NEWSLETTER

A Physician’s Guide To Management Of Diabetes During Ramadan

PAKISTAN ENDOCRINE SOCIETY

Management of diabetic patients during Ramadan - In URDU Language

The objective is to assist in the task of advising diabetic patients who fast about the potential risks associated with fasting and providing them with guidelines regarding proper management of their diabetes during Ramadan. The following is based on the recently published Ramadan recommendations by Al-Arouj et al (1), and EPIDIAR study (2).

Very high risk High risk Moderate Risk
  • Severe hypoglycemia during the three months prior to Ramadan
  • DKA within three months prior to Ramadan
  • HONK within three months prior to Ramadan
  • Type I DM
  • Patients with a history of recurrent hypoglycemia
  • Poor glycemic control
  • Acute illness
  • Pregnancy
  • Chronic dialysis
  • Patients who perform intense physical labor
  • Patients with moderate hyperglycemia
  • Patients with renal insufficiency
  • People living alone treated with insulin or sulphonylurea
  • Old age with ill health
  • Drugs that may affect
    mentation Patients with co-morbid
    conditions that may present additional risk
  • Well controlled patients on short acting insulin secretagogues such as Repiglinide or Nateglinide

 

MANAGEMENT

Education And Counseling

  • Educate the patient that they should be prepared to break their fast in case of an acute complication\
  • Educate the patient and the family about signs and symptoms of hypoglycemia and its management.
  • Educate regarding blood sugar monitoring

Risks Associated With Fasting

  • Hypoglycemia
  • Hyperglycemia or Hyperosmolar Non Ketotic hyperglycemia(HONK)
  • DKA
  • Dehydration and thrombosis

Management

Start by identifying patients with either Type I or Type II DM who are at risk of developing complications by fasting.

  • Educate regarding meal planning
  • Educate regarding physical activity

Monitoring Sugars

Check sugars

  • just before Iftar,
  • 2 hours after Iftar
  • 2 hours after Suhur

Nutrition

  • Increase fluid intake
  • Avoid food rich in fat and simple carbohydrates
  • Advice foods with complex carbohydrates at Suhur
  • Take Suhur as late as possible

Breaking The Fast

Patients should end their fast if

  • Blood glucose is <60mg/dl
  • If the sugar is <70mg/dl in first few hours after Suhur and the patient has taken insulin or sulphonylurea at Suhur
  • If blood sugar is greater than 300mg/dl
Before Ramadan During Ramadan

Patients on diet and exercise control
ensure adequate fluid intake

 

No change needed (modify time and intensity of exercise)

Patients on oral hypoglycemic agents

Ensure adequate fluid intake

Biguanide, metformin 500 mg three times a day, or sustained release metformin (glucophage R)

Metformin, 1,000 mg at the sunset meal (Iftar), 500 mg at the predawn meal (Suhur)

TZDs, pioglitazone or rosiglitazone once daily

No change needed

Sulfonylureas once a day, e.g., glimepiride 4 mg daily, gliclazide
MR 60 mg daily

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 mg or gliclazide 80 mg, twice a day (morning and evening)

 

Use half the usual evening dose at the predawn meal (Suhur) and the full morning dose at the 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.

 

Repaglinide (Novonorm)

 

Should be used as usual (ie take tablet only if meal is taken)
in usual dose.

Patients on insulin

Ensure adequate fluid intake

 
70/30 premixed insulin twice daily, e.g., 30 units in morning and 20 units in evening 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 in morning; also consider changing to glargine or detemir plus lispro or aspart

*preferred oral agents are; Glimepride, gliclazide MR, Glipizide
**preferred insulins are; Insulin Glargine (for long acting), Insulin Lispro (for short acting)

Refrences :

1. Monira Al-Arouj, Radhia Bouguerra, John Buse, Sherif Hafez, Mohamed Hassanein, Mahmoud Ashraf Ibrahim, Faramarz Ismail-Beigi, Imad El-Kebbi, Oussama Khatib, Suhail Kishawi, Abdulrazzaq Al-Madani, Aly A. Mishal, Masoud Al-Maskari, Abdalla Ben Nakhi, and Khaled Al-Rubeanm: Recommendations for Management of Diabetes During Ramadan. Diabetes Care 28: 2305-2311, 2005

2. Salti I, Benard E, Detournay B, Bianchi-Biscay M, Le Brigand C, Voinet C, Jabbar A, The EPIDIAR Study Group: A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the Epidemiology of Diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care 27:2306–2311, 2004

Back to Newsletter Section