Review
Clinical practice points for diabetes management during RAMADAN fast

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Abstract

Diabetes management during Ramadan is very crucial from the patient perspective as it can present significant risk of hypoglycemia and death when proper care is not taken. Moreover, managing diabetes in fasting Ramadan patients require different mechanisms than the routine diabetes management and pose significant challenge to the health care practitioners. Here we set forth to review the available literature of various clinical trials and studies on different antidiabetic agents in the context of Ramadan. On the basis of available evidence, we suggest that gliclazide is effective and it could be safely recommended in type 2 diabetic patients fasting during Ramadan.

Introduction

Ramadan, the ninth lunar month of Muslim calendar, commences upon sighting of the new moon and it typically lasts for about 29 to 30 days [1]. Fasting during Ramadan is one of the five pillars (announcement of faith, salaat, zakaat, fasting, and hajj) of Islam and is observed during the time when the Holy Quran was revealed to Muhammad [2]. The daily duration of fasting differs as per geographical location and season; in summer and northern latitudes it lasts up to 20 h, whereas in winter it is observed for much shorter time. During this time, devotees refrain from eating and drinking from dawn to sunset and abstain from smoking, oral medications, and sexual activities [2], [3]. During Ramadan period, most of the followers take two meals per day, one at iftar (evening meal after breaking the fast), and another at suhur (meal consumed early in the morning) [4]. Fasting during Ramadan is believed to be mandatory for every healthy Muslim individual and contravening it without sensible cause is considered as severe offence [1]. However, sick people including patients with diabetes are specifically exempted from the duty of fasting [4]. Nonetheless, most of the Muslims, even those who can be exempted, have a passionate desire to participate in this religious ritual during Ramadan [3].

Diabetes is continuously gaining the status of potential epidemic in the world and in the developing countries. Current estimate reports that there are 415 millions of people with diabetes in the world [3], [5]. India has an estimated prevalence rate of about 8.7% and ranked second in the world with approximately 69.2 million diabetic patients [3], [5]. The 2011 census of India estimates approximately 172 million Muslims in India, which is growing at the rate of 24.6% [6]. Several studies, which included Indian cohorts, reported that around 79%–94% of Muslims with type 2 diabetes mellitus (T2DM) were undergoing fasting during Ramadan for at least 15 days [7], [8]. Taken together, it can be assumed that considerable numbers of Indian Muslims with diabetes, similar to Muslims in rest of the world, follow Ramadan fast in India.

Ramadan fasting in Muslim population renders a sudden shift in diet plans, meal timings, sleep and wakefulness patterns. This change of lifestyle carries important consequences for physiology including rhythm and magnitude of fluctuations of various homeostatic and endocrine processes [3].

After taking meal the blood glucose level increases, which promotes insulin secretion. Secreted insulin stimulates the storage of glucose as glycogen in liver and muscle. Several hours after meal or fasting, the plasma glucose level decreases and insulin secretion falls down. Subsequently, the counter balancing hormones such as glucagon and catecholamines rise and induce the breakdown of glycogen to glucose. Simultaneously, a process called gluconeogenesis is also amplified. Prolonged fasting for more than a few hours deplete glycogen stores, which together with low circulating insulin stimulate energy production from fatty acid in adipocytes. Ketones produced by fatty acid oxidation serve as energy source for liver, adipose tissues, kidney, skeletal and cardiac muscles. This process spares glucose for uninterrupted use by brain and erythrocytes during tenure of prolonged fasting. In healthy individuals, as explained above, there is a subtle balance between circulating insulin and counter regulatory hormones, which keep glucose levels in physiological range. However, in patients with diabetes, this balance is distressed. In addition to underlying pathophysiology of both type 1 and type 2 diabetes, pharmacological agents used to control the disease further perturb the homeostasis [4], [9].

In agreement with above facts, alteration in diet pattern, meal timings, changes in timing and doses of medication, and physical activity during Ramadan fast generate various risks in patients with diabetes. Complications like hyperglycemia, hypoglycemia [4], [7], [8], [10], dehydration, diabetic ketoacidosis (DKA) [1], [9], and microvascular and macrovascular problems may create major challenges in diabetes patients during the fasting period [3]. Patients with type 1 diabetes mellitus (T1DM) and T2DM may suffer similar perturbations in response to a prolonged fast; however, ketoacidosis is more common in T1DM patients [1], [9]. Moreover, the severity of hyperglycemia also depends on the extent of insulin resistance and/or deficiency in T2DM patients.

The first American Diabetes Association (ADA) guidelines on the management of diabetes during Ramadan fasting was published in 2005, which was updated in 2010. They classified patients into four risk categories: very high, high, moderate, and low risk and prohibited very high risk and high risk category patients from fasting [4], [11]. Similarly South Asian Consensus Guideline was published in 2012 and highlighted the use of pharmacotherapy in the management of diabetes during Ramadan. The guideline also stratified patients according to the risks and suggested precaution measures and management plan for the diabetes patients who are on fasting. [12] International Group for Diabetes and Ramadan (IGDR) recommendations were published in 2015 with a goal of updating the lifestyle modifications and usage of newer pharmacological agents in the treatment of diabetes during Ramadan fast [13]. In addition to this, International Diabetes Federation (IDF) and Diabetes and Ramadan (DAR) International Alliance recently formulated practice guidelines for the management of diabetes during Ramadan fast [3].

Ramadan fast is a ubiquitous religio-cultural practice that is found in varying forms across the world including India. It is evident from the above reports that India has good number of Muslim population, which is projected to increase in the coming years, and majority of Indian Muslims observe fasting during Ramadan, the prevalence of diabetes is on a rise in Indian population. Furthermore, fasting during Ramadan is associated with multifactorial risks in diabetes patients. Collective analysis of these aspects urges the development of clinical practice guidelines for diabetes management during Ramadan fasting in India. This review highlights the evidence based management options for diabetes control by using various pharmacological agents.

Section snippets

Who should undergo fast or who should not?

Patients should be categorized whether or not to go for fasting with respect to diabetes associated morbidity and mortality, and safety or tolerability of medications. An international consensus meeting at Morocco concluded that patients with T1DM, unstable T2DM, and diabetes patients with complications, pregnant women with diabetes, and old age people with diabetes should not undergo fasting. However, T2DM patients with stable disease with or without oral-antihyperglycemic agents (OADs) could

Management of type 1 diabetes patients

The T1DM patient willing to observe Ramadan fasting are considered as very high-risk patients. Further, the risk replicates with patients unable/unwilling to monitor blood glucose level, uncontrolled/poorly-controlled diabetes, no access to medical care, uneducated and unawareness to hypoglycemic events and requiring recurrent hospitalizations [4]. In the EPIDIAR study, more than 40% of T1DM patients were observing fasting at least for 15 days [8].

Intensive glycemic control with multiple daily

Elderly

Elderly people do not refrain from Ramadan fasting usually. These people, particularly those with long-standing diabetes, may present with multiple concomitant diseases that have an adverse impact on the safety of fasting [49]. The IDF recommends that older people who have enjoyed fasting during Ramadan for many years should not be categorised as high risk based only on a specific age but rather should be based on health status and social circumstances [3]. The majority of clinical practice

Conclusion

Management of diabetes in Indian patients during Ramadan fast still presents a significant challenge for health care practitioners and physicians. Specifically, patients with T1DM position themselves at very high risk due to consequences of hypo- and hyper-glycemia during the fasting period. Most of the OADs produce hypoglycemia in T2DM patients which subsequently impose the need for modifications/management of the regimen during the fasting period. Very few RCTs have reported the effectiveness

Conflict of interests

All the authors declare that they have no conflict of interest.

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