMADAN

61. Patients treated with oral agents
• METFORMIN
• Minimal possibility of hypoglycaemia
• Timing of doses should be modified
• ACARBOSE
• Continue with the prescribed doses
• taken only with meals
• GLITAZONES
• Low risk of hypoglycaemia
• No change in dose required
• SHORT-ACTING INSULIN SECRETAGOGUES
• Short duration of action
• Twice-daily dosing pre-meals
• SULPHONYLUREAS
• Increased risk of hypoglycaemia
Suitable for use
during Ramadan
Use with caution
during Ramadan
Al-Arouj et al. Diabetes Care 2005;28:2305–11 & E Hui et al. BMJ 2010;340:1407–11
Management of patients
with TYPE 2 DIABETES during RAMADAN

62. He Used To Worry
About Managing
His Diabetes During
Ramadan

63. Managing diabetes during Ramadan
can be challenging1
The majority of Muslim patients with
type 2 diabetes fast during Ramadan1
proper treatment adjustments,
including INSULIN REGIMEN, are
necessary to avoid HYPOGLYCAEMIA
and HYPERGLYCAEMIA2
1. Salti I et al. Diabetes Care 2004;27:2306–2311.
2. 2. Hassanein M et al. Indian J Endocrinol Metab 2014;18(6):794–799.

66. NovoMix® 30
adds confidence to control
It Is Simple To Adjust Novomix® 30, During
Ramadan To Help Minimise The RISK Of
Hypoglycaemia Or Hyperglycaemia1
Flexible Mealtime Dosing – Patients Can Eat
Immediately After Injecting Novomix® 302
More Effective PPG Control And Lower Risk
Of Major And Nocturnal Hypoglycaemia* Vs
Human Premix Insulin3,4
1. Hassanein M et al. Indian J Endocrinol Metab 2014;18(6):794–799.
2. NovoMix® 30 Summary of Product Characteristics.
3. Hermansen K et al. Diabetes Care 2002;25:883–888.
4. Davidson JA et al. Clin Ther 2009;31:1641–1651.

67. Managing
diabetes during
Ramadan can be
challenging1
1. Hassanein M et al. Indian J Endocrinol Metab 2014;18(6

68. • 1 in 8 Muslim patients with
type 2 diabetes continue to
fast during Ramadan1
THE MAJORITY OF MUSLIM
PATIENTS WITH TYPE 2 DIABETES
WILL FAST DURING RAMADAN1
1. Salti I et al. Diabetes Care 2004;27:2306–2311.
of patients fasted
for
at least 15 days in
the Epidemiology
of Diabetes and
Ramadan
(EPIDIAR) study1
78.7%

69. Over the coming decade, the number of fasting
hours will progressively increase in the northern
hemisphere as Ramadan falls in the summer months.
Fasting increases the risk of hypoglycaemia
and hyperglycaemia as it can cause profound
changes in:1,2
DIETARY HABITS
LIFESTYLE
SLEEP PATTERNS
Despite this, only one third of patients adjust their
insulin
FASTING DURING RAMADAN
present a challenge in Muslim patients with
TYPE 2 DIABETES1
1. Salti I et al. Diabetes Care 2004;27:2306–2311. 2. Al-Arouj M et al. Diabetes Care 2005;28(9):2305–2311.

70. The Working Group for Insulin Therapy in Ramadan
developed practical advice for patients on low-ratio
premix insulin1
Guidance recommends preparation 2–3 months before
Ramadan to include:1
PREPARATION is KEY for management
of DIABETES during RAMADAN1
1. Hassanein M et al. Indian J Endocrinol Metab 2014;18(6):794–799.
In line with current ADA
guidance to include
clinical assessment and
experience from previous
Ramadan
Pre-Ramadan
individualised
assessment
To include advice on
frequency of blood
glucose monitoring, diet,
physical activity and
when to break the fast
Structured education
To assess individual
response to fasting and
insulin needs
Trial fasting
for 3 days

71. • The Working Group for Insulin Therapy in Ramadan
recommends:1
• The management plan during Ramadan should be
individualised
• Glycaemic control needs to be ascertained
• Dosage will depend on meal size and composition, post-
meal fasting
period and individual blood glucose targets
• Appropriate treatment adjustments are necessary to avoid
both hypoglycaemia and hyperglycaemia.
It is simple to adjust NovoMix® 30, during
Ramadan to help minimise the risk of hypoglycaemia
or hyperglycaemia1
Patients FASTING during RAMADAN can be
managed with NovoMix® 301
1. Hassanein M et al. Indian J Endocrinol Metab 2014;18(6):794–799.

72. 1. Hassanein M et al. Indian J Endocrinol Metab 2014;18(6):794–799.

73. It is simple to adjust NovoMix® 30
for altered mealtimes during Ramadan1
1. Adapted from Hassanein M et al. Indian J Endocrin Metab 2014;18(6):794–799.
DOSE BEFORE RAMADAN
PRE-IFTAR
(SUNSET
MEAL)
PRE-SUHUR
(DAWN
MEAL)
30/70 premix insulin
(e.g. NovoMix® 30) once
daily*
Same dose
as pre-
Ramadan
30/70 premix insulin
(e.g. NovoMix® 30) twice
daily**
Usual
morning
dose
Half usual
evening
dose
30/70 premix insulin
(e.g. NovoMix® 30) three
times daily†
Usual
morning
dose
Half usual
evening
dose
Patients receiving
human premix insulin
should be switched to
an analogue human
premix insulin:1
■ If immediate
injection before
meal is preferred1
■ If frequent
hypoglycaemia or
marked post-
prandial blood
glucose
excursions1

74. It is important for patients to
monitor blood glucose multiple times each day
during RAMADAN1
High risk
group (poor
control, high risk of
hypos)
Low risk
group (adequate
control, low risk of
hypoglycaemia)
Pre-Suhur Pre-Suhur
2 hours post-
Suhur
-
Midday Midday
Pre-Iftar Pre-Iftar
2 hours post-
Iftar
-
If symptoms of
hypoglycaemia
appear
If symptoms of
hypoglycaemia
appear
Reassure Patients That Blood
Glucose Testing Does Not Qualify
As Breaking The Fast1
The Frequency Of Monitoring Is
Dependent On Glycaemic Control
Level And Hypoglycaemia Risk1
Insulin Dose Titration And
Dosage Adjustment Should Be
Based On Pre-meal Blood Glucose
Levels1

75. It is simple to titrate
NovoMix® 30
, during Ramadan1
* Pre-Iftar dose to be adjusted based on pre-Suhur blood glucose and pre-Suhur dose to be adjusted based on pre-Iftar blood glucose levels
1. Adapted from Hassanein M et al. Indian J Endocrin Metab 2014;18(6):794–799.
Fasting/Pre-Iftar/Pre-Suhur
blood glucose level
30/70 premix insulin
dose adjustment
mmol/L mg/dL Units*
< 3.9 < 70
Break the fast
and down titrate
< 5.0 < 90 -2
5.0–7.0 90–126 0
> 7.0 > 126 +2
> 16.7 > 300
Break the fast and
increase dose by 4
units and check
ketones
It is advisable to
titrate
the low-ratio
premix insulin dose
every 3 days.1
A minimum of 2
readings on 2
consecutive days is
required to titrate
the dose.1
Fasting must be
broken if
hypoglycaemia
occurs.1

76. NovoMix® 30 offers
flexibility in dosing which may be important
during Ramadan*1,2
Relativeactionofinsulin
Physiological insulin profileTime
* HUMAN PREMIX INSULIN 30/70
1. NOVOMIX® 30 SUMMARY OF PRODUCT CHARACTERISTICS. 2. HASSANEIN M ET AL.
INDIAN J ENDOCRIN METAB 2014;18(6):794–799.

77. Human premix insulin*
should be administered at least 30 minutes before a meal1
Relativeactionofinsulin
Physiological insulin profile
Human premix insulin 30/70
30 minutes before a meal1
Time
30minutes
* Human premix insulin 30/70
1. Garber AJ et al. Diabetes Obes Metab 2007;9:630–639.
During Ramadan, this
means after a long
day fasting they will
need to wait an extra
30 minutes before
they can eat

78. Patients can take
NovoMix® 30 immediately BEFORE OR JUST AFTER
an important benefit during Ramadan
Relativeactionofinsulin
Physiological insulin profile
Human premix insulin 30/70
30 minutes before a meal3
NovoMix® 30
Immediately before a meal4
Time
30minutes
Higher maximum concentration
More effective PPG control1
Shorter acting
Reduces risk of hypoglycaemia2
Faster start action
Flexible mealtime injection – no
need to wait 30 minutes before
eating3,4
* Human premix insulin 30/70
1. Hermansen K et al. Diabetes Care 2002;25:883–888.
2. Davidson JH et al. Clin Ther 2009;31:1641–1651
3. Garber AJ et al. Diabetes Obes Metab 2007;9:630–639.
4. NovoMix® 30 Summary of Product Characteristics.

79. Hypoglycaemic
Episodes Are
More Common
During Ramadan

80. 7.5x greater risk of severe hypoglycaemia during
Ramadan*1
Severe HYPOGLYCAEMIC episodes ;
were more frequent in patients who changed their OAD
dose, insulin dose or level of physical activity1
HYPOGLYCAEMIA
is the most common reason for breaking fast during
Ramadan2
HYPOGLYCAEMIA has a negative impact on patients’
quality of life and psychological wellbeing3
Fasting during Ramadan increases the risk of
HYPOGLYCAEMIC episodes1
*Defined as hospitalisation due to hypoglycaemia
1. Salti I et al. Diabetes Care 2004;27:2306–2311. 2. Elmehdawi RR et al. Libyan J Med
2010;5:5036 - DOI: 10.3402/ljm.v5i0.5036. 3. Davis RE et al. Curr Med Res Opin
2005;21(9):1477–1483.

81. Significantly fewer MAJOR HYPOGLYCAEMIC events
with
NovoMix® 30 human premix insulin*1
*Human premix insulin 30/70 **Vs human premix insulin, Odds ratio (95% CI): 0.45 (0.22–0.93),
p<0.05
1. Adapted from Davidson JA et al. Clin Ther 2009;31:1641–1651.
Trial
038
1234
1353
1394
1466
3002
Overall
Odds ratio (95% CI)
0.50 (0.12–1.98)
0.34 (0.01–8.28)
0.57 (0.16–2.00)
0.53 (0.03–8.63)
0.31 (0.06–1.54)
0.25 (0.01–6.62)
0.45 (0.22–0.93)
p
0.32
0.50
0.38
0.66
0.15
0.41
<0.05
Favours
NovoMix® 30
Favours human
premix insulin
0.01 0.1 1 10 100
Test of heterogeneity: I2 = 0%
Meta-analysis of major hypoglycaemia in
type 2 diabetes patients1
reduction in
likelihood of major
hypoglycaemia1**

82. reduction in
likelihood of
nocturnal
hypoglycaemia1**
Significantly fewer NOCTURNAL HYPOGLYCAEMIC
events with
NovoMix® 30 vs human premix insulin*1
*Human premix insulin 30/70 **Vs human premix insulin,
Rate ratio (95% CI): 0.50 (0.38–0.67), p<0.01
1. Adapted from Davidson JA et al. Clin Ther 2009;31:1641–1651.
Trial
038
1088
1234
1353
1394
1466
1536
3002
3006
Overall
Rate ratio (95% CI)
0.57 (0.20–1.58)
0.89 (0.25–3.16)
0.44 (0.22–0.89)
1.03 (0.42–2.53)
1.03 (0.38–2.76)
0.33 (0.21–0.51)
0.44 (0.11–1.47)
1.05 (0.11–10.09)
2.43 (0.31–18.90)
0.50 (0.38–0.67)
p
0.28
0.86
0.02
0.95
0.96
0.01
0.17
0.97
0.39
<0.01
Favours
NovoMix® 30
Favours human
premix insulin
0.1 0.2 1 10 20
Test of heterogeneity: I2 = 32%
Meta-analysis of nocturnal hypoglycaemia in
type 2 diabetes patients1

83. A1chieve®:
less hypoglycaemia after upgrading to
NovoMix® 30 from human premix insulin*1
*Human premix insulin 30/70
1. Adapted from El Naggar NK et al. Diabetes Res Clin Pract 2012;98:408–413.
0.69 0.03
5.31
2.04
Major
Eventsperpatient-year 10
6
4
2
0
8
Minor
Baseline on human premix
insulin*
After 6 months on NovoMix® 30

84. A Well-documented Tolerability Profile1–
8
2002–2014
NovoMix® 30
has been
studied in at
least 50 RCTs*
2007–2010
PRESENT™
observational
study1–3
>22,000
patients
2008–2012
IMPROVE™
observational
study4–6
>51,000
patients
2010–2012
A1chieve®
observational
study7,8
>66,000
patients
In 10 Middle
East Countries
*PubMed search on 2014.07.24 using term ‘biphasic insulin aspart’ and the limit ‘randomised controlled trial’
1. Adapted from Sharma SK et al. Curr Med Res Opin 2008;24:645–652. 2. Almustafa M et al. Diabetes Res Clin
Pract 2008;81(Suppl. 1):S10–15. 3. Güler S et al. Arch Drug Inf 2009;
2:23–33. 4. Valensi P et al. Int J Clin Pract 2009;63:522–531. 5. Yang W et al. Curr Med Res Opin 2009;25:2643–
2654. 6. Gumprecht J et al. Int J Clin Pract 2009;63:966–972.
7. Home P et al. Diabetes Res Clin Pract 2011;94:352–363. 8. El Naggar NK et al. Diabetes Res Clin Pract
2012;93:408–413.
of clinical
experience*1–8
12 YEARS
NovoMix® 30
tolerability profile
demonstrated over

85. THE RISK OF
HYPERGLYCAEMIA
IS INCREASED
DURING RAMADAN

86. 5x greater risk of severe
hyperglycaemia/ketoacidosis during Ramadan1
Excessive reductions in insulin doses to avoid
hypoglycaemia or changes to diet and mealtimes
can lead to post-prandial hyperglycaemic episodes2
Post-prandial hyperglycaemia is an independent
risk factor for cardiovascular and macrovascular
disease*3
Fasting during Ramadan
increases
the RISK of HYPERGLYCAEMIA1
*There is no available data linking repeated short-term episodes of hyperglycaemia during Ramadan
to long-term complications
1. Salti I et al. Diabetes Care 2004;27:2306–2311. 2. Hassanein M et al. Indian J Endocrinol Metab
2014;18(6):794–799. 3. 2011 Guideline for Management of PostMeal Glucose in Diabetes. Available at:
www.idf.org/2011-guidelinemanagement-postmeal-glucose-diabetes (accessed March 2015).

87. Every 1% reduction in HbA1c
can reduce long-term
DIABETES COMPLICATIONS1
*p<0.0001
1. Adapted from Stratton IM et al. BMJ 2000;321:405–412.
37%
21%
14%
Microvascular
complications*
Deaths related
to diabetes*
Myocardial
infarction*

88. Targeting both PPG and FPG is an important strategy
for achieving optimal glycaemic control1
1. 2011 Guideline for Management of PostMeal Glucose in Diabetes.
Available at: www.idf.org/2011-guideline-management-postmeal-glucose-diabetes (accessed
March 2015). 2. Adapted from Monnier L et al. Diabetes Care 2003;26:881−885.
HbA1c
PPG FPG
Glucose
triad2

89. A1chieve®:
NovoMix® 30 reduced PPG and FPG
in patients switching from glargine
*82.6% of patients were on NovoMix® 30 bid by study end (24 weeks) **p<0.001 †Post-
lunch and post-dinner also significant (81.1 and 77.5 mg/dL reduction, respectively)
1. Adapted from Haddad J et al. Diabetes Ther 2013;4:309−319.
187.4
135.1
Baseline
Week 24
270.3
187.4
Pre-breakfast
FPG
Bloodglucose(mg/dL)
300
150
100
50
0
200
250
Post-breakfast
PPG**
Lower
PPG and FPG from
baseline at week
24 after switching
from glargine to
NovoMix® 301

90. A1chieve®:
NovoMix® 30 reduced PPG and FPG
in patients switching from a glargine-based basal–bolus
regimen1
*p<0.001 **Post-lunch and post-dinner also significant (73.8 and 59.4 mg/dL reduction, respectively)
1. Adapted from Dieuzeide G et al. Prim Care Diabetes 2014;8(2):111−117.
210.8
135.1
Baseline
Week 24
259.5
165.8
Pre-breakfast
FPG
Bloodglucose(mg/dL)
300
150
100
50
0
200
250
Post-breakfast
PPG**
PPG and FPG from baseline
at week 24 after switching
to NovoMix® 30 from a
glargine-based basal-bolus
regimen1
Significantly
lower

91. PRESENTTM:
PPG levels significantly improved after upgrading to
NovoMix® 30 human premix insulin1
*Human premix insulin 30/70
1. Adapted from Shestakova M et al. Curr Med Res Opin 2007;23(12):3209–3214.
Baseline on human premix insulin*
After 6 months on NovoMix® 30
275.5
188.3
Bloodglucose(mg/dL)
300
150
100
50
0
200
250
PPG

92. IMPROVETM:
PPG levels significantly improved after upgrading to
NovoMix® 30 human premix insulin1
*p<0.0001 **Human premix insulin 30/70
1. Adapted from Shah S et al. Int J Clin Pract 2009;63:574–582.
268.5
169.4
266.7
173
207.2
149.6
Baseline on human premix
insulin**
After 6 months on NovoMix® 30
PPG breakfast
Bloodglucose(mg/dL)
300
150
100
50
0
200
PPG lunch PPG dinner
250

93. A1chieve®:
PPG levels significantly improved at each meal after upgrading
to
NovoMix® 30 from human premix insulin1
*p<0.001 **Human premix insulin 30/70
1. Adapted from El Naggar NK et al. Diabetes Res Clin Pract 2012;98:408–413.
255.9
178.4
239.6
158.5
221.6
156.8
Baseline on human premix insulin**
After 6 months on NovoMix® 30
Post-breakfast
Bloodglucose(mg/dL)
300
150
100
50
0
200
Post-lunch Post-dinner
250

94. COMPLEX
REGIMEN
REDUCE
ADHERENCE
MEDICATION

95. ■During Ramadan,
the majority of
patients using a
basal-bolus
regimen will
require
3 daily injections5
COMPLEX REGIMEN
can reduce adherence,1–4
which may lead to suboptimal treatment
1. Rubin RR. Am J Med 2005;118(5A):27S−34S. 2. Vijan S et al. J Gen Intern Med 2005;20:479−482. 3.
Dieuzeide G et al. Prim Care Diabetes 2014;8(2):111–117. 4. Donnelly LA et al. Q J Med
2007;100:345−350. 5. Al-Arouj M et al. Diabetes Care 2010;33(8):1895–1902.

96. During Ramadan, the
majority of patients will
receive 2 daily injections
of a premix insulin, with
meals after sunset and
before dawn2
Premixed insulin may
be more convenient than
adding in bolus mealtime
injections, as part of a
basal–bolus regimen1
Fewer injections are required with
NovoMix® 30
Than A Basal–Bolus Regimen1
1. Inzucchi SE et al. Diabetes Care 2012;35(6):1364–1379. 2. Hassanein M et al. Indian J
Endocrinol Metab 2014;18(6):794–799.

97. IN SUMMARY
DIABETICS IN
RAMADAN
■Fasting during Ramadan increases the risk of
hypoglycaemia
■NovoMix® 30 shows a lower risk of major and
nocturnal hypoglycaemia* vs human premix insulin
■Fasting during Ramadan increases the risk of
hyperglycaemia
■Post-prandial hyperglycaemia is an independent
risk factor for cardiovascular and macrovascular
disease
■NovoMix® 30 od provides more effective PPG
control vs glargine once daily.
HYPOGLYCEMIA
HYPERGLYCEMIA

98. Managing DIABETES During RAMADAN
Can Be Challenging1
The majority of Muslim patients with type 2 diabetes fast
during Ramadan1
Appropriate treatment adjustments, including insulin
regimen, are necessary to avoid hypoglycaemia and
hyperglycaemia2
NovoMix® 30
adds confidence to control
It is simple to adjust NovoMix® 30, during Ramadan to
help minimise the risk of hypoglycaemia or
hyperglycaemia
Flexible mealtime dosing – patients can eat immediately
after injecting NovoMix® 30
More effective PPG control and lower risk of major and
nocturnal hypoglycaemia* vs human premix insulin
IN SUMMARY

99. Me
At
work

100. Me
At home

101. I need urgent
Ophthalmology consultation

102. THANK YOU
DR./ ADEL EL NAGGAR