Shafaqna English– The Elsevier Ireland Ltd has published the paper “Diabetes and Ramadhan: Practical guidelines” written by Mohamed Hassanein et al. in 2017.
According to Shafaqna, this paper provides comprehensive guidelines on Ramadhan fasting for diabetic patients that have been gathered by the International Diabetes Federation (IDF) and Diabetes and Ramadhan (DAR) International Alliance.
One of the five pillars of Islam is fasting during Ramadhan which is compulsory for all healthy adult Muslims. Within the Muslim community, there is an intense desire to participate in fasting, even among those who are eligible for exemption.
For fasting Muslims, the beginning of Ramadhan indicates an unexpected shift in meal times and sleep patterns. This has significant implications for physiology with subsequent changes in the rhythm and magnitude of fluctuations in multiple homeostatic and endocrine processes.
Sleeping patterns are often changed during Ramadhan and multiple circadian rhythm changes have been noted, including changes in body temperature and cortisol levels.
When fasting, insulin resistance/deficiency can result in excessive glycogen breakdown and increased gluconeogenesis in patients with diabetes and also ketogenesis in patients with T1DM. As a result, the risks facing patients with diabetes, including hypoglycaemia, hyperglycaemia, diabetic ketoacidosis, dehydration and thrombosis, are intensified during Ramadhan.
Risks of fasting for diabetic patients are mentioned below:
1- Major intra- and inter-individual variability in CGM profiles.
2- Higher rates of severe hypoglycaemia in people with T1DM or T2DM.
3- Excessive glycogenolysis and gluconeogenesis in individuals with T1DM or T2DM.
4- Increased ketogenesis in individuals with T1DM.
5- A rapid rise in glucose level after iftar most probably due to the carbohydrate-rich foods typically taken at this meal.
6- Hyperglycaemia incidence increased 5-fold among patients with T2DM.
Ramadhan-focused diabetes education is centered around empowering patients with the knowledge to make informed decisions regarding how to manage their condition during Ramadan:
- Risk quantification
- Blood glucose monitoring
- Nutritional advice
- Exercise advice
- Medication adjustments and knowing when to break the fast to minimize acute complications.
- Self-monitoring of blood glucose (SMBG)
It is essential for high risk patients that choose to fast and it should be emphasized that testing does not invalidate religious fast. SMBG should be performed several times during the day and, principally, whenever symptoms of hypoglycaemia or acute illness occur.
7- Breaking the fast for patients if blood glucose is <70 mg/dL (3.9 mmol/L) or >300 mg/dL (16.7 mmol/L): If they feel unwell, they should not fast.
8- Performing SMBG at the following times: pre-Suhoor, midday, pre-Iftar and whenever symptoms of hypoglycaemia or acute illness occur for Low risk patients.
9- Use of metformin and/or acarbose in patients with T2DM during Ramadan: No dose modification is needed but timings should be changed depending on the frequency of dose.
10- Not adjusting to Thiazolidinediones (TZD) medication during Ramadhan: Doses can be taken with iftar or Suhoor.
11- Use of second-generation Sulphonylureas (SUs) for patients with T2DM to fast safely during Ramadhan: Glibenclamide should be used with caution during Ramadhan. The use of these drugs should be individualized following clinician guidance.
12- Effective improvements in glycaemic control and weight loss as well as low risk of hypoglycaemia due to the use of Sodium-glucose co-transporter-2 (SGLT2) inhibitors: These drugs could be a safe treatment option for patients with T2DM during Ramadhan. However, certain safety concerns have been raised, such as an increase in dehydration or postural hypotension and also the risk of ketoacidosis.
13- Taking SGLT2 inhibitors with iftar according to most physicians and taking on extra fluids during the evening after a fast: Due to the low risk of hypoglycaemia with SGLT2 inhibitors, no dose adjustment is required.
14- Effectiveness of vildagliptin in improving glycaemic control.
15- Both vildagliptin and sitagliptin are associated with low rates of hypoglycaemia during fasting: These drugs do not require any treatment modifications during Ramadhan.
16- Liraglutide as an add-on treatment to pre-existing anti-diabetic regimens which can be effective in reducing weight and HbA1c levels during Ramadan.
17- An increased risk of hypoglycaemia due to insulin use during prolonged fasting, particularly for patients with T1DM and T2DM: The use of insulin analogues (basal, prandial and premix) is recommended over regular human insulin because of several advantages, including lower rates of hypoglycaemia. If a patient is taking NPH or premixed insulin at Suhoor, it is important to check blood glucose at noon before up titration of the pre-Suhoor dose.
If noon blood glucose is <110 mg/dL and pre-iftar blood glucose is not at target, long acting insulin analogues are preferred.
Those who cannot fast:
1- Patients with T1DM who have history of:
- Recurrent hypoglycaemia;
- Hypoglycaemia unawareness;
- Poor diabetes control;
- Brittle diabetes;
- Non-compliance with medical treatment;
- Patients who are ‘unwilling’ or ‘unable’ to monitor and manage their blood glucose levels.
2- Fasting should be avoided in adolescents with T1DM due to the observation of unknown.
3- All pregnant women have the option not to fast if they are worried about either their health or that of their foetus. Pregnant women with hyperglycaemia (gestational diabetes mellitus [GDM] or pre-existing diabetes) are classified as very high risk and are advised against fasting during pregnancy.
Source: researchgate