Suggested insulin regimens for patients with type 1 diabetes mellitus who wish to fast during the month of Ramadan

doi:10.1016/j.clinthera.2008.08.007

Clinical Therapeutics

Volume 30, Issue 8, August 2008, Pages 1408-1415

https://doi.org/10.1016/j.clinthera.2008.08.007 Get rights and content

Abstract

Objectives:This paper reviews available information on insulin regimens that may enable patients with type 1 diabetes mellitus to fast during the month of Ramadan with minimal complications. It also provides guidance for health care professionals in managing patients who wish to observe the fast.

Methods:Relevant English-language articles were identified through searches of the MEDLINE, EMBASE, and Index Medicus Eastern Mediterranean Region databases (all, 1980-2008) conducted in February 2008 using the terms Ramadan, fasting, type 1 diabetes mellitus, hypoglycemia, and hypotension. Only original research and review articles related to adult patients with type 1 diabetes were considered for review, excluding pregnant women and patients with poorly controlled disease.

Results:The literature review identified 5 clinical trials relevant to type 1 diabetes and fasting. Two main meals are eaten during Ramadan, one before dawn (Suhur) and the other at sunset (Iftar). Suggested adjustments to the insulin regimen during fasting include using 70% of the pre-Ramadan dose, divided as follows: 60% as insulin glargine given in the evening and 40% as an ultra-short-acting insulin (insulin aspart or lispro) given in 2 doses, 1 at Suhur and 1 at Iftar. Alternatively, 85% of the pre-Ramadan dose may be divided as 70% Ultralente and 30% regular insulin, both given in 2 doses, 1 at Suhur and 1 at Iftar. Another option is to give 100% of the pre-Ramadan morning dose of 70/330 premixed insulin at Iftar and 50% of the usual evening dose at Suhur. Patients who observe the fast should be advised to monitor their blood glucose regularly,avoid skipping meals or overeating,and maintain contact with their physician throughout the fast. The fast should be broken immediately if blood glucose drops below 60 mg/dL (3.3 mmol/L).Breaking the fast should be considered when blood glucose drops below 80 mg/dL (4.4 mmol/L), and the fast should be interrupted if blood glucose rises above 300 mg/dL (16.7 mmol/L) to avoid diabetic ketoacidosis. Fasting is contraindicated in patients with poorly controlled type 1 diabetes,including those with a history of severe hypoglycemia and/ or diabetic ketoacidosis at least 3 months before Ramadan; those with comorbid conditions (eg, unstable angina, uncontrolled hypertension, advanced macrovascular complications, infections, renal insufficiency);; those who are noncompliant with diet and medication; those who engage in intense physical activity; pregnant women; and the elderly.

Conclusion:Patients with type 1 diabetes who wish to fast during Ramadan should follow specific recommendations and be closely monitored by their physician.

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Cited by (44)

High HbA1c is not a reason not to fast during Ramadan in Children, adolescents and young adults with Type 1 diabetes – An observational study in Bangladesh
2021, Diabetes Research and Clinical Practice
Citation Excerpt :
EPIDIAR, a population-based study conducted among 13 countries, showed that 78.7% of patients with type 2 diabetes (T2DM) and 42.8% of T1DM could fast during Ramadan [9]. Several studies of small populations have suggested that Ramadan fasting can safely be practiced by children and adolescents with stable T1DM with good hypoglycaemic awareness [10–14]. The conditions for safety were pre-fasting medical assessment, focused education, appropriately adjusted insulin regimens, dietary advice, and management the daily activity.
Our aim was to investigate the ability, frequency of acute complications and impact on glycemic control in uncontrolled T1DM who fasted during Ramadan.
74 Patients with T1D who insisted on fasting were enrolled 1 month prior to Ramadan and given intensive education by Diabetes team on insulin dose, glucose monitoring and dietary adjustments. Patients were divided into two groups ; group A- HbA1c < 9%(<75 mmol/mol) and group B- HbA1c ≥ 9% (≥75 mmol/mol) and different variables were compared.
Most of the patients fasted 58 (78.4%) for more than 15 days. There was no significant difference (p = 0.790), while comparing the breaking the fast in the two groups. Hypoglycaemia was common acute complications among them. There was no significant difference in the frequency of hypoglycaemia between two groups (P = 0.448). There was increased insulin requirement in both groups during Ramadan (p = 0.00001), with an increase in basal insulin in well controlled (from 24 to 34 units). There was significant reduction of Post Ramadan mean HbA1C in both groups [P = 0.0001)].
Children, adolescents and young adults with T1D with poor glycaemic control can fast safely during Ramadan with proper education and intensive monitoring.
The South Asian Health Foundation (UK) guidelines for managing diabetes during Ramadan
2020, Diabetes Research and Clinical Practice
Citation Excerpt :
If the patient is taking insulin or insulin secretagogues (e.g. sulphonylurea), they must be instructed to break the fast if the morning blood glucose is < 70 mg/dL (<3.9 mmol/L) at suhoor [80]. Fasting is contraindicated in people with poorly controlled T1DM, including patients with a history of severe hypoglycaemia and/or diabetic ketoacidosis at least 3 months before Ramadan [81], and guidelines recommend that people with T1DM (even well-controlled) should not fast [37,38,59,75,82]. Taking into account the risks of poor glycaemic control, people with T1DM, on a four times daily basal bolus regimen, must be discouraged from fasting during the month of Ramadan.
Fasting in the holy month of Ramadan is among the five pillars of Islam and is considered as a religious obligation by the Muslim population. People with diabetes observing the practice of fasts are at a higher risk of complications such as hypoglycaemia, hyperglycaemia and ketoacidosis due to changes in eating patterns and circadian rhythms. With the objective of mitigating these complications, the South Asian Health Foundation (UK) has developed the present guidelines based on robust evidence derived from epidemiological studies and clinical trials.
We have highlighted the role of pre-Ramadan risk stratification and counselling by healthcare professionals with emphasis on the need for advice on adequate dietary and fluid intake, blood glucose monitoring and awareness of when to break the fast.
We reviewed the current literature and have given clinically-relevant recommendations on lifestyle modifications and glucose-lowering therapies such as metformin, sulphonylureas, dipeptidyl peptidase-4 inhibitors, sodium glucose co-transporter-2 inhibitors, thiazolidinediones, glucagon-like peptide-1 receptor agonists and insulin.
An individualised patient-centric treatment plan is essential to not only achieve optimal glycaemic outcomes but also enable people with diabetes to observe a risk-free month of fasting during Ramadan.
The incidence of diabetic ketoacidosis during Ramadan fasting: A 10-year single-centre retrospective study
2019, Diabetes Research and Clinical Practice
Citation Excerpt :
Such differences enrich the literature and lend support to the previously published studies suggesting the lack of substantial evidence of enhanced risk of DKA by the changes in lifestyle and medication during Ramadan [7–11]. The results are plausible with the fact that the pathogenesis of DKA requires more than a modest reduction of doses of inulin [12,13], particularly when new insulin preparations of better action profiles [14–16] and more modern modes of delivery such insulin pumps which showed favourable results in children and adults [16–21]. Notwithstanding, pre-Ramadan management education on insulin dose reduction and avoidance night over-eating remains the main focus of pre-Ramadan clinic visits emphasized in the recent guidelines (3–5).
There has been an increased interest in the potential metabolic derangements and acute complications of diabetes related to the Muslims’ fasting during the month of Ramadan.
We compared the incidence of admissions due to diabetic ketoacidosis (DKA) during Ramadan with the admissions during other months.
This is a retrospective electronic database and chart review study that included all Muslims who were admitted with DKA to Sheikh Khalifa Medical City in Abu Dhabi, United Arab Emirates. We explored the relationship of admissions to Ramadan over ten years (2005–2014).
There were 432 episodes of DKA involving 283 patients. Of these, 370 episodes (85.6%) involved 231 patients (81.6%) with type 1 diabetes. The number of admission episodes was not different during Ramadan from the average calendar month [3.6 ± 2.6 (Range 0–15) episodes/month versus 3.3 ± 2.1 (Range 1–7) episodes/month respectively, P = 0.77]. No recurrences of admissions were observed during Ramadan. There was a non-significant numerical tendency for more episodes in March and September (4.6 episodes for both) and fewer episodes in July (2.6 episodes) than other months; P values were 0.06; 0.13, and 0.32 respectively. This seasonality was not related to the month of Ramadan.
The present study confirmed that DKA admissions during Ramadan were not significantly higher than the average monthly admissions over ten years. Seasonality trends were not related to Ramadan.
Ramadan and diabetes: What we see, learn and understand from continuousglucose monitoring
2015, Diabetes and Metabolism
Citation Excerpt :
Thus, it is easy to understand why undesirable changes in body weight are seen in some patients with diabetes and why such people also exhibit poor overnight glycaemic control when additional meals are taken. An abundance of reports in the literature [4,22,24–30] has been devoted to the pharmacological management of diabetic patients who wish to fast during Ramadan, and a patient-centred approach is the most common recommendation made to healthcare professionals. However, when it comes to specific patients, this message is difficult to deliver, as the considerations that should be taken into account are usually general and non-specific.
Abstinence from eating and drinking from dawn to sunset characterizes the holy month of Ramadan. For the 50 million Muslims worldwide with diabetes who adhere to this religious fast, the practice results in marked changes in glucose homoeostasis. The sunset meal (Iftar) that breaks the fasting state is followed by exaggerated surges in blood glucose and sustained overnight hyperglycaemia in cases of nocturnal overfeeding. The predawn meal (Suhoor) frequently results in prolonged glucose decay over the daylight hours. These glycaemic disturbances are particularly marked in insulin-treated patients, in those with unsatisfactory diabetes control during the pre-Ramadan period and in patients who are poorly compliant with lifestyle recommendations. Whether such patients should be exempt from the Islamic fast remains an open debate, which might be partially resolved by long-term controlled studies using the technology of continuous glucose monitoring in large populations of patients with diabetes.
Diabetes and Ramadan: An update on recent guidelines
2014, Medecine des Maladies Metaboliques
Le jeûne du mois de Ramadan expose à un risque métabolique majoré chez les patients diabétiques, qui consiste en un déséquilibre du diabète et/ou des hypoglycémies. Toutefois, même si religieusement le patient diabétique peut être exempt du jeûne, un grand nombre de diabétiques le réalise, avec ou sans concertation avec leur médecin traitant, et donc sans ajustement thérapeutique, ni renforcement du suivi. Plusieurs recommandations et consensus d’experts ont permis récemment d’établir des propositions pour optimiser la prise en charge du diabète au cours du Ramadan. Des ajustements thérapeutiques rendent possible le jeûne du mois de Ramadan. Le médecin traitant a toute sa place pour informer le patient des modifications proposées et de la surveillance à adopter durant ce mois. Cette revue de la littérature vise à faire la synthèse des recommandations récemment émises par plusieurs experts et associations scientifiques.
Ramadan fasting induces a high metabolic risk in some diabetic patients. Diabetic patients during Ramadan have a high at risk of uncontrolled diabetes and hypoglycemia. Therefore, even if diabetic patient can religiously not fast because of the underlying disease, most of diabetic patients fast with or without consulting their physician, and so without any treatment adjustment. Many recommendations and experts’ consensus have tried to establish some guidelines concerning diabetes in Ramadan. Diabetic patients who insist for fasting should have their treatment adapted so they can fast more safely. These adjustments can be done by their doctor before the month of Ramadan, so patients can be informed about their new treatment and self monitoring blood glucose. The following update relates data concerning various recommendations published in recent years regarding diabetes management during Ramadan.
Diabetes and Ramadan
2012, Presse Medicale
Ramadan, one of the five pillars of Islam, is a holy month for Muslims. During this month, they have a duty to fast every day from sunrise to sunset.
This religion spares diabetics and persons with chronic illnesses from this duty, because lack of eating and drinking all the day has many bad consequences on their health.
But, because of a very strong habit, by solidarity with the family, or by fear of exclusion from the society, many diabetics insist on fasting as demonstrated by numerous studies.
The problem is, when they fast, diabetics are at risk from complications such as severe hypoglycemia, hyperglycemia, ketoacidosis, deshydratation and thrombosis. To avoid this, consensus and recommendations have emerged in order to develop new approaches that would minimize the various complications.
It appears from different recommendations that only diabetics whose equilibrium is stable, free of degenerative complications, and able to manage properly their diseases will be allowed to fast.
The physician's role is to assist the faithful person to Ramadan by raising awareness of lifestyle and dietary rules, daily self-monitoring, and a new adjustment of treatment.
Le Ramadan est un mois sacré pour les musulmans, durant lequel ils ont le devoir de jeûner tous les jours du lever au coucher du soleil ; c’est l’un des cinq piliers de l’islam.
Cette religion dispense de cette obligation les diabétiques, car le jeûne n’est pas sans conséquence sur leur santé. Par habitude, par solidarité avec la famille, ou par crainte d’exclusion vis-à-vis de la société, nombreux sont les diabétiques qui veulent à tout prix jeûner comme cela a été démontré dans nombreuses études.
Mais en jeûnant, les diabétiques s’exposent à des complications telles que : les hypoglycémies sévères, les hyperglycémies, l’acidocétose, la déshydration et les thromboses.
Pour éviter cette situation, des consensus et des recommandations ont vu le jour pour essayer de définir de nouvelles approches qui minimiseraient les différentes complications.
Il ressort des différentes recommandations que seuls les diabétiques dont l’équilibre est stable, indemnes de complications dégénératives et capables de gérer convenablement leur maladie sont autoriser à jeûner.
Le rôle du médecin est d’accompagner les fidèles durant le Ramadan en les sensibilisant davantage aux règles hygiénodiététiques, à l’autosurveillance pluriquotidienne et à une nouvelle adaptation thérapeutique.

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Suggested insulin regimens for patients with type 1 diabetes mellitus who wish to fast during the month of Ramadan

Abstract

Diabetes Res Clin Pract

Am J Med

J Diabetes Complications

Recommendations for management of diabetes during Ramadan

Diabetes Care

Treatment of type 1 diabetes with insulin lispro during Ramadan

Diabetes Metab

Ramadan fasting and diabetes mellitus

Arch Iran Med

Management of people with diabetes during Ramadan

Br J Nurs

Diabetes mellitus and Ramadan fasting: The need for critical appraisal

Diabet Med

Ramadan fasting in type-1 diabetics

LMJ

A study of fasting diabetic patients during the month of Ramadan

Med J Malaya

The fast of Ramadan

BMJ