Measures Required To Contain Risks
Question: You are a pharmacotherapist. What’s that exactly?
Answer: I have a pharmacy degree, which is someone who is trained in optimizing the medication management of the patient to ensure that it is safe, effective and also cost effective. So you have to manage the patient’s regimen as a whole, and also work on managing various diseases in collaboration with doctors. It’s a new field and is not currently present in Kuwait. But it’s catching up in the region, Saudi Arabia now has a clinical pharmacist, the University here has approved pharmacy programs. So Kuwait is kind of next in line.
Q: Well that is what you must be doing here in Dasman Diabetes Institute also. But can you tell us more about the nature of your job here, with respect to diabetic patients?
A: What we started here in Dasman is a pharmacy therapy clinic. We see patients that meet a certain criteria, primarily people that are older, over 60 years of age, and people that are on five or more medications, all those who have a new medication added to their regimen can come to our clinic. What happens is that we do a comprehensive medication review. So we ask patients to come to the clinic bringing all their medication or lists of medication that they have and we go through a systematic process; I have my staff here who take care of that.
First we study the list of medication, why they are taking it and how they are taking it, because there is a lot of mixed information out there. We do a drug interaction check on all the medication. Then we systematically try to identify any drug related problems that are occurring. This usually comes from looking at the regimen and talking to the patient about how they are taking the drugs and what they are taking it for, so that we know if there are any problems. Usually we see many types of problems of people taking too much of a dose or people taking the same drug but different brand names and they don’t know.
Q: How does this sort of misinformation happen? Is it because patients try to treat themselves or is it because they have been badly advised by some healthcare worker or what?
A: I have seen in Kuwait that there is a lot of going around to different doctors and requesting drugs that people have heard about in the news, or some family member... sometimes it is very easy to get access to these drugs... some of them you can get without a prescription and so they go to the pharmacies straight. Another thing that I noticed here is that there is a lack of education. Most people don’t know why they have been prescribed the drugs. Once we explain to the patients why they have to take the medicines that they are taking, they are more likely to stay on the drug and be more adherent to the regimen, and their perception of the drug increases.
And people are not asking the right questions. When you take a pill, I don’t expect patients to know everything about that pill, but they should know if there are any side effects that can occur, or any interactions that can occur with other drugs they are taking. They must also find out the right way to take the drug to get the best benefit.
Doctors may not be giving all the information to patients; the patients themselves don’t know what questions to ask, and I have actually tried to resolve that by doing a mini campaign for a week at the Avenues Mall, basically to encourage patients to ask about their medication. We encouraged people to ask questions: what medicines you are taking, why are you taking it, for how long, and how did it come along with the other drugs that you are taking so that they are more informed about the drugs that you are taking, instead of getting information from the Internet; there is a lot of false information out there.
Q: What are the commonly found drug interactions seen among diabetics, because diabetes usually accompanied by other complications for which the patients might be taking drugs also?
A: Generally people with diabetes also have hypertension, high blood pressure, most of these drugs don’t interact, but some for example tend to lower the potassium level in the body. But it really depends on the patient. People have heart failure and other conditions that make that likelihood of interactions higher.
Q: Is there a possibility of interaction between diabetes and hypertension drugs?
A: What I am saying is that if a drug triggers a lowering of electrolyte that can cause disturbances. So there needs to be a level of monitoring the electrolytes and a general follow up. There are certain drugs for example where you need to monitor the liver enzymes to make sure the drug is cleared from the body properly, because a lot of drugs are cleared through the liver and kidneys also.
A lot of people with diabetes are older Type 2 for example, and have underlying renal dysfunction, which means their kidneys are not functioning to their best capacity. So when their regimen includes drugs that are cleared by the kidney, you have to be more careful, to make sure that the drug levels in the body are not high.
So it depends on what your complications are, at what stage of the illness you are in, and what kind of medicines you are having and all that.
Q: If you have a diabetic patient who has renal dysfunction, but is also in need of a high dose of drug, then how do you balance the two?
A: There are medications that are not cleared by the kidney, and so there is always alternative medication that they can use. There is no any one medication for every patient. One nice thing about diabetes treatment is that we have many kinds of drugs and we have many new ones coming out in the market. So we have a lot of options. There are many drugs that are metabolized by the liver and so will not go to the kidney.
Q: How advisable is it for a diabetic patient to fast in Ramadan?
A: Actually the right question to ask would be: is it safe for a diabetic patient to fast? Again it is very dependent on the individual, depending on whether they have Type 1 or Type 2 diabetes and their level of control of the disease. They might be at a very high risk of complication if they fast. For example you can have a condition called hyperglycemia, which is very high level of blood sugar that can lead to hospitalization. Then there is hypoglycemia which is very low blood sugar level, when they really need to break the fast and eat something. So, I recommend diabetic patients to meet their doctor and discuss whether it is safe for them to fast in Ramadan or not. And if they are going to fast, how they are going to fast and all that. How they are going to do it safely? There are certain medications and changes that need to occur... there is a lot that needs to be done to ensure that someone is fasting safely.
For people whom diabetes is controlled just by diet without the need for any medication, for such people fasting might even be beneficial. But in the right way without overindulging of course.
Q: You said that some people run the risk of hyperglycemia when they fast. How is that, because when you fast your sugar level should only drop down?
A: When you don’t have diabetes and you fast, your body has a natural mechanism to balance the body sugar in the right way and to the right degree. But people with diabetes, because of the disturbances in the hormone in the system, their body over compensates sometimes. So usually people with Type 1 diabetes have to have insulin on board. If you don’t have insulin on board, you are risking a lot of these complications.
Whenever your body does not have enough sugar for your cells to function appropriately, your body will go into different sources. It usually goes into the reserves of fat in your body. But since diabetic patients have an underlying dysfunction, you have to be more careful. So diabetics need to know about these complications, and what to do if they suffer complications while fasting and so on. They have to know what the safest way to fast is.
Q: What is the safest way to fast?
A: Every patient will have to meet his or her doctor and work out the safest way. But speaking generally, you need to be mindful of maintaining your weight, not to decrease or increase your weight a lot. People usually tend to eat a huge meal at sundown. The recommendation generally is to split that up into smaller meals, and try to have more of the carbohydrates for the predawn meal or Suhoor as opposed to Iftar. Because if you have food rich in carbohydrates for Iftar then your blood sugar level shoots up. Go for a balanced diet even during Ramadan.
But each patient will have to discuss it with their doctors. Some might be taking drugs which you can’t have without food, and so that needs to be discussed and managed.
Q: Does it matter when they take their medication, because usually they might be taking their drugs in the day time, and now they would have to switch to the night?
A: Yes, it matters. And if people are making their own changes to the times at which they take medicines, then it could affect their blood glucose levels differently. They might be putting themselves at risk. It depends on how the drug works in the body. If you are taking drugs that increase insulin in your body in a short period of time, you can’t take it while fasting. Also in some cases you can’t take all your drugs at the same time. So, it needs to be seen by your doctor and you will have to make adjustments prior to Ramadan.
Q: What about exercise in Ramadan?
A: The general recommendation, and these recommendations are from the American Diabetes Association, is that you have to be mindful of physical activities because you can’t energize while you are fasting. You have to be careful with your Taraweeh prayers, because though it’s not seen by many as a physical activity, it can be quite stressful. So, try not to be too vigorous. It’s healthy to go for a small walk after meals.
But here because of the summer heat, people could easily get dehydrated and so you need to be careful about that as well. Even people without diabetes tend to get dehydrated and sometimes need to get hospitalized for IV fluids. So, people with diabetes are at a slightly higher risk and have to be careful about doing physical exercise.
Q: What have you to tell Muslims who prefer to undertake fast despite all odds?
A: We all know that fasting is one of the five pillars of Islam and it is compulsory for every able Muslim adult. But we also know that there are certain categories of people who are exempted from fasting.
One of the challenges that face healthcare professionals managing people with diabetes is that many patients will make a decision to fast without informing or discussing this with their medical provider. It is true that for some individuals it is actually very healthy to fast potentially improving their condition; doctors have long prescribed fasting as a prescription for certain ailments. However, for many people and I am focusing on those with diabetes, fasting is not recommended and can in fact be a huge detriment to a person’s health.
Unfortunately, and this is not any one person’s fault, many Muslims with diabetes are unaware of the risks associated with fasting and passionately fast despite their doctor’s recommendations.
Just to give some background to the issue, a large, international, population-based study, called the EPIDIAR study, was conducted in 13 countries on 12,243 individuals with diabetes who fasted during the month of Ramadan around the world. The results showed that during Ramadan, 42.8 percent of people with Type 1 diabetes and 78.7 percent of people with Type 2 diabetes fasted for at least 15 days.
Results also showed that less than 50 percent of the whole population changed their treatment dose.
In regards to complications, the study found an increased risk of acute complications such as frequency of low blood sugar episodes. So what does this tell us? First, that many people with Diabetes fast despite their health condition, second that there is an increased risk of complications, and finally and more importantly that not many individuals adjust their medications during this time which indicates that people with Diabetes are not working closely with their healthcare team.
We cannot say that all people with Diabetes should not fast nor can we say that all people with Diabetes can fast because it is very individual situation and depends on a person’s health condition. In general, people with Diabetes fall under certain risk categories just to name a few, people with Type 1 Diabetes, Type 2 with poor glycemic control (which means that your HbA1c is not at target level), and the elderly are considered at very high risk and are discouraged from fasting by the medical profession.
These recommendations come from expert medical opinion, primarily those of the American Diabetes Association. The reasons for these recommendations are because fasting affects blood sugar levels, and there are certain medications like insulin that need to be taken on a daily basis at the appropriate doses, without which serious complications can occur. Missing a dose for someone with Diabetes is not safe, especially for those being treated with insulin. The main complications encountered during fasting include worsening of glycemic control, increased low blood sugar episodes or hypoglycemia, high blood sugar levels or hyperglycemia, diabetic ketoacidosis (which happens because of a lack of insulin in the blood where the body switches to burning fatty acids and producing acidic ketone bodies that can be life-threatening), dehydration, and thrombosis. As you can see these complications are significant and should not be taken lightly.
Dr Nadine Halawa, Pharm D, BCPS, CGP, is the Head of Clinical Pharmacology Department at Dasman Diabetes Institute. She relocated to Kuwait about a year ago to join the institute. She did her training in the University of North Carolina, USA, where she got her Doctorate of Pharmacy degree. She practiced in a variety of different areas in the US in the primary care clinics, working with people with diabetes, hypertension and asthma among others.