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R e v i e w s / C o m m e n t a r i e s / A D A S t a t e m e n t s
W O R K G R O U P
Recommendations for Management of
Diabetes During Ramadan
ONIRA AL-AROUJ, MD
OUSSAMA KHATIB, MD, PHD
ADHIA BOUGUERRA, MD
SUHAIL KISHAWI, MD
OHN BUSE, MD, PHD
BDULRAZZAQ AL-MADANI, MD
HERIF HAFEZ, MD, FACP
LY A. MISHAL, MD, FACP
OHAMED HASSANEIN, FRCP
ASOUD AL-MASKARI, MD, PHD
AHMOUD ASHRAF IBRAHIM, MD
BDALLA BEN NAKHI, MD
ARAMARZ ISMAIL-BEIGI, MD, PHD
HALED AL-RUBEAN, MD
MAD EL-KEBBI, MD
tive studies on the effects of fasting duringRamadan, a group of endocrinologistsand diabetologists from a number of Mus-lim and non-Muslim countries met to ex- Itisestimatedthatthereare1.1–1.5bil- peopleconsumetwomealsperdaydur- changeinformationandopinionsandto
ing this month, one after sunset, referred 18 –25% of the world population (1,2).
to in Arabic as Iftar (breaking of the fast ment of diabetes in patients who elect to Islam, is an obligatory duty for all healthy not meant to create excessive hardship on 185), especially if fasting might lead to harmful consequences for the individual.
Patients with diabetes fall under this cat- medical issue. The purposes of the recom- mendations that follow are threefold: 1) to tients with type 2 diabetes fast during Ra- invite an open dialogue on this important topic, 2) to offer a set of medical opinions some 40 –50 million people with diabetes and suggestions, and 3) to identify topics “God likes his permission to be fulfilled, as he likes his will to be executed.” Nev- terms “indications” or “contraindications” ertheless, many patients with diabetes in- for fasting because fasting is a religious selves and their physicians. It is therefore ing, use of oral medications, and smoking aware of potential risks that may be asso- ever, we emphasize that fasting, especially there are no restrictions on food or fluid familiarity and knowledge is as important poor glycemic control, is associated with ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● multiple risks. In addition to highlighting From the 1Ministry of Health, Amiri Hospital, Rawda, Kuwait; the 2National Institute of Nutrition, Tunis, Tunisia; the 3Diabetes Care Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina; the 4Department of Internal Medicine & Diabetes, Faculty of Medicine, Cairo University, Cairo, Egypt; the 5Department of Medicine, Glan Clwyd Hospital, Rhyl, Denbighshire, U.K.; the 6Egyptian Diabetes Center, Cairo, Egypt; the 7Division of Clinical and Molecular Endocrinology, Case Western Reserve Uni-versity, Cleveland, Ohio; the 8Department of Medicine, Emory University School of Medicine, Atlanta,Georgia; 9Regional Advisor/Non Communicable Diseases/World Health Organization/Eastern Mediterra- PATHOPHYSIOLOGY OF
nean Region, Cairo, Egypt; the 10Ministry of Health, Palestinian National Authority, Ghaza, Palestine;11 FASTING — Insulin secretion in
Dubai Hospital, Dubai, United Arab Emirates; the 12Diabetes & Endocrinology Center, Islamic Hospital, Amman, Jordan; the 13College of Medicine, Sultan Qaboos University, Sultante of Oman; and the 14Diabetes Center, Medical College, King Saud University, Riyadh, Saudi Arabia.
Address correspondence and reprint requests to Mahmoud Ashraf Ibrahim, MD, 19 Nasouh St., Zeitoun, glucose in liver and muscle as glycogen.
Cairo 11321, Egypt. E-mail: mahmoud@arab-diabetes.com.
Abbreviations: DCCT, Diabetes Control and Complications Trial; EPIDIAR, Epidemiology of Diabetes
glucose levels tend to fall, leading to de- 2005 by the American Diabetes Association.
creased secretion of insulin. At the same DIABETES CARE, VOLUME 28, NUMBER 9, SEPTEMBER 2005 Management of diabetes during Ramadan
Table 1—Major risks associated with fasting
in patients with diabetes
is augmented (6). As fasting becomes pro- tracted for more than several hours, gly- low levels of circulating insulin allow in- creased fatty acid release from adipocytes.
Oxidation of fatty acids generates ketones yearly episodes of short-term hyperglyce- cardiac muscle, liver, kidney, and adipose mia (e.g., 4-week duration) and diabetes- tissue, thus sparing glucose for continued utilization by brain and erythrocytes.
by a delicate balance between circulating glycemia. Results of the Diabetes Control a threefold increase in the risk of severe concentrations in the physiological range.
In patients with diabetes, however, insu- in patients with type 2 diabetes (from 1 to lin secretion is perturbed by the underly- 5 events ⅐ 100 peopleϪ1 ⅐ monthϪ1) and counts for 2– 4% of mortality in patients incidence of severe hyperglycemia with or hance or supplement insulin secretion. In without ketoacidosis in patients with type reliable estimates concerning the contri- 1 diabetes (from 5 to 17 events ⅐ 100 peo- type 2 diabetes; however, it is felt that some patients with type 1 diabetes due to death in this group of patients. Rates of and defects associated with recurrent hy- significantly higher rates of severe hyper- type 1 diabetes (4), with rates being even insulin deficiency, a prolonged fast in the on rates of hypoglycemia in patients with with type 1 diabetes, who fast during Ra- diabetes is not known with certainty. The sis. Patients with type 2 diabetes may suf- ment of diabetic ketoacidosis, particularly fer similar perturbations in response to a study (4), which showed that fasting dur- Ramadan (4). In addition, the risk for di- patients with type 1 diabetes (from 3 to 14 events ⅐ 100 peopleϪ1 ⅐ monthϪ1) and RISKS ASSOCIATED WITH
ϳ7.5-fold in patients with type 2 diabetes month.
FASTING IN PATIENTS
(from 0.4 to 3 events ⅐ 100 peopleϪ1 ⅐ WITH DIABETES — Fasting during
Limitation of fluid intake during the fast, this study, since events requiring assis- especially if prolonged, is a cause of dehy- tients with diabetes. In keeping with this, tance from a third party without the need for hospitalization were not included.
physical labor, all conditions that result in given, it is unlikely that the patients in this complications (4). However, a few studies perglycemia can result in osmotic diuresis on this topic using relatively small groups of patients suggest that complication rates may not be significantly increased (7–11).
develop, especially in patients with pre- nificant change in their lifestyle (4).
falls, injuries, and bone fractures may re- DIABETES CARE, VOLUME 28, NUMBER 9, SEPTEMBER 2005 Al-Arouj and Associates
Table 2—Categories of risks in patients with type 1 or type 2 diabetes who fast
monitor their blood glucose levels multi- during Ramadan
ple times daily. This is especially criticalin patients with type 1 diabetes and in patients with type 2 diabetes who require Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Nutrition. The diet during Ramadan
Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan most studies, 50 – 60% of individuals who fast maintain their body weight during the Hyperosmolar hyperglycemic coma within the previous 3 months month, while 20 –25% either gain or lose Patients who perform intense physical labor weight (4); occasionally, the weight loss foods rich in carbohydrate and fat, espe- Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mg/dl, avoided. Because of the delay in digestion Patients with advanced macrovascular complications taining “complex” carbohydrates may be People living alone that are treated with insulin or sulfonylureas Patients with comorbid conditions that present additional risk factors Well-controlled patients treated with short-acting insulin secretagogues such as repaglinide as late as possible before the start of the Exercise. Normal levels of physical ac-
Well-controlled patients treated with diet alone, metformin, or a thiazolidinedione who are cessive physical activity may lead tohigher risk of hypoglycemia and should take fasting. However, patients who insist hours before the sunset meal. If Tarawaih the intravascular space can contribute to a on fasting need to be aware of the associ- prayer (multiple prayers after the sunset meal) is performed, then it should be con- sidered a part of the daily exercise pro- percoagulable state due to an increase in providers to achieve a safer fasting expe- clotting factors, a decrease in endogenous rience. Patients may be at higher or lower anticoagulants, and impaired fibrinolysis risk for fasting-related complications de- (16). Increased blood viscosity secondary Breaking the fast. All patients should
their risk factors. Conditions associated with “very high,” “high,” “moderate,” and suggested an increased incidence of reti- “low” risk for adverse events in patients nal vein occlusion in patients who fasted with type 1 or type 2 diabetes who decide l]) occurs, since there is no guarantee that to fast during Ramadan are listed in Table their blood glucose will not drop further if izations due to coronary events or stroke 2. This classification is based largely on expert opinion and not on scientific data (18,19). There are no data concerning the effect of fasting on mortality in patients first few hours after the start of the fast, es- pecially if insulin, sulfonylurea drugs, or meglitinide are taken at predawn. Finally, MANAGEMENT — It is worth re-
the fast should be broken if blood glucose emphasizing that fasting for patients with Individualization. Perhaps the most
exceeds 300 mg/dl (16.7 mmol/l). Patients diabetes represents an important personal crucial issue is the realization that care after careful consideration of the associ- Frequent monitoring of glycemia. It is
All patients with diabetes who wish to fast essential that patients have the means to DIABETES CARE, VOLUME 28, NUMBER 9, SEPTEMBER 2005 Management of diabetes during Ramadan
essary preparations to undertake the fast as safely as possible. These include medical as- sessment and educational counseling.
Diet-controlled patients. In patients
Medical assessment. This assessment
justments in this setting are essential to should take place within 1–2 months be- trolled with diet alone, the risk associated with fasting is quite low. However, there be devoted to the overall well-being of the is still a potential risk for occurrence of patient and to the control of their glyce- postprandial hyperglycemia after the pre- termediate- or long-acting insulin admin- dawn and sunset meals if patients overin- dulge in eating. Distributing calories over 24 h. Typically, patients will need to use tient concerning the potential risks they two daily injections of NPH as intermedi- are accepting in deciding to fast, even if tients controlled with diet alone usually combine this with a regular daily exercise nation with a short-acting insulin to cover food intake at the associated meals. How- be made so that the patient initiates fast- ever, there is an increased risk of hypogly- ing while being on a stable and effective of the exercise could be changed to ϳ2 h the early morning insulin dose. Using the after the sunset meal. Finally, in this usu- Educational counseling. It is essential
long-acting insulin ultralente is an option, ally older age-group, often with hyperten- with twice-daily injections at ϳ12-h in- necessary education concerning self-care, tervals to mimic basal insulin, and a rap- added before the two meals. Still, ultra- Patients treated with oral agents. The
toring, meal planning, physical activity, choice of oral agents should be individu- lente cannot be considered truly basal in- alized. In general, agents that act by in- sulin, since it has a broad peak of action at creasing insulin sensitivity are associated 8 –14 h. Therefore, protracted hypogly- with a significantly lower risk of hypogly- promptly should it occur, even if it is mild ● Metformin. Patients treated with met- liquids, glucose tablets, or glucagons in- daily injection of the long-acting insulin possibility of hypoglycemia is minimal.
analog glargine or twice-daily injections premeal rapid-acting insulin analogs. Re- sults of a study using insulin glargine in 15 relatively well-controlled patients with In general, patients with type 1 diabetes, third be given before the predawn meal.
especially if “brittle” or poorly controlled, ● Glitazones. Patients on insulin sensitiz- are at very high risk of developing severe during the fast (21). Two episodes of mild ● Sulfonylureas. This group of drugs was unable to monitor their blood glucose lev- the duration of the fast in Ramadan is typ- els multiple times daily are at high risk sulin during fasting are limited. A study on patients with type 1 diabetes using in- sulin lispro or insulin aspart instead of regular insulin in combination with inter- glycemia and was associated with less hy- agement is protective against microvascu- lar complications and that the benefits are effective, resulting in a lower risk of hy- long lasting (12,20). Glycemic control at near-normal levels requires use of multi- more expensive and still requires frequent ple daily insulin injections (three or more) DIABETES CARE, VOLUME 28, NUMBER 9, SEPTEMBER 2005 Al-Arouj and Associates
then special attention should be given to appropriately individualized. A single in- jection of intermediate-acting insulin ad- their medical condition is essential. This sufficient to provide acceptable glycemic control in patients with reasonable basal insulin secretion. In such a situation, the peak action of intermediate insulin would aged in high-risk clinics staffed by an ob- still require short-acting insulin adminis- stetrician, diabetologists, a nutritionist, did not change during the study (24).
ate- or long-acting insulin at the sunset meal to cover the large caloric load of If- and intensive insulin therapy. The issues ing that use of insulin lispro instead of generations) may be used with caution.
● Short-acting insulin secretagogues. Mem- earlier, the overall dosage of medications, justed in conjunction with the weight loss with fasting during Ramadan, especially if or gain that may occur during Ramadan.
madan in patients with type 2 diabetes are Patients treated with insulin. Prob-
lems facing patients with type 2 diabetes rated fats is increased during Ramadan.
those with type 1 diabetes, except that the Pregnancy is a state of increased insulin incidence of hypoglycemia is less. Again, resistance and insulin secretion and of re- the aim is to maintain necessary levels of duced hepatic insulin extraction. Fasting basal insulin to remedy the prevailing rel- existing insulin resistance. A major objec- tive is to suppress hepatic glucose output women than those who are not pregnant.
CONCLUSIONS — Fasting during
to near-physiologic levels during the fast- ing period. Judicious use of intermediate- ries a risk of an assortment of complica- or long-acting insulin preparations plus a risk for major congenital malformations.
diabetes should be strongly advised to not meals would be an effective strategy. Al- though hypoglycemia tends to be less fre- and mortality to the fetus and mother, al- poorly controlled are at very high risk for apy for a number of years, suggesting that ␤-cell failure has occurred and that a sig- known diabetes (type 1, type 2, or gesta- other hand, an excessive reduction in thenificant component of insulin deficiency tional) insist on fasting during Ramadan.
insulin dosage in these patients (to pre- exists. Very elderly patients with type 2 diabetes may be at especially high risk.
risk for hyperglycemia and diabetic keto- insulin analog, such as insulin glargine, or also occur in patients with type 2 diabetes but generally less frequently and with less madan. However, if they insist on fasting, tients with type 1 diabetes. A patient’s de- DIABETES CARE, VOLUME 28, NUMBER 9, SEPTEMBER 2005 Management of diabetes during Ramadan
Table 3—Recommended changes to treatment regimen in patients with type 2 diabetes who fast during Ramadan
Patients on diet and exercise control
No change needed (modify time and intensity of exercise), ensure adequate fluid intake Patients on oral hypoglycemic agents
Biguanide, metformin 500 mg three times a day, Metformin, 1,000 mg at the sunset meal (Iftar), 500 mg at the predawn meal (Suhur) or sustained release metformin (glucophage R) TZDs, pioglitazone or rosiglitazone once daily Sulfonylureas once a day, e.g., glimepiride 4 mg Dose should be given before the sunset meal (Iftar); adjust the dose based on the glycemic control and the risk of hypoglycemia Sulfonylureas twice a day, e.g., glibenclamide 5 Use half the usual morning dose at the predawn meal (Suhur) and the full dose at the mg or gliclazide 80 mg, twice a day (morning sunset meal (Iftar), e.g., glibenclamide 2.5 mg or gliclazide 40 mg in the morning, glibenclamide 5 mg or gliclazide 80 mg in evening Patients on insulin
70/30 premixed insulin twice daily, e.g., 30 Use the usual morning dose at the sunset meal (Iftar) and half the usual evening dose at predawn (Suhur), e.g., 70/30 premixed insulin, 30 units in evening and 10 units inmorning; also consider changing to glargine or detemir plus lispro or aspart The recommendations given in this table are for illustrative purposes and are largely based on expert clinical opinion and not on scientific data derived from clinicalstudies. The recommendations must be adjusted for each specific patient. Adapted from Akbani et al. (30). TZD, thiazolidinedione.
cision to fast should be made after ample Kuwait), Baha Arafah and Saul Genuth (Cleve- discussion with his or her physician con- land, OH), Mahdi Gibani (North West Wales fects of fastingin 41 type 2 diabetic pa- NHS Trust, Bangor, U.K.), and Rayaz Malik tients during Ramadan (Letter). Diabetes U.K.) for their critical review of the manuscript 8. Laajam MA: Ramadan fasting and non-in- sulin-dependent diabetes: effect on meta- priate education and instructions related bolic control. East Afr Med J 67:732–736, to physical activity, meal planning, glu- References
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