Recently, a bunch of us got into a discussion of how patients with diabetes should approach fasting during Ramadan. Dr. Stefanie Nigro who is an Assistant Clinical Professor at the University of CT School of Pharmacy wrote the following blog post with the help of others at CHC. She notes that decisions about fasting are personal decisions that need to be made by a patient in collaboration with their healthcare provider. The blog post provides a framework and important information for patients to consider, but it should not substitute for the clinical judgment or expertise of medical providers.
“To fast or not to fast? How to manage diabetes during Ramadan”
With the holy month of Ramadan rapidly approaching, I am often asked, “How does daily fasting affect diabetes management?” Many of you may be aware that Ramadan is a holy month observed and required for all healthy adult Muslims. Fasting is a tradition, where followers are not allowed to eat, drink, smoke or use medications from predawn to after sunset. Because Ramadan is a lunar based month, fasting can range from a few hours to > 20 hours in some cases. Although the Koran states that those who are “sick” (i.e. chronic medical conditions) are excused from fasting, many patients with diabetes insist on fasting, thereby creating a medical challenge for themselves and their health care providers. Intrigued, I decided to interview Drs. Fusani Mohammadu and Syed Hassan, both practicing physicians inNew Britainand faithful observers of Ramadan. Their personal and professional insights lead me on the path to determine the best way to manage patients with diabetes during Ramadan.
Planning is key!
A universal recommendation for ALL patients with diabetes who observe Ramadan is to schedule a “check-up” visit with their health care provider 1-3 months prior to discuss the potential risks associated with fasting. This open dialogue between patient and provider should address the current health status of the patient, medical advice and self-care strategies. Remember, the decision to fast or not is an important personal decision made by the patient, not the provider. The potential risks include high blood sugar (hyperglycemia), low blood sugar (hypoglycemia), diabetic ketoacidosis and dehydration. If patients have frequently experienced these symptoms within the last 3 months, healthcare providers should advise against fasting during Ramadan.
Another important recommendation for ALL patients is frequent monitoring of blood sugars. In fact, those who are unable to test their blood sugar several times per day OR who have hypoglycemia unawareness are discouraged from fasting. Frequent testing allows both patients and providers to identify high or low blood sugars. Patients should test at least 4 or more times per day.
Type 1, type 2…what to do?
Keep in mind that care must be individualized for each patient; “one size does NOT fit all.” It is universally accepted that patients with Type 1 diabetes should refrain from fasting since their management is dependent on insulin injections throughout the day. If a patient does not eat while administering insulin, they are at significant risk for hypoglycemia. It is also unlikely that one injection of long-acting insulin before the evening meal (Iftar) will provide adequate coverage for 24 hours.
When it comes to managing those with Type 2 diabetes, the consensus is less clear. Here are some suggestions for patients and providers:
- Diet (only) controlled patients – Distribute calories over two to three smaller meals during the non-fasting time. Encourage intake of complex carbohydrates (whole grain products, foods high in dietary fiber) to help maintain blood sugar levels during the day. Try to avoid intense exercise during the fasting time.
- Patients on insulin – Determine severity of disease prior to Ramadan. If poorly controlled, avoid fasting. If well controlled, administer rapid acting insulin (Humalog, Novolog, Apidra) 10-15 minutes before the predawn and sunset meals only. Consider administering long acting insulin (Lantus, Levemir) with the sunset meal. Careful use of insulin is recommended. Consider decreased doses if appropriate. Diet as recommended above.
- Patients on oral medications –
- Patients on metformin can continue to take regularly as hypoglycemia risk is low. Give 2/3 of dose at the sunset meal and 1/3 of dose at pre-dawn meal.
- Patients on sulfonylureas (glipizide, glimeperide) should be switched over to short acting versions (repaglinide, nateglinide). These short acting formulations can be taken at the pre-dawn and sunset meals.
- Patients on glitazones (Actos or Avandia) – Take as usual. No dose change needed.
- Patients on incretin mimetics (Januvia) – Take as usual. No dose change needed. If taking Byetta, inject with predawn and sunset meal.
- For patients on combinations of oral medications, consultation with a healthcare professional is needed to weigh the risks and benefits of treatment
When to break fast…not breakfast
Another critical element of managing diabetes during Ramadan is knowing when to “break the fast.” If blood sugars fall below 60mg/dL, the fast MUST be stopped immediately due to increased risk of having significant hypoglycemia which may include hospitalization. Additionally, the fast should also be stopped if the blood sugar is less than 70mg/dL in the first few hours after the start of the fast if medications (i.e. insulin, glipizide) were taken at the predawn meal (Suhar).
To fast or not to fast…that is the question
With all of these factors to consider, it ultimately comes down to clinical judgment and patient preference. This decision takes careful planning and education on the part of both patient and provider. In the end, the goal is to keep patients safe and healthy during the holy month of Ramadan.
Stefanie C. Nigro, Pharm.D. with assistance from Jennifer Dolecki, Pharm.D. Candidate, Fusani Mohammadu, MD & Syed Hassan, MD