Ramadan and Diabetes

KYAMC Journal Vol. 6, No.-2, January 2016 Review Article Ramadan and Diabetes Hoque MA1, Rahman SMT2, Islam MD3, Akter N4, Rahman M5 Abstract During Ramadan, Muslims fast from dawn to dusk for one lunar month. Although a majority of Muslim patients with type 2 diabetes fast during the month of Ramadan, there are no accepted guidelines for its management during this period. The few studies on this subject suggest that there are important alterations in energy intake and physical activity, and that most patients change their pattern of drug intake. The objectives of this article is to assist in the task of advising diabetic patients who fast and provide them with guidelines regarding proper management of their diabetes during Ramadan. Key words: Ramadan Diabetes, Muslim, Management, Drugs, Font. Introduction Ramadan is a religious fast between sunrise and sunset for one lunar month each year. During this period adult Muslims are required to abstain from foods, water, beverages, oral drugs and sexual intercourse. All healthy Muslims are obliged to fast during Ramadan. Although Islam exempts persons who are sick from fasting, different international consensus meeting to establish guidelines suggested that patients with stable type 2 diabetes mellitus without progressive co-morbid pathology, under treatment with sulphonylureas could safely undertake the fast1. Nevertheless, many Muslims with diabetes choose to fast during Ramadan. The population-based epidemiological study, Epidemiology of Diabetes and Ramadan (EPIDIAR), showed that 43% of patients with Type 1 diabetes and 79% of patients with Type 2 diabetes reported fasting in 13 Islamic countries during Ramadan2. It is essential to develop a guideline for the people fasting with diabetes mellitus. The first international attempt to develop guidelines for the fasting diabetic patients during Ramadan was made at a consensus meeting held in Casablanca, Morocco in January 19951. Different guidelines recommended about various matters, but almost all of them covered following issues: (1) The psychological aspects of Ramadan fasting, (2) diabetic subjects who should fast, (3) diabetic subjects who should not fast, (4) glucose monitoring before, during and after Ramadan, (5) patient education before Ramadan, (6) therapeutic considerations, (7) research needs, and (8) methodological aspects of research in Ramadan2,3,4. This article tries to develop a common recommendation for the people fasting during Ramadan with diabetes mellitus after reviewing different articles published in renowned journals. Risks associated with fasting There are various risks for diabetic patients fasting during Ramadan2,3 and they are: l Hypoglycemia l Hyperglycemia or Hyperosmolar Hyperglycemia State (HHS) l Dabetic Ketoacidosis (DKA) l Dehydration and thrombosis 1. Dr. Md. Azizul Hoque, Associate Professor, Department of Endocrinology, Shaheed M Monsur Ali Medical College, Sirajgonj. 2. Dr. S M Tajdit Rahman, 27, Navana Garden, Kallyanpur, Dhaka-1207. 3. Dr. Md. Daharul Islam, Assistant Professor, Department of Medicine, Sir Salimullah Medical College, Dhaka 4. Dr. Nazma Akter, Resident Physician (Medicine), MARKS Medical College and Hospital, Mirpur, Dhaka. 5. Dr. Md. Motlabur Rahman, Assistant Professor, Department of Medicine, Dhaka Medical College, Dhaka. Correspondence: Dr. Md. Azizul Hoque, Associate Professor, Department of Endocrinology, Shaheed M Monsur Ali Medical College, Sirajgonj, Bangladesh. Mobile no: + 8801712622707, E-mail: azizul.endocrine@yahoo.com 649 KYAMC Journal But these risk factors are not true for all patients. Some diabetic patients are more vulnerable than others. For type 1 diabetes, it was recommended in different literatures that no patient should fast. However, if patients did insist in fasting against medical advice, a list of absolute contra-indications was identified (e.g. recent ketoacidosis). All patients with type 1 diabetes should not fast because of this vulnerability3. However, if a patient insists against medical advice, we can consider the following: Absolute contra-indications: l l l l Brittle diabetes mellitus (DM) Patients on insulin pump Patients on multiple insulin injections per day Ketoacidosis or severe hypoglycemia in the last 3 months before Ramadan l People living alone l Advanced micro- or macro-vascular complications Relative contra-indications (fast with risk): l l l l Well controlled type1 DM No diabetes ketoacidosis (DKA) No recent hypoglycemia Not more than 2 injections per day For type 2 diabetes, contra-indications to fasting identified fell into several categories. These included diabetes-related complications (e.g. nephropathy), comorbid pathologies which are contra-indications to fasting (such as uncontrolled infections), pregnancy, lactation, and multiple insulin dosing. It was felt that a specific category of contra-indications for the elderly was not required, since the majority of elderly patients who would be at risk from fasting would be so because of some other medical contr-aindications2,3. Patients with one or more of the followings are advised not to fast. Conditions related to diabetes: l l l l l l Nephropathy with serum creatinine more than 1.5 mg/dL Severe retinopathy Autonomic neuropathy: gastroparesis, postural hypotension Hypoglycemia unawareness Major macrovascular complications: coronary and cerebrovascular Recent Hyperglycemic hyperosmolar State (HHS) Vol. 6, No.-2, January 2016 or Diabetic ketoacidosis (DKA ) l Poorly controlled diabetes (Mean Random Blood Glucose (BG) > 300mg/dl) l Multiple insulin injections per day Physiological conditions: l Pregnancy l Lactation Co-existing major medical conditions such as: l l l l l l l l Acute peptic ulcer Pulmonary tuberculosis and uncontrolled infections Severe bronchial asthma People prone to urinary stones formation with frequent urinary tract infections Cancer Overt cardiovascular diseases (recent MI, unstable angina) Severe psychiatric conditions Hepatic dysfunction (liver enzymes > 2 x ULN) [Upper limit of normal ] Management of Diabetes during Ramadan Management during month of Ramadan is different. Several factors should be kept in mind during treatment. At first, we should start by identifying patients with either Type I or Type II DM who are at risk of developing complications by fasting3,4,5,6. Table no.1: Risk assessment. VeryHigh Risk Severe hypoglycemia during the three months prior to Ramadan DKA within three months prior to Ramadan HONK within three months prior to Ramadan High Risk Patients with moderate hyperglycemia patients with renal insufficiency People living alone treated with insulin or sulphonylurea Type IDM Patients with a history Old age with ill health Drugs that may affect of recurrent hypoglycemia mentation Patients with co-morbid Poor glycemic control conditions that may present additional risk Acute illness Pregnancy Moderate Risk Well controlled patients on short acting insulin secretagogues such as Repiglinide or Nateglinide Chronic dialysis Patients who perform intense physical labor Life style recommendations: Special precautions are recommended to avoid hypoglycemia events: l To take Sahur (morning meal) close to last time of Sahur. 650 KYAMC Journal l To change in the schedule, amount and composition of meals. l To reduce physical activities during the day. However, physiscal exercises can be performed about one hour after Iftar (evening meal). l To keep the same diet during Ramadan as before2,3. Therapeutic prescriptions: l Understanding and compliance with treatment is crucial for patients receiving Oral Antidiabetic Drugs (OAD) once daily2,7. l To administer the OAD at breaking of fasting time for patients receiving divided doses of OAD7. l To administer the higher dose of OAD before breaking of fasting and the lower dose at sahur time. It is recommended to administer half the preRamadan lower dose initially to avoid hypoglycemia2,8,9. l For type 2 diabetic patients treated with insulin to use intermediate acting insulin which, must be administrated at the breaking of fasting table 22,8,9. Monitoring during Ramadan Patients should monitor their blood glucose even during the fast to recognize subclinical hypo and hyperglycemia2,3. l 2 hours post sahure and one hour pre iftar are likely to pick subclinical hypoglycemia. l 1-2 hours post iftar is likely to pick subclinical hyperglycemia. l If blood glucose is noted to be low, the fast must be broken. l If blood glucose is noted to be >300 mg/dL, ketones in urine should be checked and medical advice sought. Education of diabetic patients and of their families: l Must focus on: The situations contra-indicating fasting. Treatment of diabetics and its modifications. Importance and tools of medical monitoring and selfmonitoring. l Must insist on: The risks of acute complication and means to prevent them. Generalization of information on the problem of diabetes and Ramadan. l Must be performed by: Nurses, patient associations and concerned authorities. Vol. 6, No.-2, January 2016 l Must be achieved: Before Ramadan using various methods (individual or group education, meetings for public information, document, audiovisual media, Friday prayers). Breaking the Fast: Patients should end their fast if l Blood glucose is <60mg/dL (3.3 mmol/L) l If the sugar is <70 mg/dL (3.9 mmol/L) in first few hours after Sahur and the patient has taken insulin or sulphonylurea at Sahur l If blood sugar is greater than 300 mg/dL (16.7 mmol/L) and patient is very much symptomatic Table 2 : Changes of diabetes management during Ramadan. Before Ramadan During Ramadan Patients on diet and exercise control No change needed (modify time and intensity of exercise), ensure adequate fluid intake Patients on oral hypoglycemic agents Ensure adequate fluid intake Biguanide, metformin 500 mg three Metformin, 1,000 mg at the sunset meal (Iftar), 500 mg at the predawn meal (Suhur) times a day, or sustained release metformin Sulfonylureas once a day, e.g., Dose should be given before the sunset meal (Iftar); gliclazide MR, glimepiride adjust the dose based on the glycemic control and the risk of hypoglycemia Sulfonylureas twice a day, e.g., Use half of the usual evening dose at the predawn meal glibenclamide 5 mg or gliclazide (Suhur) and the full morning dose at the sunset meal 80 mg, twice a day (morning and (Iftar), e.g., glibenclamide 2.5 mg or gliclazide 40 mg in the evening) morning, glibenclamide 5 mg or gliclazide 80 mg in evening. Repaglinide Should be used as usual (ie take tablet only if meal is taken) in usual dose. Thiazolidinedione No change needed Patients on insulin Ensure adequate fluid intake in all cases 70/30 premixed insulin twice daily, Use the usual morning dose at the sunset meal (Iftar) e.g., 30 units in morning and 20 and half of the usual evening dose at predawn (Suhur). units in evening e.g., 70/30 premixed insulin, 30 units in evening and 10 units in morning; also consider changing to insulin analogue. Conclusion These recommendations were established based on the little scientific knowledge available on fasting in Ramadan, and is the responsibility of physicians to apply their knowledge at their discretion. But it is high time to develop a proper guideline especially for Bangladeshi diabetic patient who are fasting during Ramadan. References 1. International Meeting on Diabetes and Ramadan Recommendations: Edition of the Hassan II Foundation for Scientific and Medical Research on Ramadan. Casablanca, Morocco, FRSMR; 1995. 651 KYAMC Journal 2. Joint meeting of the board of the Egyptian Group of Diabetes (EGD) and the Egyptian Society for Endocrinology, Metabolism and Diabetes (ESEMD) in Alexandria, Egypt during the 6th and 7th annual diabetes congress. September 2001 and 2002. 3. Al-Arouj M, et al.: Recommendations for Management of Diabetes During Ramadan Diabetes Care 2005; 28: 2305-2311. 4. Al-Arouji M, et al. Recommendations for Management of Diabetes During Ramadan Diabetes Care 2010;33(8): 1895-1902. 5. Zarger A H, Siraj M, Jawa A A, Hasan M, Mahtab M. Maintenance of glycaemic control with evening Vol. 6, No.-2, January 2016 administration of a long acting sulphonylurea in male type 2 diabetic patients undertaking the Ramadan fast. Int J Pract 2010; 64(8): 1090-94. 6. Aadil N, Houti I E and Moussamih S. Drug intake during Ramadan. BMJ 2004; 329: 778-82. 7. Aslam M, Assad A. Drug regimens and fasting during Ramadan: a survey in Kuwait. Public health 1986; 100:49-53. 8. Subekti I. Jakarta diabetes updates. November 2002. 9. Chowdhury TA, Hussain HA, Hayes M. Diabetes self-management during Ramadan. Practical Diabetes International 2003; 20: 305. 652