Recommendation for Management

of Diabetes During Ramadan:

How to Achieve Glycemic Control and Safety
 Content

• Review the pathophysiology of fasting

• Discuss the effects of 1 to 2 day fasts and of
prolonged fasting (more than 18 hrs/day)
• Address safety, use, and limitations of existing
medications
• Recognize the value of structured education and
support for safe fasting
 The World’s Total Muslim Population
(1.57 billion people; 23% of the world population)
Less than 20% are Arabs
Islam's centre of gravity lies not in Mecca or Cairo, but much farther East on
the Indian subcontinent (380 million)
Indonesia (205 million) has the largest Muslim population of any country on earth

http://www.pewforum.org/Muslim/Muslim-Population-of-Indonesia.aspx. Downloaded January 15, 2013.

 Facts Sheet on Fasting Month of Ramadan
• Time : Days 1-29/30 of the lunar month
• Duration : fasting starts 75 minutes before sunrise and ends
15 minutes after sunset (or immediately at sunset)*
• Fasting day : abstaining from all eating, drinking, and smoking
• Who fasts : all mature (religiously responsible) adults
(females above 9 years and males above 15 years of age)
• Exemptions: those who are ill (if fasting is expected to inflict
significant harm), travellers, and menstruating females
• Food consumption : usually, two main meals are taken
[at sunset (Iftar) and 2 hours before sunrise (suhur)]
• Work and school hours may be shortened to 5-6 hours

* May results in a fast for 11-12 hours in equatorial countries and 16-20 hours or more in countries away
from the equator
AlMaatouq MA. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2012:5:109-19.
 Islam and Fasting
• Worldwide, >50 million people with diabetes fast
during Ramadan
• Approx. 43% of Muslims with T1DM and
79% of Muslims with T2DM fast
• Ramadan=29/30 days; 2 meals/day permitted,
one after sunset and
one before dawn

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

 Those Who Cannot Fast
1. Physically sick (Quran 2:184-5)
2. Traveller on a journey (Quran 2: 184-5)
3. Women during menstruation
4. ? Pregnant and lactating women
5. Pre-pubertal children
The five phases of glucose homeostasis
Pathophysiology of Fasting:Three Stages

1) Post-absorptive phase: 6-24 hours after

beginning the fast
2) Gluconeogenic phase: from 2-10 days
of fasting
3) The protein conservation phase,>10 days of
fasting

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

 Pathophysiology of Fasting
• After an overnight fast, average rate of glucose
utilization in healthy adults is
approx. 7 g/hr
• 70-80 g glycogen in liver can provide glucose to
the brain and peripheral tissues for about 12 hrs

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

 Major Risks with Fasting
• Hypoglycemia

• Hyperglycemia

• Diabetic ketoacidosis

• Dehydration and thrombosis

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

 Risks of Fasting: Hypoglycemia
• Decreased food intake is a risk factor
for hypoglycemia

• Fasting during Ramadan increases risk

of severe hypoglycemia (hospitalization required)
4.7 fold in T1DM and 7.5 fold
in T2DM

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

 Risks of Fasting: Hyperglycemia
• EPIDIAR study showed
– a fivefold increase in the
incidence of severe
hyperglycemia in T2DM
– threefold increase in the
incidence of severe
hyperglycemia with T1DM
• may have been due
– to excessive reduction in
dosages of medications
– An increase in food and/or
sugar intake
Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.
 Risks of Fasting: Ketoacidosis
• T1DM patients at increased risk for ketoacidosis,
particularly if diabetes is poorly controlled before
Ramadan

• Reduction of insulin doses (to compensate for

reduced food intake) poses extra
risk factor

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

 Risks of Fasting:
Dehydration and Thrombosis
• Dehydration caused by limitation of fluid intake,
hot and humid climates, and hard physical labour

• Hyperglycemia causes osmotic diuresis

= electrolyte depletion

• Orthostatic hypertension increases risk for falls, injuries,

bone fractures

• Increased blood viscosity increases risk for thrombosis

and stroke

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

Risk Stratification Before
Ramadan Fasting
 Assessment before Ramadan-
Very high risk
• Severe hypoglycemia within the 3
months prior to Ramadan
• A history of recurrent
hypoglycemia
• Hypoglycemia unawareness
• Sustained poor glycemic control
• Ketoacidosis within the 3 months
prior to Ramadan
• Type 1 diabetes
• Acute illness
• Hyperosmolar hyperglycemic
coma within the previous 3
months
• Performing intense physical labor
• Pregnancy
• Chronic dialysis
Al-arouj M, et al. Diabetes Care 2010;33 (8) 1895-902
Risk Stratification
High risk Moderate risk
• Moderate hyperglycemia • Well-controlled diabetes treated
(average blood glucose 150–300 with short-acting insulin
mg/dl or A1C 7.5–9.0%) secretagogues (repaglinide or
• Renal insufficiency nateglinide)
• Advanced macrovascular
complications
• Living alone and treated with Low risk
insulin or sulfonylureas
• Well-controlled diabetes treated
• Patients with comorbid
with lifestyle therapy, metformin,
conditions that present additional
acarbose, thiazolidinediones,
risk factors
and/or incretin-based therapies in
• Old age with ill health
otherwise healthy patients
• Treatment with drugs that may
affect mentation
 Recommendations in T2DM
During Ramadan1
Before Ramadan During Ramadan
Patients on diet and exercise Ensure enough fluids
control Modify time & intensity of exercise
Patients on oral hypoglycemic Ensure enough fluids
agents
Biguanide, metformin 500 mg Metformin 1000 mg at
3x/day, or sustained-release sunset meal (Iftar), 500 mg at
metformin (glucophage R) predawn meal (suhur)

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

 Recommendations in T2DM
During Ramadan2
Before Ramadan During Ramadan
TZDs, pioglitazone, or rosiglitazone 1x No change
daily
Sulfonylureas 1x day, Dose should be given before the sunset
e.g. glimepiride 4 mg daily, meal (Iftar); adjust dose based on
gliclazide MR 60 mg daily glycemic control &
risk of hypoglycemia
Sulfonylureas 2x day, Use half the usual morning dose at
e.g. glibenclamide 5 mg or predawn meal (suhur) and full dose at
gliclazide 80 mg, 2x day sunset meal (Iftar),
(morning and evening) e.g. glibenclamide 2.5 mg or gliclazide
40 mg in the morning, glibenclamide 5
mg or
gliclazide 80 mg in evening

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

 Recommendations in T2DM
During Ramadan3
Before Ramadan During Ramadan
Patients on insulin Ensure adequate fluid intake

70/30 premixed insulin 2x day, Use the usual morning dose at

e.g. 30 units in morning and sunset meal (Iftar) and half the
20 units in evening usual evening dose at predawn
(suhur), e.g. 70/30 premixed
insulin, 30 units in evening and
10 units in morning; consider
changing to glargine or detemir
+ lispro or aspart

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

Adjustments of Non-Insulin Anti diabetic Regimens in People
with Type 2 Diabetes Who Are Fasting for Ramadan

Al Maatouq MA. Diab Metab Syndr Obesity 2012; 5:109-10.

 Insulin Regimen Adjustments in People with
Type 2 Diabetes Who Are Fasting for Ramadan1

Al Maatouq MA. Diab Metab Syndr Obesity 2012; 5:109-10.

 Insulin Regimen Adjustments in People with
Type 2 Diabetes Who Are Fasting for Ramadan2

Al Maatouq MA. Diab Metab Syndr Obesity 2012; 5:109-10.

 Nutrition1
• Studies show 50-60% of patients maintain
body weight, and 20-25% lose or gain weight
during Ramadan

• Diet during Ramadan should be healthy,

balanced diet

• Aim at maintaining constant body mass

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

 Nutrition2
• Avoid eating a lot of carbs and sugars at Iftar

• Eat complex carbs at suhur

(as late as possible before the start of the fast)

• Avoid foods high in saturated fat

• Before and after fasting, include high-fibre foods:

fruits, vegetables, salads, whole grains

• Increase fluid intake during non-fasting hours

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

Hui E, et al. Clinical Review 2010;3490:1407-11.
 Exercise
• Maintain normal physical activity
• Avoid excessive activity, especially in
last few hours before Iftar – could lead
to hyperglycemia
• Multiple prayers (and rising, kneeling,
etc.) before Iftar count as exercise
• Exercise in poorly controlled T1DM can
lead to severe hyperglycemia

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

 When to End the Fast
• BG<60 mg/dL (hypoglycemia)

• BG reaches <70 mg/dL in the first few hours of

fast, especially if insulin, sulfonylurea drugs, or
meglitinide is taken at predawn

• BG>300 mg/dL

• If patient is sick

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

Ramadan-Focused
Diabetes Education
 Ramadan-Focused Diabetes Education
• Provide Ramadan-specific diabetes education (to
healthcare providers, patients, families, etc )

• Pre-Ramadan, review patient’s clinical profile

including glycemic control and
diabetes-unrelated comorbidities

• Make Ramadan-specific therapeutic adjustments

• Provide care before, during, and after Ramadan,

including home glucose monitoring; ensure access
and availability of medications

Al Maatouq MA. Diab Metab Syndr Obesity 2012;5:109-10.

 Pre-Ramadan Medical Assessment
• Medical assessment: 1-2 months before Ramadan
– Overall well-being
– Glycemic control
– Blood pressure, lipids
– Appropriate blood tests

• Provide advice : potential risks of fasting

• Make diet or medication changes before Ramadan so
patients are stable before
they start to fast

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

 Ramadan-Focused
Diabetes Education: Three Parts
1. Awareness campaign aimed at people with
diabetes, religious/community leaders, and
general public

2. Ramadan-focused structured education

for healthcare professionals

3. Ramadan-focused structured education

for people with diabetes

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

 Ramadan-Focused Diabetes Education

• Ramadan is a golden opportunity to educate

• Stress importance of glucose monitoring

during fasting and non-fasting hours, when
to stop
a fast, meal planning to avoid hypoglycemia,
dehydration, postprandial hyperglycemia

• Discuss timing and intensity of physical

activity, use of medication during fasting
Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.
 Results of Ramadan-Focused Diabetes
Education Study (READ study)

Patients Who Received Control Group

Ramadan-Focused Diabetes (No Ramadan-Focused Diabetes
Education Education)

• 50% reduction in hypoglycemic • 4-fold increase in hypoglycemic

events despite fasting events from baseline during
fasting
• Small weight loss • Weight gain

N=111 T2DM, in whom glycemic control had been maintained at same level for 12 months;
patients on insulin excluded, although 90% were being treated with secretagogues

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

Barvis V. Diabetic Medicine 2012;327-31.
Prevalence of fasting in Muslims with DM
EPIDIAR Study

Type 1 DM Type 2 DM
 Management of T1DM Patients
• Fasting is high risk for T1DM

• Intensive glycemia management required

• Multiple daily insulin injections (≥3) or use

continuous SubC insulin infusion via pump

• Close monitoring and frequent dose

adjustments required to avoid hypo- or
hyperglycemia SubC =
subcutaneous
Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.
 Management of T1DM Patients
• Many T1DM patients who fast change
their regimen before, during, and a few days
after Ramadan

• Basal-bolus regimen preferred

• 1-2x daily injections of intermediate- or

long-acting insulin with pre-meal rapid-
acting insulin is frequent option

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

 Pregnancy and Fasting
• Pregnant women are exempt from fasting

• Pregnant women with T1DM, T2DM, GDM who

fast are at high risk

• Women with GDM should be advised not

to fast

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

 Pregnant and Fasting:
Counselling Requirements
• Achieve near-normal BG and A1C

• Poor glycemic control = maternal and

fetal complications

• Increase self-management skills

• Appropriate diet and intensive insulin

therapy required

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

 Management of Hypertension
and Dyslipidemia
• Adjust antihypertensive medication

– Dehydration, volume depletion, and hypotension may

occur with fasting, especially if fast is long and there is
excessive perspiration
– Diuretics may not be appropriate

• Avoid high-carb foods and saturated fats

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.

Clinical Evidence
 Summary
• Fasting during Ramadan has risk for patients with
diabetes

• Very high risk of complications for T1DM

– Poorly controlled = high risk of hypoglycemia
– Excessive reduction in insulin
= risk for hyperglycemia and ketoacidosis

• Risk for hypo- and hyperglycemia also in T2DM,

but risk not as high
Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.
 Summary
• Newer pharmacological agents have less
hypoglycemic potential and may offer advantages
during Ramadan

• Insulin pump therapy may provide

greater safety

Al-arouj M, et al. Diabetes Care 2010;33(8):1895-902.