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South Asian Guidelines for Management of Endocrine Disorders

in Ramadan

Diabetic emergencies including hypoglycemia

during Ramadan
Jamal Ahmad, Md Faruque Pathan1, Mohammed Abdul Jaleel2, Farah Naaz Fathima3, Syed Abbas Raza4,
A. K. Azad Khan5, Osama Ishtiaq6, Aisha Sheikh7
Rajiv Gandhi Centre for Diabetes and Endocrinology, J. N. Medical College, Aligarh Muslim University, Aligarh, 1Department of Endocrinology,
BIRDEM, Dhaka, 2Department of Medicine, Bangalore Diabetes Hospital, Vasanthanagar, and AJ Diabetes Care and Polyclinic, BTM Layout,
3
Department of PSM, St. Johns Medical College, and Hospital, Bangalore, India, 4Department of Endocrinology, Shaukhat Khanum Cancer
Hospital and Research Center, Lahore, 5President, Diabetic Association of Bangladesh, 6Department of Endocrinology, Shifa International
Hospital, Islamabad, 7Section of Endocrinology, Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan

A B S T R A C T

Majority of physicians are of the opinion that Ramadan fasting is acceptable for well-balanced type 2 patients conscious of their disease
and compliant with their diet and drug intake. Fasting during Ramadan for patients with diabetes carries a risk of an assortment of
complications. Islamic rules allow patients not to fast. However, if patient with diabetes wish to fast, it is necessary to advice them to
undertake regular monitoring of blood glucose levels several times a day, to reduce the risk of hypoglycemia during day time fasting
or hyperglycemia during the night. Patient with type 1 diabetes who fast during Ramadan may be better managed with fast-acting
insulin. They should have basic knowledge of carbohydrate metabolism, the standard principles of diabetes care, and pharmacology
of various antidiabetic drugs. This Consensus Statement describes the management of the various diabetic emergencies that may
occur during Ramadan.

Key words: Diabetic ketoacidosis, fasting, hyperglycemia, hypoglycemia, infection, ketosis

Introduction upto 50 million people with diabetes worldwide fast for

a month each year.
It is estimated that there are 1.11.5 billion Muslims
The Quran (the sacred religious text of Islam, specifically
worldwide comprising 1825% of the worlds
exempts people with a medical condition from the duty of
population.[1,2] The population-based epidemiology of
fasting, especially if it might have harmful consequences.
Diabetes and Ramadan (EPIDIAR) study involving
People with diabetes fall within this category since this is a
12,243 people with diabetes in 13 Islamic countries found
chronic metabolic disorder which can place them at high risk
that about 43% of people with type 1 diabetes and 79% of
for various complications if the pattern and amount of their
people with type 2 diabetes fast during Ramadan.[3] Based
meals and fluid intake are altered markedly. Nevertheless,
on a worldwide prevalence of 4.6%, we can estimate that
many people with diabetes insist on fasting during Ramadan.
The decision to fast is usually taken by three people: the
Access this article online
person with diabetes, his or her healthcare providers, and
Quick Response Code:
a religious advisor. It is therefore of utmost importance
Website:
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that people with diabetes and their healthcare providers
are aware of the potential risk associated with fasting. This
DOI: familiarity and knowledge is as important in India, Pakistan,
10.4103/2230-8210.97996 Bangladesh, Indonesia, Palestine, and the Middle East as it
is in Europe, North America, New Zealand, and Australia.

Corresponding Author: Prof. Jamal Ahmad, Department of Endocrinology, Director, Rajiv Gandhi Centre for Diabetes & Endocrinology,
J. N. Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India. E-mail: jamalahmad11@rediffmail.com

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Ahmad, et al.: Diabetic emergencies during Ramadan

Fasting in Islam means absolute self-restrain from food, Hyperglycemia

drink, and sex from dawn to sunset which is not a very Long-term mortality and morbidity studies in people
difficult duty for healthy subjects; nevertheless, it might be with diabetes, such as the DCCT and the UKPDS,
difficult or impossible for sick people to cope with fasting, demonstrated the link among hyperglycemia,
thereby by the mercy of Allah they were exempted from microvascular complications, and possible macrovascular
fasting Ramadan. The period of fast may vary depending complications.[6,7] However, there is no information linking
on the geographical location of the country and the repeated yearly episodes of short-term hyperglycemia and
season of the year.[4] However, people with diabetes find diabetes-related complications during Ramadan fasting.
it psychologically unacceptable not to fast and they do not Control of glycemia in patients with diabetes who fasted
agree to be considered as ill people, therefore they usually during Ramadan has been reported to deteriorate, improve,
attempt to fast and on most occasions they succeed. or show no change.[8-12] The extensive EPIDIAR study
showed a 5-fold increase in the incidence of severe
Major Diabetic Emergencies Associated hyperglycemia (requiring hospitalization) during Ramadan
with Fasting in patients with type 2 diabetes (from 1 to 5 events/100
people/month) and an approximately 3-fold increase in
Some of the major potential complications associated with the incidence of severe hyperglycemia with or without
fasting in patients with diabetes are: ketoacidosis in patients with type 1 diabetes (from 5 to
Hypoglycemia 17 events/100 people/month).[3] Hyperglycemia may have
Hyperglycemia been due to excessive reduction in dosage of medications
Diabetic ketoacidosis to prevent hypoglycemia. Patients who reported an increase
Dehydration and thrombosis in food and/ or sugar intake had significantly higher rates
of severe hyperglycemia.[3]
Hypoglycemia
Decreased food intake is a well-known risk factor for Diabetic ketoacidosis
hypoglycemia. There are no reliable estimates concerning The risk of Diabetic ketoacidosis (DKA) is thought to be
the contribution of hypoglycemia to mortality in type 2 higher during Ramadan (at least theoretically) as fasting
diabetes; however, it is felt that hypoglycemia is an will result in hypoinsulinemia and hyperglucagonemia
infrequent cause of death in this group of patients. and ketones body formation and eventually development
Rates of hypoglycemia are some several folds lower in of DKA.[13] However, this remains just a speculation as
patients with type 2 diabetes when compared with type there are no studies showing that incidence of DKA is
1 diabetes,[3] with rates being even lower in patients actually increased during Ramadan, as a matter of fact
with type 2 diabetes treated with oral agents.[3] Loke SC there are some evidence against this assumptions. For
et al. in their prospective cohort study on the effect of instance, Kadika reported that only 2.5% of Libyan
various risk factors on hypoglycemia in diabetics who diabetes in a study developed DKA during Ramadan
fast during Ramadan reported the rate of hypoglycemia fasting; similarly in another study Abusreiwil reported
to be 1.6 times higher during the fasting compared with that 1.8% of type 1 diabetes patients developed DKA
non-fasting periods.[5] The difference was smaller than during Ramadan fasting figures that are comparable with
indicated in the EPIDAR study.[2] They observed that the non-fasting months.[14,15] Similarly, Rafik et al. 2009
good metabolic control (<8%) and old age (>60 years) reported that there was no increase in the incidence
increased RR more than twice, while taking breakfast and mortality from DKA during Ramadan which might
prior to fasting reduces RR to less than half. The effect indicate that Ramadan fasting is not a significant risk
of fasting during Ramadan on rates of hypoglycemia in factor for DKA.[16]
patients with diabetes is not known with certainty. The
EPIDAR study[3] showed that fasting during Ramadan Risks of DKA associated with Fasting in Patients with
increased the risk of severe hypoglycemia (defined as Diabetes:
hospitalization due to hypoglycemia) some 4.7-fold on Patients with diabetes, especially those with type 1
patients with type 1 diabetes (from 3 to 14 events/100 diabetes, who fast during Ramadan, are at an increased
people/month) and 7.5-fold in patients with type 2 risk for development of DKA, particularly if they are
diabetes (from 0.4 to 3 events/100 people/month). grossly hyperglycemic before Ramadan.[3] In addition,
Severe hypoglycemia was more frequent in patients in the risk for DKA may be further increased due to
whom the dosage of oral hypoglycemic agents or insulin excessive reduction of insulin dosages based on the
was changed and in those who reported a significant assumption that food intake is reduced during the
change in their life style.[3] month.

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Ahmad, et al.: Diabetic emergencies during Ramadan

Patients with diabetes exhibit a hypercoagulable state Prevention of c o m p l i c at i o n s /

due to an increase in clotting factors and impaired
emergencies
fibrinolysis. Increased blood viscosity secondary to
dehydration may enhance the risk of thrombosis. General considerations
Additionally, patients are at high risk if they have Several important issues deserve special attention. Patients
moderate to severe hyperglycemia (average blood should be encouraged to maintain their good dietary habits
glucose 150300 mg/dl) before fast, renal insufficiency, and to resist any temptation to break their dietary restrictions,
advanced micro- and macrovascular complications and as during Ramadan, social functions are frequent and food
other comorbid conditions.
is a common way of hospitality. It is always emphasized
Dose reduction in the setting of acute infection that
that adherence to diabetic diet is essential during Ramadan
becomes insufficient to meet the stress demands
in order to avoid the potential risk of hypoglycemia. This
induced by raised catecholamines and steroids.
is particularly important since some patients may gorge
Dehydration and thrombosis excessively after the fast is broken and others may completely
Limitation of fluid intake during the fast, especially of stop their medication during the holy month.
prolonged, is a cause of dehydration. Limitation of
The following life style should be re-enforced before and
fluid intake during the fast especially if prolonged is a
cause of dehydration. Dehydration may become severe during Ramadan:
in hot and humid climates and among individuals who Arrange your pre-Ramadan fasting consultation with
perform hard physical labor, all conditions that result the doctor or diabetes educator to review your control
in excessive perspiration. In addition, hyperglycemia and feasibility of fasting safely and make note of the
can result in osmotic diuresis and continue to volume changes you need to do during the fast.
and electrolyte depletion. Orthostatic hypotension may Record weight daily and inform doctor of a change of
develop especially in patients with pre-existing autonomic more than 2 kg.
neuropathy. Learn the warning symptoms of hyperglycemia and
hypoglycemia.
Management Take medication regularly as instructed.
Continue gentle to moderate physical activity
It is worth emphasizing that fasting for patients with particularly in the evening.
diabetes represent an important personal decision that Do not overeat after the fast is broken and minimize
should be made in light of guidelines for religious eating sweet or fatty foods.
exemptions and after careful considerations of the Record daily diet intake to help prevent excessive or
associated risks following ample decision with the very low consumption.
treating physicians. The ritual of fasting in the month If a complication occurs, break the fast immediately and
of Ramadan is compulsory for all mature followers seek medical help. Resist any temptation to persevere
of Islam, but exemptions are there to accommodate with the fasting till the end of the day.
individuals who cannot fast for various reasons. These Test blood glucose before and 2 hours after Iftar, before
includes, but are not limited to, very old/very young, the Sohur and at mid day.
sick, the travellers, pregnant and lactating women, and At the end of Ramadan, reflect on your achievements
women during their postdelivery and menstrual periods. and problems and feed back to the doctor/diabetes
Those people who fall into the above-specified categories educator.
and avail themselves of the provision of exemption
should compensate for the missed/lost days of fasting Frequent monitoring of glycemia
of Ramadan by various means described in religion. It is essential that patients have the means to monitor their
Individuals who are permanently incapacitated are also blood glucose levels multiple times daily. This is especially
given leverage to compensate accordingly. Explanation critical in patients with type 1 diabetes and in patients
of these issues to high-risk patients will help reduce the with type 2 diabetes who require insulin. Regular glucose
incidence of diabetic emergencies. testing will help in early detection of glycemic swings and
minimize complications.
Patients who insist on fasting need to be aware of
the associated risks and be ready to adhere to the Testing 2 hours after the dawn meal (Sahoor) is necessary
recommendations of their healthcare providers to achieve as well. It should be stressed that its essential for patients
a safer fasting experience. at least do frequent SMBGs in the first few days of fast

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Ahmad, et al.: Diabetic emergencies during Ramadan

so that they become aware of their glycemic profile with encountered during this holy month. They should be
the changed level of meal intake and with altered dosage aware of the pathophysiology, as well as preventive and
of medications and/or insulin. Thereafter they can reduce management strategies of these medical conditions.
the frequency of testing.
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Conclusion
Cite this article as: Ahmad J, Pathan M, Jaleel MA, Fathima FN, Raza SA,
Apart from a detailed understanding of the management Azad Khan AK, et al. Diabetic emergencies including hypoglycemia during
of diabetes during Ramadan, healthcare providers should Ramadan. Indian J Endocr Metab 2012;16:512-5.

have in-depth understanding of the diabetic emergencies Source of Support: Nil, Conflict of Interest: None declared.

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