Medical Management of Diabetes During Ramadan

Jennifer Hamilton, MDAugust, 2007 CERajab, 1428 AH

Ramadan

Holy month in IslamFrom sunrise to sunset:

No foodNo drinkingNo smoking

Ramadan

Holy month in IslamFrom sunrise to sunset:

No foodNo drinkingNo smokingAnd no oral medications

Specific exemption in the Qur'an if fasting would be harmful

Eating During Ramadan

Usually two meals65% of calories at post-sunset meal!Some studies suggest that calories,

carbohydrates dropIncreased fried foods

Medications during Ramadan

Ear, eye dropsTransdermals, creams, ointmentsSuppositoriesInjections (except IV feeding)OxygenSublingual nitroglycerin

Warning: limited data

Ramadan is never the sameStudies may not be generalizable

Ramadan: a lunar month

2007: September 13 – October 122008: September 1 – September 302009: August 21 – September 192010: August 11 – September 92015: June 18 – July 17

Diabetes, Fasting, and Ramadan

2001/1422 Epidemiology of Diabetes and Ramadan (EPIDAR) study in 13 countries79% of Type II DM fast43% of Type I DM fastEstimate 40-50 million people with DM

observe the Ramadan fast

During fasting

Glucose, insulin levels fallGlucagon gluconeogenesis from

glycogenFree fatty acids ketones

Risks during fasting

Hypoglycemia: hospitalizations

increased 4.7 times for Type I (3/100 to 14/100)

Increased 7.5 times for Type II (0.4/100 to 3/100)

HyperglycemiaNo consistent study

findingEPIDAR: increase

in hospitalization in both types of DM

Risks during fasting

DKADehydration

Orthostatic hypotension syncope, falls

Electrolyte abnormalities

Thrombosis?

M. al-Arouj et al, “Recommendations for management of diabetes during Ramadan,” Diabetes Care, 28(2005), 2305-2311.

Risks during fasting

“Most often, the recommendation will be to not undertake fasting.

However, patients who insist on fasting need to be aware of the associated risks and be ready to adhere to the recommendations of their health care providers to achieve a safer fasting experience.”

Very High Risk

Severe hypoglycemia within the last 3 months prior to Ramadan

Patient with a history of recurrent hypoglycemia

Patients with hypoglycemia unawareness

Acute illness Pregnancy Patients on chronic

dialysis

Patients with sustained poor glycemic control

Ketoacidosis within the last 3 months prior to Ramadan

Type 1 diabetes Hyperosmolar

hyperglycemic coma within the previous 3 months

Patients who perform intense physical labor

High Risk

Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mg/dl, A1C 7.5–9.0%)

Patients with renal insufficiency

Patients living alone Drugs that may affect

mentation

Patients with advanced macrovascular complications

People living alone that are treated with insulin or sulfonylureas

Patients with comorbid conditions that present additional risk factors

Old age with ill health

Better candidates

Moderate riskWell-controlled

patients treated with short-acting insulin secretagogues such as repaglinide or nateglinide

Low riskWell-controlled

patients treated with diet alone, metformin, or a thiazolidinedione who are otherwise healthy

Type II DM

Diet-ControlledChange timing and intensity of exercise to

reduce risk of hypoglycemiaEat two or 3 times a night

MetforminLow risk of hypoglycemiaChange dosing schedule to after sunset meal

(2/3) and before dawn meal (1/3)

Type II DM

Insulin sensitizers/glitazonesLow risk of hypoglycemiaMay not need to change dose

SulfonylureasHigh risk of hypoglycemia

Short-acting insulin secretagoguesReschedule doses

Type II and insulin

Much higher risk of trouble!Studies are limited!Shorter-acting insulins may be better

Lispro at each meal? (Less hypoglycemia than human insulin)

Intermediate-acting insulin at sunset meal?

Type I Diabetes

Just don't do it.

Type I Diabetes

Just don't do it.Frequent monitoringBreak the fast if hypoglycemia or

hyperglycemia develop

Other concerns

HypertensionDrug scheduling & interactions

Change to longer-acting medications? (naproxyn vs. ibuprofen)

Change to other forms of medication?“empty-stomach” medicationsFood interactions

Before Ramadan

Talk with your patientsDo they want to attempt the fast?Share concerns

Way Before Ramadan

Consider talking with an imam at a local mosque

How is Ramadan approached by the local congregation?

Sources

N Aadil, IE Houti, and S Moussamih, “Drug Intake During Ramadan,” BMJ, 329(7469), 2 October 2004, 778-782.

M. al-Arouj et al, “Recommendations for management of diabetes during Ramadan,” Diabetes Care, 28(2005), 2305-2311.

B.Benaji et al, “Diabetes and Ramadan: Review of the literature,” Diabetes Research and Clinical Practice 73(2006), 117-125.