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.
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