Management of diabetes in patients observing Ramadan fasting.

1. Diabetes management in Ramadan
- Dr. Mohammed Sadiq Azam

2. 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.”

3. 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

4. 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

5. 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

6. RISKS ASSOCIATED WITH FASTING IN
PATIENTS WITH DIABETES
Major risks associated with fasting
in patients with diabetes
•Hypoglycemia
•Hyperglycemia
•Diabetic ketoacidosis
•Dehydration and thrombosis

7. 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 risk
control •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 physical
labor
•Pregnancy
•Chronic dialysis

8. Can a diabetic patient fast during
Ramadan?

9. 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.

10. 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.

11. The physiological state of diabetics
during Ramadan
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.

12. The physiological state of diabetics
during Ramadan
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.

13. The physiological state of diabetics during
Ramadan
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)

14. Major risks associated with fasting in
patients with diabetes
 Hypoglycemia
 Hyperglycemia
 Diabetic ketoacidosis
 Dehydration and
thrombosis
DIABETES CARE, VOLUME 28, NUMBER 9 SEPTEMBER 2005

15. 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

16. Risks associated with fasting in patients
with 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

17. Risks associated with fasting in
patients 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

18. Risks associated with fasting in patients
with diabetes
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

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

20. 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

21. 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.

22. 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; 1:1396
N Engl J Med. 1991; 325: 196-199.

23. Recommendations during Ramadan
fasting
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.

24. Recommendations during Ramadan
fasting
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).

25. Recommendations during Ramadan
fasting
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.

26. Ramadan Education and Awareness in
Diabetes (READ) program for Muslims with
Type 2 diabetes who fast during Ramadan
Diabet. Med. 27, 327–331 (2010)

27. Benefits of Education & Counseling
according to the READ study
Diabet. Med. 27, 327–331 (2010)

29. General considerations
 Several important issues deserve special attention:
– Individualization
– Frequent monitoring of glycemia
– Nutrition
– Exercise
– Breaking the fast

30. BMJ,2010; 340: 1407-1411

31. Changes in treatment regimen
Before Ramadan During Ramadan
Patients on diet and exercise control No change needed (modify time and intensity
of exercise), adequate fluid intake
Ensure adequate fluid intake
Patients on oral hypoglycemic agents
Biguanide, 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 needed
TZDs, pioglitazone or rosiglitazone once daily
Dose should be given before the sunset meal
Sulfonylureas once a day, e.g., glimepiride 4 (Iftar); adjust the dose based on the
mg daily, gliclazide MR 60 mg daily glycemic control and the risk of
hypoglycemia
Sulfonylureas twice a day, e.g., glibenclamide Use half the usual morning dose at the
5 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

32. Changes in treatment regimen
Before Ramadan During Ramadan
Patients on insulin
70/30 premixed insulin twice daily, e.g., Ensure adequate fluid intake
30 units in morning and 20 units in
evening 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

33. 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

34. Management of type 1 diabetes
during 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.

35. Management of type 1 diabetes
during 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).

36. 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 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.

37. 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.

38. 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

39. 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

40. 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

41. 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

42. 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

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

44. Insulin Lispro Compared with Regular
Human 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.

45. Lispro Compared with Regular Human
Insulin 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.

46. Lispro Compared with Regular
Human 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 meal
Kadiri A et al. Diabetes Metab (Paris) 2001;27:482-6.

47. 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

48. 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

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

50. 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).

51. Can a patient monitor blood
sugar while fasting?

52. 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

53. 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.

54. 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

55. THANK YOU