“If the patient is not drinking liquids during Ramadan — some of my patients drink water during their Ramadan fast and some do not — they should avoid therapies which could promote dehydration, such as alpha-glucosidase inhibitors and SGLT2 inhibitors, since both of these agents will promote water loss. If a patient is at risk for pre-renal azotemia from dehydration. they should also stop metformin.” 

Patients with type 1 diabetes should never stop their basal insulin, Fowler said. A small reduction in insulin dosage may be warranted, especially if the patient loses some weight, but he said withholding basal insulin would inevitably result in diabetic ketoacidosis. Fowler recommends patients continue to use rapid-acting insulin when they eat, usually based on their insulin-to-carbohydrate ratio.


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It is generally recommended that all patients have the means to monitor their blood glucose levels several times a day, and this is particularly important in patients who take insulin. Carmichael said the fast should be broken immediately in the event of extreme hypoglycemia or hyperglycemia. 

“Persons prone to frequent hypoglycemia should carry a medical alert identification and have a glucagon injection device for emergency use. Persons should avoid fasting on sick days. Fasting is also not medically advised during pregnancy so expectant mothers observing Ramadan will need intensive monitoring by a high-risk specialty group,” said Carmichael.

A Growing Issue

There are an estimated 1.57 billion Muslims in the world, and it is also the world’s second largest religious group, according to the Pew Research Center.1 Additionally, the ranks are growing rapidly, partially due to differences in fertility rates and the size of youth populations among the world’s largest religions.

By 2050, the Pew Research Center estimates Islam will replace Judaism as the largest non-Christian religion in the United States.

With these numbers increasing, more endocrinologists are now managing Muslim patients with diabetes who are passionate about their religious tenets. The fact that more and more Muslims are developing diabetes after adopting more Western-style eating habits is further compounding the issue.

Fasting during Ramadan, however, has been uniformly discouraged by the medical profession for patients with diabetes.

“The Holy Koran specifically exempts the sick from the duty of fasting, especially if fasting leads to comorbidities for the individual. Patients with diabetes mellitus fall under this category because their chronic metabolic disorder may place them at high risk for various complications, if the pattern and amount of their meal and fluid intake is markedly altered,” Farhad Zangenah, assistant clinical professor of medicine at George Washington University School of Medicine in Sterling, Virginia, told Endocrinology Advisor.

“Nevertheless, many patients with diabetes insist on fasting during Ramadan,” he said.

Many Muslims with diabetes insist on fasting as an expression of their faith or for other reasons, but some patients do end up in the hospital for a host of complications. As the number of Muslims in the U.S. continues to grow, it is expected that more hospitals will need to be prepared to treat an increasing number of patients with diabetes in the emergency room during the month of Ramadan. 

“Hospitalizations have increased for type 1 and type 2 diabetes during this month for hypoglycemia and hyperglycemia. The risks include diabetic ketoacidosis, dehydration, syncope, falls, orthostatic and hypotension,” said Zangenah.

“The most important potential complications of diabetes during Ramadan are poor glucose control and dehydration. Although there are few studies on these, the incidence of hypoglycemia may increase up to 4.7-fold in type 1 diabetes and 7.5-fold in type 2 diabetes.”

Additionally, in patients with type 1 diabetes, there may be an increase in the risk for dangerous hyperglycemia, Carmichael said, but most experts agree that this risk may be reduced by having better glucose control before Ramadan.

Zangenah also emphasized the need for evidence-based guidelines for managing patients with diabetes who want to fast during Ramadan, and there has been a call for this issue to be addressed sooner rather than later.2

Until then, even though Ramadan can be a challenge for patients with diabetes, clinicians contend that it can be an opportunity to improve diabetes management education overall. Studies suggest that the best possible approach is advanced education for each patient and making sure that all treatment plans are highly tailored to that specific patient.

“Medication management must be individualized, particularly as many persons with diabetes take multiple types of agents,” said Carmichael.

References

  1. The Future of World Religions: Population Growth Projections, 2010-2050. Pew Research Center website. http://www.pewforum.org/2015/04/02/religious-projections-2010-2050/. April 2, 2015. Accessed June 2015.
  2. Yaqub F. Lancet Diabetes Endocrinol. 2014;2(6):454.