6 tips for management of Diabetes during Ramadan

 7 medical tips for management of diabetes in patients who elect to fast during Ramadhan according to the findings of a research on “ Recommendations for Management of Diabetes During Ramadhan” which was published in 2010 by Monira Al-Arouj et al.

Fasting during Ramadhan, a holy month of Islam, is a duty for all healthy adult Muslims. Fasting is not meant to create excessive hardship on the Muslim individual according to religious tenets. Nevertheless, many patients with diabetes insist on fasting during Ramadhan, thereby creating a medical challenge for themselves and their health care providers.

1. Major risks associated with fasting in patients with diabetes

A. Hypoglycaemia: Decreased food intake is a well-known risk factor for the development of hypoglycaemia. It has been estimated that hypoglycaemia accounts for 2–4% of mortality in patients with type 1 diabetes. There are no reliable estimates concerning the contribution of hypoglycaemia to mortality in type 2 diabetes.

B. Hyperglycaemia: Long-term morbidity and mortality studies in people with diabetes, such as the Diabetes Control and Complications Trial (DCCT) and the UK Prospective Diabetes Study (UKPDS), demonstrated the link among hyperglycaemia, microvascular complications, and possibly macrovascular complications. Hyperglycaemia may have been due to excessive reduction in dosages of medications to prevent hypoglycaemia.

C. Diabetic ketoacidosis: Patients with diabetes, especially those with type 1 diabetes, who fast during Ramadan, are at increased risk for development of diabetic ketoacidosis, particularly if their diabetes is poorly controlled before Ramadan.

D. Dehydration and thrombosis: Limitation of fluid intake during the fast, especially if prolonged, is a cause of dehydration. The dehydration may become severe as a result of excessive perspiration in hot and humid climates and among individuals who perform hard physical labor.

2. Pre-Ramadhan medical assessment

All patients with diabetes who wish to fast during Ramadhan should prepare by undergoing a medical assessment and engaging in a structured education program to undertake the fast as safely as possible. This assessment should take place 1–2 months before Ramadan. Specific attention should be devoted to patients’ overall well-being and to the control of their glycemia, blood pressure, and lipids.

3. Management of patients with type 1 diabetes

Fasting at Ramadhan carries a very high risk for people with type 1 diabetes. This risk is particularly exacerbated in poorly controlled patients and those with limited access to medical care, hypoglycemic unawareness, unstable glycaemic control, or recurrent hospitalizations.

It is currently recommended that treatment regimens aimed at intensive glycemia management be used in patients with diabetes.

4. Management of patients with type 2 diabetes

A. 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. However, there is still a potential risk for occurrence of postprandial hyperglycaemia after the predawn and sunset meals if patients overindulge in eating.

B. Patients treated with oral agents: The choice of oral agents should be individualized.

C. Metformin: Patients treated with metformin alone may safely fast because the possibility of severe hypoglycaemia is minimal.

D. Gloxazones: The thiazolidinedione or gloxazone agents (pioglitazone and rosiglitazone) are not independently associated with hypoglycaemia, though they can amplify the hypoglycaemic effects of sulfonylureas, glinides, and insulin.

E. Sulfonylureas: It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycaemia. However, severe or fatal hypoglycaemia is a relatively rare complication of sulfonylurea use. Nevertheless, their use should be individualized with caution.

F. Short-acting insulin secretagogues: Members of this group (repaglinide and Nate glinide) are useful because of their short duration of action. They could be taken twice daily before the sunset and predawn meals.

G. Incretin-based therapy: Therapies that affect the incretin system include glucagon-like peptide-1 receptor agonists (GLP-1ras) exenatide and liraglutide and dipeptidylpeptidase-4 inhibitors (DPP-4is) alogliptin, sitagliptin, sitagliptin, and vildagliptin. These classes of agents are not independently associated with hypoglycemia, though they can increase the hypoglycaemic effects of sulfonylureas, glinides, and insulin. Exenatide in particular can be dosed before meals to minimize appetite and promote weight loss.

H. α-Glucosidase inhibitors: Acarbose, miglitol, and voglibose slow the absorption of carbohydrates when taken with the first bite of a meal. Because they are not associated with an independent risk of hypoglycaemia, particularly in the fasting state, they may be particularly useful during Ramadan.

I. 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 hypoglycaemia is less. Again, the aim is to maintain necessary levels of basal insulin to prevent fasting hyperglycaemia. An effective strategy would be judicious use of intermediate- or long-acting insulin preparations plus a short-acting insulin administered before meals.

5. Pregnancy and fasting during Ramadhan

Pregnancy is a state of increased insulin resistance and insulin secretion and of reduced hepatic insulin extraction. Fasting glucose concentrations are lower and postprandial glucose and insulin levels are substantially higher in healthy pregnant women than in healthy women who are not pregnant. Elevated blood glucose and A1C levels in pregnancy are associated with increased risk for major congenital malformations. Fasting during pregnancy would be expected to carry a high risk of morbidity and mortality to the foetus and mother, although controversy exists.

6. Management of hypertension and dyslipidaemia

Dehydration, volume depletion, and a tendency toward hypotension may occur with fasting during Ramadan, especially if the fast is prolonged and is associated with excessive perspiration. Hence, the dosage and/or the type of antihypertensive medications may need to be adjusted to prevent hypotension.

Source: shafaqna