Though Ramadan represents a period of reflection and religious devotion for those who follow Islam, it can also present a significant medical challenge for endocrinologists and their Muslim patients with diabetes.
Ramadan is a lunar-based month that can last from 29 to 30 days during which many Muslims fast. Because the lunar calendar is about 11 days shorter than the solar calendar, Islamic holidays move each year. In 2015, Ramadan is expected to begin at sundown on June 18 in the United States, with dates varying throughout the world. Depending on the geographical location and season, the duration of the daily fast may range from a few hours to more than 20 hours.
However, although the timing may range from city to city and country to country, the challenges that patients with diabetes face remain the same, according to experts.
One major problem for patients with diabetes during Ramadan is diet.
Ramadan involves fasting during the day, but there are no restrictions on food or fluid intake between sunset and dawn. Therefore, during this time, many Muslims consume two meals per day, often having one after sunset and another before sunrise.
Unfortunately, complications can occur in patients with diabetes during this time due to overeating and insufficient sleep that arise from these changes in eating patterns.
Although no evidence-based guidelines exist, clinicians recommend that an individual’s diet should not differ significantly during Ramadan for patients with diabetes. Meals need to be healthy and balanced, with a goal of maintaining the same BMI, according to Kim A. Carmichael, MD, who is an associate professor of medicine in the division of endocrinology, metabolism and lipid research at the Washington University School of Medicine in St. Louis.
Nevertheless, this is not always the case. One significant concern, for instance, is the common practice of ingesting large amounts of foods rich in carbohydrates and fats at the sunset meal. Clearly, this is something that should be avoided and discussed with patients with diabetes. Clinicians instead suggest that patients eat foods containing “complex” carbohydrates at the predawn meal because these foods are more likely to delay ingestion and absorption.
“Important factors to improve safety include a sensible diet, minimizing the use of simple carbohydrates and fats during the evening and early morning meals, maintaining good sleep hygiene, avoiding excessive exercise, maintaining adequate fluid intake and checking blood glucose levels frequently,” Carmichael told Endocrinology Advisor.
Importance of Monitoring Medications
Another problem that clinicians and patients need to keep tabs on is careful monitoring of medications during Ramadan.
“In general, insulin and sulfonylureas increase the risk of hypoglycemia and their effects may be potentiated by other agents, dehydration or altered diet. Sulfonylureas in general should be avoided since they are hard to adjust and regulate,” Carmichael said.
However, he noted that sulfonylureas are relatively inexpensive and commonly prescribed. So, Carmichael said clinicians and patients should exercise extreme caution if their use is deemed necessary during Ramadan.
Glinides may be substituted since they are short-acting and may be timed with meals, he added.
Additionally, insulin therapy is best given with a flexible regimen, according to Carmichael. Consequently, specific adjustments in the timing and amounts given must be based on the new mealtime and activity schedule. All patients on insulin should discuss an individual plan with their health care team 4 to 8 weeks before Ramadan.
“Metformin therapy is considered to be safe during Ramadan, as long as persons maintain good fluid intake. Other classes considered to be safe include DPP-4 inhibitors, GLP-1 agonists, an amylin analog, thiazolidinediones and alpha-glucosidase inhibitors. There are no data regarding the newer class of SGLT2 inhibitors, but since these increase the risk of dehydration and hypotension, they would need to be given with caution,” explained Carmichael.
Michael Fowler, MD, who is an associate professor of medicine and director of Vanderbilt Diabetes Outreach in the division of diabetes, endocrinology and metabolism at Vanderbilt University Medical Center in Nashville, Tennessee, also underscored the importance of assessing medications and treatment regimens during Ramadan.
Sulfonylureas and metaglinides trigger endogenous insulin release, he said, and the absence of these agents in individuals who normally take them predispose patients to fasting hypoglycemia. This is especially true when activity levels are high, Fowler said.
Also, patients using mealtime insulin should continue to use insulin when they eat in order to control postprandial hyperglycemia, he noted.
“Patients may need to use regular or rapid-acting insulin in ‘correction’ doses in the event of hyperglycemia, but this should be done with caution,” Fowler told Endocrinology Advisor.
“Basal insulin is a different matter. This is provided by agents such as insulin glargine and detemir in the United States. In other countries, insulin degludec and ultralente insulin may be available. Basal insulin acts to keep blood sugar stable during the fasting state; therefore, when dosed carefully, blood sugar should remain stable when a person is not eating,” he said.
“The catch is that if activity level increases, if someone’s dose is too high already or if a patient loses weight and becomes more insulin-sensitive during the month of Ramadan, they may still experience hypoglycemia while fasting.”
Fowler said he keeps his patients with type 2 diabetes on basal insulin, but reduces the dosage by 10% to 20% during the month of Ramadan. He does this because many patients tend to lose weight during this time.
However, all agents can cause hypoglycemia, Fowler cautioned, but some agents are much less likely to do so than others.
“Ones less likely to do so during the fasting state include metformin, DPP-4 inhibitors such as sitagliptin, SGLT2 inhibitors such as canagliflozin, GLP-1 agonists such as exenatide, thiazolidinediones such as pioglitazone and alpha-glucosidase inhibitors such as acarbose. Using these agents, the risk of hypoglycemia is low, but not zero,” he said.