Diabetes management in Ramadan - Dr. Mohammed Sadiq Azam
The Holy Quran,Surah Al Baqarah 2:185 – “Ramadan is the (month) in which was sent down the Quran, as a guide to mankind, also clear (Signs) for guidance and judgment (between right and wrong). So every one of you who is present (at his home) during that month should spend it in fasting, but if any one is ill, or on a journey, the prescribed period (should be made up) by days later. Allah intends every facility for you; He does not want to put to difficulties. (He wants you) to complete the prescribed period, and to glorify Him in that He has guided you; and perchance ye shall be grateful.”
Islam and Ramadan Islam has 1.57 billion adherents – 23% of the world population of 6.8 billion – Growing by ~3% per year Fasting during Ramadan, a holy month of Islam, is a duty for all healthy adult Muslims Muslims who fast during Ramadan must abstain from eating, drinking, use of oral medications, and smoking from pre-dawn to after sunset; however, there are no restrictions on food or ﬂuid intake between sunset and dawn
Islam and Ramadan Many patients with diabetes insist on fasting during Ramadan, thereby creating a medical challenge for themselves and their health care providers It is important that medical professionals be aware of potential risks associated with fasting during Ramadan and with approaches to mitigate those risks
From Fed state to Fasting state The transition from a fed to a fasted state can be divided into three stages: – The postabsorptive phase, 6–24 h after beginning fasting – The gluconeogenic phase, from 2–10 days of fasting – The protein conservation phase, beyond 10 days of fasting
RISKS ASSOCIATED WITH FASTING INPATIENTS WITH DIABETES Major risks associated with fasting in patients with diabetes •Hypoglycemia •Hyperglycemia •Diabetic ketoacidosis •Dehydration and thrombosis
Categories of risk in patients with type 1 or type 2 diabetes who fast during Ramadan Very high risk High risk Moderate risk•Severe hypoglycemia within •Moderate hyperglycemia •Well-controlled diabetes the 3 months prior to Ramadan (average blood glucose 150– treated with short-acting insulin•A history of recurrent 300 mg/dl or A1C 7.5–9.0%) secretagogues hypoglycemia •Renal insufﬁciency•Hypoglycemia unawareness •Advanced macrovascular•Sustained poor glycemic complications Low riskcontrol •Living alone and treated with•Ketoacidosis within the 3 insulin or sulfonylureas •Well-controlled diabetes months prior to Ramadan •Patients with comorbid treated with lifestyle therapy,•Type 1 diabetes conditions that present metformin, acarbose,•Acute illness additional risk factors thiazolidinediones, and/or•Hyperosmolar hyperglycemic •Old age with ill health incretin-based therapies in coma within the previous 3 •Treatment with drugs that may otherwise healthy patients months affect mentation•Performing intense physicallabor•Pregnancy•Chronic dialysis
The bulk of literature indicates that fasting inRamadan is safe for the majority of type 2diabetic patients with proper education anddiabetic management.
The physiological state of diabetics duringRamadan1. Carbohydrate metabolism in healthy persons Most of the studies show slight decrease in serum glucose to 3.3 mmol to 3.9 mmol (60 mg/dl to 70 mg/dl) occurs in normal adults a few hours after fasting has begun. Changes in serum glucose may occur in individuals depending upon food habits and individual differences in metabolism and energy regulation.
The physiological state of diabetics during Ramadan2.Body weightWeight losses of 1.7-3.8 kg have been reported in normal weight individuals after they have fasted for the month of Ramadan. (1-4)Some studies also show no change or slight increase.
The physiological state of diabeticsduring Ramadan3.Blood glucose variations in patients with diabetes Most patients show no significant change in their glucose control. In some patients, serum glucose concentration may fall or rise. This variation may be due to the amount or type of food consumption, regularity of taking medications, engorging after the fast is broken, or decreased physical activities.
The physiological state of diabetics duringRamadanHbAIC values show no change or even improvement during Ramadan. Only two studies have reported slight increases in glycated hemoglobin levels. (1-3)The amount of fructosamine , insulin, C-peptide also has been reported to have no significant change before and during Ramadan fasting.(4-5)
Major risks associated with fasting in patients with diabetes Hypoglycemia Hyperglycemia Diabetic ketoacidosis Dehydration and thrombosisDIABETES CARE, VOLUME 28, NUMBER 9 SEPTEMBER 2005
Risks associated with fasting in patientswith diabetes Hypoglycemia: It has been estimated that hypoglycemia accounts for 2–4% of mortality in patients with type 1 diabetes (much lesser with type2). The recent EPIDIAR study showed that fasting during Ramadan increased the risk of severe hypoglycemia (4.7-fold in patients with type 1 diabetes and 7.5-fold in patients with type 2 diabetes). Diabetes Care 2004;27:2306–2311
Risks associated with fasting in patientswith diabetes Hyperglycemia The EPIDIAR study showed 5 fold increase in the incidence of severe hyperglycemia (requiring hospitalization) in patients with type 2 diabetes 3 fold increase in the incidence of severe hyperglycemia with or without ketoacidosis in patients with type 1 diabetes. Diabetes Care 2004;27:2306–2311
Risks associated with fasting inpatients with diabetes Diabetic ketoacidosis Patients with diabetes, who fast during Ramadan, are at increased risk for development of diabetic ketoacidosis, particularly if poorly controlled before Ramadan. The risk may further increase due to excessive reduction of insulin dosage based on the assumption that food intake is reduced during the month. Diabetes Care 2004;27:2306–2311
Risks associated with fasting in patientswith diabetesDehydration and thrombosis Reports have suggested an increased incidence of retinal vein occlusion. However, hospitalizations due to coronary events or stroke were not increased during Ramadan Limitation of fluid intake during the fast, especially if prolonged, is a cause of dehydration. In addition, hyperglycemia produces an osmotic diuresis, further contributing to volume and electrolyte depletion DIABETES CARE, VOLUME 33, NUMBER 8, AUGUST 2010
Patients with one or more of the following are advised not to fast Conditions related to diabetes: - Advanced nephropathy Physiological conditions: - Severe retinopathy - Pregnancy - Autonomic neuropathy - Lactation - Hypoglycemic unawareness - Major macrovascular diseases - Recent hyper-osmolar state or DKA - Poorly controlled diabetes (Mean RBG> 300) - Multiple insulin injections per dayClinical Diabetes ( Middle East Edition)- Volume 3, Number 3, 2004
Patients with one or more of the following are advised not to fast Co-existing major medical conditions such as: - Acute peptic ulcer - Severe Pulmonary Tuberculosis - Severe infection - Severe bronchial asthma - Recurrent stones formation - Cancer with poor general condition - Overt cardiovascular diseases (Recent MI) - Severe psychiatric conditions - Hepatic dysfunction (liver enzymes > 2 × ULN)Clinical Diabetes ( Middle East Edition)- Volume 3, Number 3, 2004
The principles of Pre-Ramadanconsiderations(a) Physical well being assessment;(b) assessment of metabolic control;(c) adjustment of the diet protocol for Ramadan fasting;(d) adjustment of the drug regimen (e.g. change long-acting hypoglycemic drugs to short-acting drugs to prevent hypoglycemia);(e) encouragement of continued proper physical activity;(f) recognition of warning symptoms of dehydration, hypoglycemia and other possible complications.
Recommendations during Ramadanfasting I. Nutrition and Ramadan fasting: Abstain from the high-calorie and highly- refined foods prepared during this month. II. Physical activity and Ramadan fasting: It has been shown that fasting does not interfere with tolerance to exercise. It is necessary to continue their usual physical activity especially during non-fasting periods Lancet. 1989; 1:1396 N Engl J Med. 1991; 325: 196-199.
Recommendations during Ramadanfasting III. Other health tips for reduction of complications: 1. Implementation of the 3D Triangle of Ramadan - - drug regimen adjustment, diet control and daily activity -- as the three pillars for more successful fasting during Ramadan.
Recommendations during Ramadanfasting2. Diabetic home management that consists of: Monitoring home blood glucose especially for IDDM patients Checking urine for acetone (IDDM patients); Measuring daily weights and informing physicians of weight reduction (dehydration, low food intake, polyuria) or weight increase (excessive calorie intake) above two kilograms; Recording daily diet intake (prevention of excessive and very low energy consumption).
Recommendations during Ramadanfasting 3. Education about warning symptoms of dehydration, hypoglycemia and hyperglycemia. 4. Education about breaking fast as soon as any complication or new harmful condition occurs. 5. Immediate medical help for diabetics who need medical help quickly, rather than waiting for medial assistance the next day.
Ramadan Education and Awareness inDiabetes (READ) program for Muslims withType 2 diabetes who fast during Ramadan Diabet. Med. 27, 327–331 (2010)
Benefits of Education & Counselingaccording to the READ study Diabet. Med. 27, 327–331 (2010)
General considerations Several important issues deserve special attention: – Individualization – Frequent monitoring of glycemia – Nutrition – Exercise – Breaking the fast
Changes in treatment regimenBefore Ramadan During RamadanPatients on diet and exercise control No change needed (modify time and intensity of exercise), adequate fluid intake Ensure adequate fluid intakePatients on oral hypoglycemic agentsBiguanide, metformin 500 mg three times a Metformin, 1,000 mg at the sunset meal (Iftar),day, or sustained release metformin 500 mg at the predawn meal (Suhur)(glucophage R) No change neededTZDs, pioglitazone or rosiglitazone once daily Dose should be given before the sunset mealSulfonylureas once a day, e.g., glimepiride 4 (Iftar); adjust the dose based on themg daily, gliclazide MR 60 mg daily glycemic control and the risk of hypoglycemiaSulfonylureas twice a day, e.g., glibenclamide Use half the usual morning dose at the5 mg or gliclazide 80 mg, twice a day predawn meal (Suhur) and the full dose at the sunset meal (Iftar), e.g., glibenclamide 2.5 mg or gliclazide 40 mg in the morning,glibenclamide 5 mg or gliclazide 80 mg in evening. DIABETES CARE, VOLUME 33, NUMBER 8, AUGUST 2010
Changes in treatment regimenBefore Ramadan During RamadanPatients on insulin70/30 premixed insulin twice daily, e.g., Ensure adequate fluid intake30 units in morning and 20 units inevening Use the usual morning dose at the sunset meal (Iftar) and half the usual evening dose at predawn (Saher), e.g., 70/30 premixed insulin, 30 units in evening and 10 units in morning; also consider changing to glargine or detemir plus lispro or aspart DIABETES CARE, VOLUME 33, NUMBER 8, AUGUST 2010
Management of patients with Type 1Diabetes Fasting at Ramadan carries a very high risk for people with type 1 diabetes Risk is particularly exacerbated in poorly controlled patients and those with limited access to medical care, hypoglycemic un-awareness, unstable glycemic control, or recurrent hospitalizations The risk is also very high in patients who are unwilling or unable to monitor their blood glucose levels several times daily
Management of type 1 diabetesduring Ramadan If patients choose to fast against medical advice, it is advantageous if they are on a basal bolus regime and are familiar with carbohydrate counting. A small study (n = 9) of patients with type 1 diabetes using insulin glargine and insulin Lispro or aspart, divided in a 6 : 4 ratio of the total 24-h insulin dose, reported no episodes of severe hypoglycaemia or diabetic ketoacidosis requiring hospitalization, and the haemoglobin A1c remained stable at the end of Ramadan.
Management of type 1 diabetesduring Ramadan Insulin Lispro, as a short-acting component of the basal bolus regimen, has been found to have a lower 2-h post- prandial glucose level after the sunset meal (p = 0.026), with less hypoglycaemia (p < 0.01), as compared to regular human insulin when given with neutral protamine hagedorn insulin in an open-label crossover study (n = 64).
Management of patients with Type 1Diabetes A recent small study with insulin glargine suggests the relative safety and efﬁcacy of this agent in 15 relatively well-controlled patients with type 1 diabetes who fasted for 18 h and experienced a minimal decline in mean plasma glucose from 125 to 93 mg/dl with only two episodes of mild hypoglycemia Mucha GT et al. Diabetes Care, 2004. Another study in patients with type 1 diabetes using insulin glulisine, Lispro, or aspart instead of regular insulin in combination with intermediate-acting insulin injected twice a day led to improvement in postprandial glycemia and was associated with fewer hypoglycemic events Kadiri A et al. Diabetes Metab, 2001.
Management of patients with Type 1Diabetes Continuous subcutaneous insulin infusion (pump) management is an appealing alternative strategy, but at a substantially greater expense Compared with those who did not fast during Ramadan, patients with type 1 diabetes on insulin pump therapy who fasted showed a slight improvement in A1C Benbarka MM et al. Diabetes Technol Ther, 2010.
Management of patients with Type 2Diabetes Diet-controlled patients: In patients with type 2 diabetes who are well controlled with lifestyle therapy alone, the risk associated with fasting is quite low Patients treated with oral agents: The choice of oral agents should be individualized – Metformin – Glitazones – Sulfonylureas – Short-acting insulin secretagogues – Incretin-based therapy – α-Glucosidase inhibitors
DM type2 patients treated with insulin Problems facing patients with type 2 diabetes who administer insulin are similar to those with type 1 diabetes, except that the incidence of hypoglycemia is less Aim is to maintain necessary levels of basal insulin to prevent fasting hyperglycemia An effective strategy would be judicious use of intermediate- or long-acting insulin preparations plus a short-acting insulin administered before meals
DM type2 patients treated with insulin Although hypoglycemia tends to be less frequent, it is still a risk, especially in patients who have required insulin therapy for a number of years or in whom insulin deﬁciency predominates in the pathophysiology Very elderly patients with type 2 diabetes may be at especially high risk
DM type2 patients treated with insulin Using one injection of a long-acting or intermediate-acting insulin can provide adequate coverage in some patients as long as the dosage is appropriately individualized However, most patients will require rapid- or short-acting insulin administered in combination with the basal insulin at meals, particularly at the evening meal
DM type2 patients treated with insulin In a recent study, premixed Lispro with neutral protamine Lispro in a 50:50 ratio was used along the evening meal and regular human insulin with NPH in a 30:70 ratio at the early morning meal during Ramadan was compared with regular human insulin at 30:70 twice daily It was observed that changing to Lispro Mix 50 during Ramadan resulted in improvement in glycaemic control without increasing the incidence of hypoglycaemia. Int J Clin Pract, July 2010, 64, 8, 1095–1099
Insulin Lispro Compared with RegularHuman Insulin During Ramadan Study Design Open-label, randomized, two-way crossover study; 2 weeks on each arm 67 patients (21 female, 43 male), mean age 31.8 years Treated with Lispro immediately before meals plus NPH immediately before meals for 2 weeks then with regular human insulin 30 minutes before meals plus NPH 30 minutes before meals for 2 weeks, or the opposite sequence Kadiri A et al. Diabetes Metab (Paris) 2001;27:482-6.
Lispro Compared with Regular HumanInsulin During Ramadan Postprandial Blood Glucose 5 Blood glucose excursion (mmol/L) 4 * P = 0.026 3 * 2 1 Humalog Regular insulin 0 Fasting 1- 1-h 2- 2-h Postprandial time Kadiri A et al. Diabetes Metab (Paris) 2001;27:482-6.
Lispro Compared with RegularHuman Insulin During Ramadan Hypoglycemia by Time of Day 20 27 Insulin Lispro Regular insulin Episodes of hypoglycemia 15 27 12 10 11 5 5 5 4 3 2 0 0 0 0 Sunrise 2-h 6-h Sunset 2-h 6-h Sunrise meal meal mealKadiri A et al. Diabetes Metab (Paris) 2001;27:482-6.
A comparison of insulin Lispro Mix25 andhuman insulin 30/70 in the treatment of type 2diabetes during Ramadan Mattoo et al, Diabetes Research and Clinical Practice 59 (2003) 137/143
Influence of Insulin treatment on the quality of life duringRamadan: Results from a multicentre study:3 Practical Diabetes International Supplement January/February 1998 Vo1.15 No.1
Recommended changes to treatment regimen inpatients with type 2 diabetes who fast duringRamadan
Recommendations – Pregnancy Muslim pregnant women are exempt from fasting during Ramadan type 1, type 2 or Gestational They should be strongly advised to not fast during Ramadan These women constitute a high-risk group and their management requires intensified care Diabetes Care. 2005; 28 (9).
Can a patient monitor bloodsugar while fasting?
Monitoring Recommendations Patients should monitor their blood glucose even during the fast to recognize subclinical hypo and hyperglycemia Islam allows diabetics to have regular blood test while fasting If blood glucose is noted to be low (<60mg/dl), the fast must be broken If blood glucose is noted to be (>300mg/dl), ketones in urine should be checked & medical advice sought
Post-Ramadan supervision The patients therapeutic regimen should be changed back to its previous schedule. Patients should also be required to get an overall education about the impact of fasting on their physiology Degenerative complications check up Monthly weight, blood pressure, HbA1c and renal function evaluation every six months. Diabetes Care. 1997; 20:1925-1926.
Conclusion Majority of uncomplicated type 2 diabetic patients can fast during Ramadan safely Pre-Ramadan medical assessment, education and motivation are very important to prevent diabetic related complications Islam allows diabetics to have regular blood test while fasting Fasting along with regular prayer have been proved to aid in better control of diabetes Individualization and frequent monitoring of glycemia can significantly reduced the major risks associated with fasting