diabetes management in ramadan

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 IN PATIENTS WITH DIABETES

Major risks associated with fastingin 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

•Severe hypoglycemia within the 3 months prior to Ramadan

•A history of recurrent hypoglycemia

•Hypoglycemia unawareness•Sustained poor glycemic control•Ketoacidosis within the 3 months prior to Ramadan

•Type 1 diabetes•Acute illness•Hyperosmolar hyperglycemic coma within the previous 3 months

•Performing intense physical labor•Pregnancy•Chronic dialysis

High risk

•Moderate hyperglycemia (average blood glucose 150–300 mg/dl or A1C 7.5–9.0%)

•Renal insufficiency•Advanced macrovascular complications

•Living alone and treated with insulin or sulfonylureas

•Patients with comorbid conditions that present additional risk factors

•Old age with ill health•Treatment with drugs that may affect mentation

Low risk

•Well-controlled diabetes treated with lifestyle therapy, metformin, acarbose, thiazolidinediones, and/or incretin-based therapies in otherwise healthy patients

Moderate risk

•Well-controlled diabetes treated with short-acting insulin secretagogues

Can a diabetic patient fast during Ramadan?

The bulk of literature indicates that fasting in Ramadan is safe for the majority of type 2 diabetic patients with proper education and diabetic management.

The physiological state of diabetics during Ramadan

1. 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.

2.Body weight

Weight 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.


3.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.


HbAIC 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 thrombosis

DIABETES CARE, VOLUME 28, NUMBER 9 SEPTEMBER 2005

Risks associated with fasting in patients with 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

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

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

Dehydration 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

Conditions related to diabetes:

- Advanced nephropathy

- Severe retinopathy

- Autonomic neuropathy

- Hypoglycemic unawareness

- Major macrovascular diseases

- Recent hyper-osmolar state or DKA

- Poorly controlled diabetes (Mean RBG> 300)

- Multiple insulin injections per day

Patients with one or more of the followingare advised not to fast

Physiological conditions:- Pregnancy- Lactation

Clinical Diabetes ( Middle East Edition)- Volume 3, Number 3, 2004

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

Patients with one or more of the followingare advised not to fast

The principles of Pre-Ramadan considerations

(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 Ramadan fasting

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; 1:1396N Engl J Med. 1991; 325: 196-199.


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.


2. 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).


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 in Diabetes (READ) program for Muslims with Type 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)

MANAGEMENT

General considerations

Several important issues deserve special attention:

– Individualization

– Frequent monitoring of glycemia

– Nutrition

– Exercise

– Breaking the fast

BMJ,2010; 340: 1407-1411

Changes in treatment regimen Before Ramadan During Ramadan

Patients on diet and exercise control

Patients on oral hypoglycemic agents

Biguanide, metformin 500 mg three times a day, or sustained release metformin (glucophage R)

TZDs, pioglitazone or rosiglitazone once daily

Sulfonylureas once a day, e.g., glimepiride 4 mg daily, gliclazide MR 60 mg daily

Sulfonylureas twice a day, e.g., glibenclamide 5 mg or gliclazide 80 mg, twice a day

No change needed (modify time and intensity of exercise), adequate fluid intakeEnsure adequate fluid intake

Metformin, 1,000 mg at the sunset meal (Iftar), 500 mg at the predawn meal (Suhur)

No change needed

Dose should be given before the sunset meal (Iftar); adjust the dose based on the glycemic control and the risk of hypoglycemia

Use half the usual morning dose at the 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.


Changes in treatment regimen

Before Ramadan During Ramadan

Patients on insulin70/30 premixed insulin twice daily, e.g., 30 units in morning and 20 units in evening

Ensure adequate fluid intake

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


Management of patients with Type 1 Diabetes 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 1 Diabetes 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

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

Mucha GT et al. Diabetes Care, 2004.

Kadiri A et al. Diabetes Metab, 2001.

Management of patients with Type 1 Diabetes

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 2 Diabetes 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


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


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


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

Int J Clin Pract, July 2010, 64, 8, 1095–1099

Insulin Lispro Compared with Regular Human Insulin During Ramadan

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.

Study Design

Lispro Compared with Regular Human Insulin During Ramadan


0

3

5

4

1

2

Fasting 1-h 2-hPostprandial time

*

HumalogRegular insulin

* P = 0.026

0

3

5

4

1

2

Fasting 1- 2-Postprandial time

*

HumalogRegular insulin

* P = 0.026

Postprandial Blood GlucoseB

lood

glu

cose

exc

ursi

on (

mm

ol/L

)

Lispro Compared with Regular Human Insulin During Ramadan


Epi

sode

s of

hyp

ogly

cem

ia

Hypoglycemia by Time of Day

0

5

10

15

20

000

Insulin LisproRegular insulin

Sunrise meal

Sunrise meal

Sunset meal

2-h 6-h 2-h 6-h

27

5

12

27

11

5

2

43

0

5

10

15

20

000

Regular insulin

Sunrise meal

Sunrise meal

Sunset meal

2-h 6-h 2-h 6-h

27

5

12

27

11

5

2

43

A comparison of insulin Lispro Mix25 and human insulin 30/70 in the treatment of type 2 diabetes during Ramadan

Mattoo et al, Diabetes Research and Clinical Practice 59 (2003) 137/143

Influence of Insulin treatment on the quality of life during Ramadan: Results from a multicentre study:3

Practical Diabetes International Supplement January/February 1998 Vo1.15 No.1

Recommended changes to treatment regimen in patients with type 2 diabetes who fast during Ramadan

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 blood sugar 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

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