Fasting

Fasting

The holy month of Ramadan is one of five main pillars of being a Muslim. Most Muslims are passionate about fasting during this month. Although the Koran exempts sick people from the duty of fasting,  many Muslims with diabetes may not perceive themselves as sick and are keen to fast. A large epidemiological study of Muslims with diabetes in 13 Muslim countries showed that 43% of patients with type 1 and 79% of those with type 2 diabetes fasted during Ramadan.

What does fasting during Ramadan involve?

Fasting during Ramadan involves abstaining from food and drink from dawn to sunset for about 30 days. Most people take two meals a day during Ramadan—suhur (the meal before dawn and iftar (the meal after sunset).

Expert opinion recommends that if a patient has made it clear that they wish to fast during Ramadan their primary physicians and/or diabetes care specialists should assess whether they increase their health risk by doing so

Risk stratification of Diabetic patients during Ramadan

Very High risk

  •  History of recurrent hypoglycaemia
  •  History of hypoglycaemia unawareness
  •  Severe hypoglycaemia within the 3 months prior to Ramadan
  •  DKA or HHS  within the 3 months prior to Ramadan
  •  Poorly controlled T1DM
  •  Acute illness
  •  Pregnancy in pre-existing diabetes, or GDM treated with insulin or Sus
  •  Chronic dialysis or CKD stage 4 & 5
  •  Advanced macrovascular complications
  •  Old age with ill health

High risk

  •  T2DM with sustained poor glycaemic control
  •  Well-controlled T1DM
  •  Well-controlled T2DM on MDI or mixed insulin
  •  Pregnant T2DM or GDM controlled by diet only or metformin
  •  CKD stage 3
  •  Stable macrovascular complications
  •  Patients with comorbid conditions that present additional risk factors
  •  People with diabetes performing intense physical labour
  •  Treatment with drugs that may affect cognitive function

Moderate/Low risk

  •  Well-controlled T2DM treated with one or more of the following:

– Lifestyle therapy

– Metformin

– Acarbose

– Thiazolidinediones

– Second-generation SUs

– Incretin-based therapy

– SGLT2 inhibitors

– Basal insulin

Patients at Very high/high risk

If patients insist on fasting then they should:

  •  Receive structured education
  •  Be followed by a qualified diabetes team
  •  Check their blood glucose regularly (SMBG)
  •  Adjust medication dose as per recommendations
  •  Be prepared to break the fast in case of hypo- or hyperglycaemia
  •  Be prepared to stop the fast in case of frequent hypo- or hyperglycaemia or worsening of other related medical

Moderate/Low risk

Patients who fast should:

  •  Receive structured education
  •  Check their blood glucose regularly (SMBG)
  •  Adjust medication dose as per recommendations

Patients classed as very high risk are advised not to fast as it can lead to worsening diabetes control, resulting in, for example, severe hypoglycaemia and diabetes ketoacidosis.

Patients at high risk can reduce their level of risk if they see a healthcare professional several months before Ramadan and make necessary changes to their diabetes treatment.

SBGM should be performed

  1. Pre-dawn meal
  2.  At 8-10 am
  3.  In the middle of the day, at 12 Noon
  4.  At 3-4 PM
  5.  Just before the sunset meal
  6.  2 hours after the sunset meal
  7.  If the patient gets symptoms of Hypoglycemia or get unwell.
  •  Patients must always and immediately end their fast if:

– Blood Sugar < 3.9 mmol/L

– Blood Sugar exceeds 16.7 mmol/L

-If the patients get hypoglycemia or become sick.

What is the treatment of falling sugar

1. Take fast-changing carbohydrates to glucose such as a glass of juice or half a pack of soft drink (not diet) or a teaspoon of honey or a glass of water dissolved in it   a tablespoon of sugar or Glucagon injection.

2. Recheck your blood sugar after 15 minutes.

3. Retake fast-changing carbohydrates until your blood sugar reaches more than 3.9 ml.

4. This should be followed by slow-moving sugars such as biscuits, sandwiches, or a grain of fruit to prevent the sugar from falling again.

5. Consider change of insulin dose if required.

Meal planning and dietary advice

  •  The diet during Ramadan should be a healthy balanced diet
  •  Slow energy release foods (such as wheat, semolina, beans, rice) should be taken before and after fasting, whereas foods high in saturated fat (such as ghee, samosas, and pakoras) should be minimised
  •  Advise patients to use only a small amount of monounsaturated oils (such as rapeseed or olive oil) in cooking
  •  Before and after fasting include high fibre foods such as wholegrain cereals, granary bread, brown rice; beans and pulses; fruit, vegetables, and salads

Exercise

  • Regular light and moderate exercise is safe in type 2 diabetes patients11
  • Rigorous exercise is not recommended as the risk of hypoglycaemia may be increased, particularly in patients taking sulphonylureas or insulin
  • Encourage patients to continue their usual physical activity, especially during non-fasting periods
  • Tarawaih prayers (a series of prayers after the sunset meal) should be considered as part of the daily exercise regimen as they involve standing, bowing, prostrating, and sitting

Modifications

Modifications for medications for patients with T2DM

Medications

Daily dose

Daily dose redistribution

Metformin

Prolonged release OD

No change

Take at iftar

Metformin

Immediate release

OD

BID

TID

No change

Take at iftar

Take at iftar and suhoor

Take morning dose at suhoor, combine afternoon and evening dose at iftar

TZDs (Pioglitazone)

No change

can be taken with iftar or suhoor

Glinides

Repaglinide TID

Nateglinide TID

↓ to 2 doses

taken with iftar and suhoor

Alpha glucosidase inhibitors

Acarbose TID

Voglibose

Miglitol

↓ to 2 doses

taken with iftar and suhoor

DPP-4 inhibitors

Sitagliptin 100 mg OD

Linagliptin 5 mg OD

Vildagliptin 50 mg BID

No change

With Iftar

With Iftar

With iftar and Suhor

GLP-1 Ras: Liraglutide

No dose modifications are needed once appropriate

dose titration has been achieved prior to Ramadan (6 weeks before)

SGLT2 inhibitors

Empagliflozin

No change

With iftar

Advise excess fluids intake

Avoid in the elderly, renal impairment, hypotension, or diuretics use

SU (avoid glibenclamide)

Gliclazide MR OD

Glimepiride OD

↓ if good glycaemic control

With iftar

Gliclazide BID

↓ if good glycaemic control

With Iftar & Suhoor

(Suhoor dose may be ↓ if good glycaemic control)

Insulin Therapy

Medications

Daily dose

Daily dose redistribution

Long- or intermediate-acting basal insulin

NPH/Detemir/Glargine/ Degludec  OD

↓ the dose

Take at iftar. ↓ dose by 15–30%

NPH/Detemir/Glargine

           BID

Take usual morning dose at iftar. ↓evening dose by 50% and take at suhoor

Rapid- or short-acting prandial/bolus insulin

Actrapid/Lispro/Aspart/

Glulisine

↓ the dose

Take normal dose at iftar. Omit lunch-time dose. ↓ suhoor dose by 25–50%

Premixed insulin

OD

No change

Take normal dose at iftar

BID

↓ the dose

Take usual morning dose at iftar. ↓ evening dose by 25–50% and take at suhoor

TID

↓ the dose

Omit lunch dose, Adjust iftar and suhoor doses

Insulin Dose Titration should be performed every three days and dose adjustments made according to BG levels

Fasting/Pre-iftar/Pre-suhoor BG

Pre-iftar**

Post-iftar**/Post-suhoor***

Basal insulin

bolus insulin

Premixed insulin

< 3.9 mmol/L or symptoms

↓ by 4 units

↓ by 4 units

↓ by 4 units

3.9–5.0 mmol/L

↓ by 2 units

↓ by 2 units

↓ by 2 units

5.0–7.0 mmol/L

No change required

No change required

No change required

7.0–11.1 mmol/L

↑e by 2 units

↑ by 2 units

↑ by 2 units

> 11.1 mmol/L

↑ by 4 units

↑by 4 units

↑ by 4 units

Insulin pump:

• Basal rate – ↓ dose by 20–40% in the last 3–4 h of fasting.

              ↑dose by 0–30% early after iftar

• Bolus rate – Normal carbohydrate counting and insulin sensitivity principles apply

Copyrights - Oman Diabetes Association © 2019 جميع الحقوق محفوظة - الجمعية العمانية لمرض السكري