Managing diabetes in primary care during Ramadan

Ramadan is the holiest month of the Islamic calendar, during which there is an obligation for healthy adult Muslims to fast (Moolla et al, 2013). The period of fasting continues for 30 days, commencing at sunrise and continuing until sunset, and includes abstinence from both food and drink. Usually two meals per 24 hours are eaten, one pre-dawn (Suhoor) and one post-sunset (Iftar). Fasting is believed to bring spiritual, psychological and physical benefits. The dates of Ramadan are based on the lunar calendar and advance 10 to 11 days each (solar) year. This year in the UK, Ramadan commences after sunset on Thursday 23 April and ends at sundown on Saturday 23 May.

The adoption of fasting together with alteration of mealtimes, sleeping arrangements and exercise, places physiological demands on the individual that are likely to be greater in those with diabetes (Hassanein et al, 2017). This article looks at the challenges faced by people with diabetes during Ramadan and how these individuals can best be advised to manage their diabetes during this period.

Ramadan and diabetes

Vulnerable people with diabetes can be exempted from fasting during Ramadan (Table 1) (Muslim Council of Britain Diabetes Advisory Group and Diabetes UK, 2014). However, many Muslims with diabetes feel strongly committed to observing Ramadan and the EPIDIAR study estimated that up to 79% of those with type 2 diabetes, and 43% of those with type 1 diabetes, fasted during Ramadan (Salti et al, 2004). The later CREED study found an even higher proportion of individuals with type 2 diabetes practiced fasting during Ramadan (Babineaux et al, 2015).

There may be convincing medical reasons why fasting during Ramadan would be inadvisable for a person with diabetes, but the decision to fast or not lies with the individual. Health professionals involved in the care of these patients need to offer timely advice on the risks associated with fasting in those with diabetes and, where fasting is planned, support and empower these individuals.

Detailed guidance on managing diabetes in Ramadan has been issued by the International Diabetes Federation (IAF) and the Diabetes and Ramadan (DAR) International Alliance (Hassanein et al, 2016).

Problems associated with fasting

Key medical problems facing patients with diabetes who fast are hypoglycaemia, hyperglycaemia, diabetic ketoacidosis (DKA), dehydration and thrombosis (Al-Arouj et al, 2010).

The EPIDIAR study of 12 000 patients with diabetes in 13 countries found that the risk of severe hypoglycaemia during Ramadan, compared with other months, was increased in both type 1 diabetes and type 2 diabetes (Salti et al, 2004). The risk was highest in type 1 diabetes, then in those with type 2 diabetes using insulin, ahead of those using oral agents alone. The CREED study also reported a (less pronounced) increase in hypoglycaemia in subjects with type 2 diabetes who fasted during Ramadan (Babineaux et al, 2015).

The risk of severe hyperglycaemia during Ramadan predisposing to DKA in type 1 diabetes and hyperosmolar hyperglycaemic state (HHS) (a dangerous condition resulting from very high blood glucose levels) in type 2 diabetes was also found to be increased in the EPIDIAR study (Salti et al, 2004). This may be explained by the propensity to eat unusually large quantities of food before and after the daytime fast and possibly due to discontinuation of diabetes medications because of concerns over hypoglycaemia. A further study (Abdelgadir et al, 2015) confirmed the increased risk of DKA during Ramadan and immediately after, most commonly occurring in the individual with a recent history of DKA.

Abstinence from daytime fluids can predispose to dehydration, a situation that may be exacerbated by osmotic diuresis (increased urine volume) secondary to glycosuria. Hot climates and heavy physical work or exercise may aggravate the problem. A further consequence of dehydration may be postural hypotension and an accompanying risk of falls, notably in the elderly and those with pre-existing autonomic neuropathy. Increased blood viscosity following dehydration can predispose individuals to thrombosis.

The high-risk individual

Risk-stratification has, for some time, been seen as crucial to the management of diabetes during Ramadan (Al-Arouj et al, 2010). The aim is to assess an individual's risk of complications when fasting during Ramadan, taking into account the type of diabetes, medication, co-morbidities and personal circumstances (Hassanein et al, 2017). The recent IDF-DAR guidelines (Hassanein et al, 2016) advise that very high-risk and high-risk category individuals should not fast during Ramadan, although those in the moderate/low risk category may be suitable for fasting (Table 2).

What to cover in a pre-Ramadan consultation

It makes good sense that individuals with diabetes planning to observe fasting are seen by a health professional ahead of Ramadan for risk assessment and advice. People should be made aware of their individual risk of complications (see above) and, if they choose to proceed, how to minimise these risks. Self-monitoring of blood glucose levels, adjustment of medication, and the need to break the fast in the event of hypoglycaemia or illness are areas that will need to be addressed (Al-Arouj et al, 2010; Hassanein et al, 2017).

An educational programme delivered in the READ study to patients with type 2 diabetes undertaking Ramadan, encompassing diet, exercise and blood glucose monitoring, demonstrated a nearly 50% reduction in hypoglycaemic episodes compared to the control group (Bravis et al, 2010).

The offer of an appointment with the diabetes nurse or doctor could be advertised in the practice, the local mosque or the local press. Opportunistic advice may be given at a routine diabetes clinic. The extent to which people will need advice may vary, as many will have lengthy experience of managing their diabetes during Ramadan and be adept at this.

Issues that might be covered with the person with diabetes in a consultation regarding fasting during Ramadan are outlined in Table 3.

Diet and exercise

Offering specific dietary advice during Ramadan can be difficult for health professionals, as this requires knowledge of the dietary habits of the local Muslim population. However, for individuals with diabetes observing Ramadan it is advisable to eat starchy carbohydrates that release energy over a long period of time. This is of particular importance at the pre-dawn meal, which has to provide energy during the fasting period. Suitable foods might include oat-based cereals, wholegrain bread, basmati rice, chapatis and pitta bread along with beans, pulses, lentils, fruit and vegetables (Al-Arouj et al, 2010; Bravis et al, 2010; Diabetes UK, 2017).

There is a danger of overeating in the non-fasting period leading to hyperglycaemia, and dietary moderation, most notably at the post-sunset meal, should be encouraged.

A good fluid intake in the non-fasting period is of great importance to counter dehydration in people with diabetes.

Exercise should be undertaken with caution during fasting to reduce the risk of hypoglycaemia and dehydration.

Choosing treatments for type 2 diabetes

Fasting during Ramadan may increase the risks associated with certain medications, most notably that of hypoglycaemia. It is important that changes to medications are made by appropriately experienced health professionals. Specialist advice should be sought if necessary.

Metformin

Metformin carries a low risk of hypoglycaemia and remains a first-choice treatment for type 2 diabetes during Ramadan. If taken once daily this should be at Iftar (post-sunset meal); if taken twice daily, then split between Iftar and Suhoor (pre-sunset meal); if three times daily, the morning dose should be taken at Suhoor and the afternoon and evening meal doses combined at Iftar (Hassanein et al, 2016). Modified-release metformin is best taken at Iftar to deal with the overnight carbohydrate load.

Sulphonylureas

Sulphonylureas (SUs) predispose to hypoglycaemia and this risk will be greatest if they are taken at Suhoor ahead of the fasting period. Thus, health professionals should consider reducing the morning dose of SU with Suhoor. A sensible precaution is to weight the dose of SU towards the evening meal or, in the case of once daily SU, to take this at Iftar. It is safer to use shorter-acting second-generation SUs such as gliclazide and glipizide (rather than the longer-acting glibenclamide) (Aravind et al, 2011; Al-Arouj et al, 2013).

Meglitinides

The meglitinides (repaglinide and nateglinide) act as insulin secretagogues (help the pancreas to secrete insulin) and, in common with SUs, can induce hypoglycaemia. However, their faster onset of action and shorter duration of action potentially offers less risk of hypoglycaemia (than SUs) during the fasting period following the morning dose, making them a more attractive option to be taken with Suhoor and Iftar (Sari et al, 2004; Anwar et al, 2006).

DPP-4 inhibitors

The mode of action of the DPP-4 inhibitors (gliptins) confers a low risk of hypoglycaemia. There is evidence that the incidence of hypoglycaemia during Ramadan is significantly lower in those taking sitagliptin (Al Sifri et al, 2011; Aravind et al, 2012) or vildagliptin (Al Arouj et al, 2013; Hassanein et al, 2014) compared to an SU (with at least as good glycaemic control). The DPP-4 inhibitors are an effective and safe treatment option during Ramadan and do not require dose modification.

Thiazolidinediones

The thiazolidinedione, pioglitazone, is effective in improving glycaemic control during Ramadan and can be continued without dose change, as it does not have a propensity to induce hypoglycaemia (Hassanein et al, 2016). Perhaps the optimal time to take a gliptin or pioglitazone is with the post-sunset meal, which synchronises peak activity of the drug with the heaviest carbohydrate load.

SGLT-2 inhibitors

The SGLT-2 inhibitors (eg dapagliflozin, canagliflozin, empagliflozin) carry a low risk of hypoglycaemia. However, the glycosuria they induce is associated with fluid loss and this raises the concern that they could aggravate dehydration and postural hypotension (notably in the elderly in hot climates), as well as predisposing to DKA in the starved state (Peters et al, 2015; Fralick et al, 2017). A study comparing dapagliflozin versus SU therapy in subjects with type 2 diabetes during Ramadan confirmed a reduction in hypoglycaemia and, reassuringly, did not find an increased risk of dehydration and postural hypotension (Wan Seman et al, 2016). Sensible precautions when using SGLT-2 inhibitors during Ramadan would be to take them with the post-sunset meal and ensure good fluid intake during the non-fasting period. Initiation of SGLT-2 inhibitors should be avoided when estimated glomerular filtration rate (eGFR) is <60 mls/min and caution exercised over their use during Ramadan in patients taking diuretics.

Alpha-glucosidase inhibitors

Acarbose is an alpha-glucosidase inhibitor that slows metabolism of carbohydrates and subsequent hyperglycaemia. This together with a low risk of hypoglycaemia makes acarbose a reasonable option during Ramadan (Hassanein et al, 2016). If taken three times daily the midday dose should be omitted. Use may be limited by gastrointestinal side-effects.

GLP-1 agonists

The GLP-1 agonists (eg exenatide, liraglutide) are considered safe to use during the Ramadan fast without dose modification. Their propensity to cause hypoglycaemia is low. The safety and efficacy of liraglutide compared with SU therapy was demonstrated in the TREAT 4 (Brady et al, 2014) and LIRA-Ramadan (Azar et al, 2016) studies, in which the liraglutide groups achieved superior glycaemic control and weight control together with a reduced incidence of hypoglycaemia compared to the SU groups.

Using insulin in type 2 diabetes

The major challenge with insulin is to avoid hypoglycaemia during the fasting period. Commonly in type 2 diabetes the insulin regime will consist of a basal insulin alone. If the individual is taking human isophane (NPH) insulin (Insulatard, Humulin I, Insuman Basal) then the time-action profile of this insulin dictates that it should be administered with the evening meal (Iftar) to deal with the overnight glucose load, but with reduced effects during the subsequent daytime fast. If a longer-acting basal insulin analogue (Levemir, Lantus, Toujeo, Tresiba, Abasaglar) is being used then this is again best taken at Iftar, but may require a reduction in dose of around 20% to avoid daytime hypoglycaemia (Hassanein et al, 2017). If the basal insulin is taken twice daily, then the dose at Suhoor (pre-dawn meal) should be reduced (by up to 50%).

If a twice daily premixed biphasic insulin (eg Humulin M3, Novomix 30, Humalog Mix 25 and 50) is being used then the dose at Suhoor will need to be reduced by around 25–50% to avoid daytime hypoglycaemia. One strategy if the morning dose is larger, is to reverse morning and evening doses (Hassanein et al, 2017).

Advice will need to be individualised responding to blood glucose profile. Community diabetes nurses are an important source of information and advice.

Type 1 diabetes

Religious leaders, in conjunction with diabetes experts, do not recommend fasting during Ramadan for subjects with type 1 diabetes (Al-Arouj et al, 2010). Highest risk people include those with recurrent hypoglycaemia, hypoglycaemic unawareness, poor diabetic control, poor treatment compliance and lack of blood glucose monitoring. If fasting is undertaken, it is essential that close monitoring of blood glucose levels is practised. A fast-acting supply of carbohydrate should always be carried with instructions to break the fast should hypoglycaemia occur.

There are few studies to guide management, but a basal-bolus insulin regime is considered the preferred option (Al-Arouj et al, 2010). Fast-acting insulin analogues (Novorapid, Humalog, Apidra, Fiasp) appear to be preferable to human soluble insulin, because their faster onset of action and shorter duration of action can reduce the incidence of hypoglycaemia and improve post-prandial hyperglycaemia (Kadiri et al, 2001). The Suhoor dose of prandial insulin should be reduced by 25–50% to avoid daytime hypoglycaemia, and the midday dose omitted during the period of fast (Hassanein et al, 2017).

Insulin pumps may allow greater responsiveness to blood glucose variation and help avoid the incidence of severe hypoglycaemia during fasting (Benbarka et al, 2010).

Conclusion

The observation of fasting during Ramadan is of great importance to Muslims. Exemption from fasting is recommended for those with diabetes at high risk of complications. Ideally a risk assessment with a health professional should take place ahead of Ramadan and, for those who choose to fast, an individualised plan on how to manage their diabetes should be made. Advice should focus on fluids and diet, medication changes, glucose monitoring and when breaking the fast is needed, with an emphasis on avoiding hypoglycaemia.

KEY POINTS:

• During the month of Ramadan there is a period of fasting (both food and drink) from sunrise to sunset
• Vulnerable people with diabetes can be exempted from fasting, including those treated with insulin, children and frail elderly, pregnant and breastfeeding women, and those with complications of diabetes
• Many Muslims with diabetes will choose to fast, sometimes against medical advice
• Risks associated with fasting in the person with diabetes include hypoglycaemia, hyperglycaemia, dehydration and thrombosis
• It is useful before Ramadan to see the individual with diabetes planning to fast and perform a risk-stratification assessment
• The health professional should inform, advise and support individuals with diabetes who are planning to fast during Ramadan
• Advice should cover fluid intake, diet, exercise, blood glucose monitoring, medication management and when to break their fast
• A key factor in choice or adjustment of diabetes medication will be the avoidance of daytime hypoglycaemia during the fasting period

CPD reflective practice:

• What are the key risks when a person with diabetes fasts during Ramadan?
• Consider how you would manage a consultation where the person with diabetes was determined to fast against medical advice. What safety netting tips could you provide?
• How confident are you at managing the medication of a person with diabetes who plans to fast? Who could you ask for further advice?