Diabetes control during Ramadan fasting
ABSTRACT
For diabetic patients, fasting during Ramadan, the ninth month of the Islamic calendar, can cause wide fluctuations in blood sugar levels, posing a medical challenge for patients and physicians and increasing the risk of acute metabolic complications including hypoglycemia, hyperglycemia, diabetic ketoacidosis, dehydration, and thrombosis. Proper patient education, risk stratification, and modification of antidiabetic medications can reduce the risk of complications.
KEY POINTS
- A diabetic patient who develops signs or symptoms of hypoglycemia during Ramadan fasting should break the fast to avoid serious complications.
- Management of complications in diabetic patients during Ramadan is similar to that for nonfasting diabetic patients. Complications include hypo- and hyperglycemia, diabetic ketoacidosis, and dehydration.
- A common misconception among patients is that pricking the finger for blood sugar testing during fasting hours breaks the fast; this should be addressed during Ramadan-focused diabetes education.
DIET AND EXERCISE
All diabetic patients should be encouraged to remember to eat the predawn meal on fasting days. They should maintain a balanced diet, with complex carbohydrates with slow energy release for the predawn meal and simple carbohydrates for the sunset meal. Foods with a low glycemic index and high fiber content are recommended, and patients should be advised to avoid saturated fats and to drink plenty of fluids between sunset and sunrise to avoid dehydration.6
Diabetic patients can perform their usual physical activity, including moderate exercise, but should avoid excessive physical activity especially toward evening hours to prevent hypoglycemia.
Some patients may decide not to monitor their blood glucose as they believe that pricking the finger for blood sugar testing breaks the fast.7 Patients should be advised that this is a misconception.
ADJUSTING DIABETES MEDICATIONS
Oral diabetes drugs
Drugs such as metformin, alpha glucosidase inhibitors, thiazolidinediones, the short-acting insulin secretagogue nateglinide, dipeptidyl peptidase 4 inhibitors (eg, sitagliptin), and glucagon-like peptide 1 receptor agonists are associated with a lower risk of hypoglycemia and can be used during Ramadan fasting without significant changes in the daily dose (Table 3).8
Sulfonylureas carry a higher risk of hypoglycemia and should be used cautiously during fasting, with appropriate modification in dose and timing.9,10
Sodium-glucose cotransporter 2 inhibitors, when not combined with insulin or sulfonylureas, carry a lower risk of hypoglycemia, but during Ramadan fasting there is an increased risk of dehydration, urinary tract infection, and postural hypotension since fluids cannot be taken during fasting hours.
Dipeptidyl peptidase 4 inhibitors carry a low risk of hypoglycemia and can be used during Ramadan without dosing modification. Glucagon-like peptide 1 agonists also can be used without adjusting the dosage.11
Insulins
Insulin treatment is associated with a higher risk of hypoglycemia during Ramadan fasting.12 During fasting, the risk of hypoglycemia from premixed insulin can be minimized by changing to a multiple-dose regimen involving a basal insulin and short-acting insulin before meals, with adjustment of the short- acting insulin dose based on the anticipated carbohydrate intake for each meal.13
Patients taking premixed insulin preparations consisting of 70% intermediate-acting or long-acting insulin and 30% short-acting insulin should change to a 50/50 preparation during Ramadan fasting to reduce hypoglycemic risk and improve glycemic control; taking more of the fast-acting component controls postprandial hyperglycemia, and taking less of the intermediate or long-acting component minimizes the risk of hypoglycemia during fasting hours.14,15
Insulin analogues carry a lower risk of hypoglycemia than human insulin. Compared with a human insulin 70/30 preparation, an analogue premix containing 75% neutral protamine lispro and 25% insulin lispro resulted in better glycemic control during Ramadan fasting.16 This could be related to the pharmacodynamics of low-ratio premix analogues, as well as to the mealtime flexibility of analogue insulin, as the injections of the 75/25 mix were given immediately before the morning and evening meals. Insulin analogues are also less likely to cause postprandial hypoglycemia.16
A multiple-dose insulin regimen involving a long-acting basal insulin (eg, glargine, detemir, degludec) and a short-acting insulin (eg, glulisine, aspart, lispro) before meals is preferred in view of better glycemic control and lower risk of hypoglycemia.17
Use of an insulin pump during Ramadan is associated with a reduced risk of hypoglycemia.18 In patients with an insulin pump, the rate of basal insulin must be reduced during daytime, and the postprandial bolus of insulin must be increased after breaking the fast.
FREQUENT MONITORING OF BLOOD GLUCOSE DURING FASTING
Frequent monitoring reduces the risk of both hypoglycemia and hyperglycemia and helps control blood sugar levels during Ramadan fasting. As mentioned above, pricking the finger for blood sugar testing during fasting hours does not break the fast, and this should be emphasized during Ramadan-focused diabetes education.
The exact frequency of blood sugar testing is not defined. In patients with well-controlled diabetes without complications, testing once or twice a day is enough. Patients with poorly controlled diabetes and those with complications should test more often.
ADVICE REGARDING WHEN TO BREAK THE FAST
If signs or symptoms of hypoglycemia develop, the patient should break the fast in order to avoid serious complications. This is acceptable under Islamic law.3,19–21
MANAGEMENT OF COMPLICATIONS
Management of diabetic complications in patients during Ramadan fasting is similar to that for other diabetic patients and includes management of hypo- and hyperglycemia, diabetic ketoacidosis, and dehydration.
