Individuals with diabetes who fast for Ramadan need regular glucose monitoring and may need to adjust their treatment regimen, according to updated recommendations from the International Group for Diabetes and Ramadan.

The recommendations were published online June 16 in BMJ Open Diabetes Research & Care.

“In general, patients should be instructed on the use of glucose monitoring and frequency of glucose testing [and] patients receiving insulin or insulin secretagogues should be monitored two to four times daily before, during, and after the fasting period,” wrote Dr. Mahmoud Ibrahim of the Center for Diabetes Education, McDonough, Ga., and his associates.

Metformin was the ideal agent for managing patients with type 2 diabetes who are undergoing prolonged fasting, as it carries a low risk of hypoglycemia and is associated with a 1%-2% reduction in hemoglobin A1c (BMJ Open Diab. Res. Care 2015, June 16 [doi: 10.1136/bmjdrc-2015-000108 ]).

Similarly, thiazolidinediones are considered a useful agent for use during Ramadan because of the low risk of hypoglycemia and the effectiveness in improving glucose control.

Thiazolidinedione therapy should be initiated well before the start of the fast as these agents may take up to 10-12 weeks to reach maximum effectiveness, the researchers noted.

Dipeptidyl peptidase-4 (DPP4) inhibitors are another option for Ramadan fasting, as there is a low risk of hypoglycemia, and studies suggest that they are effective at improving glycemic control during fasting.

However, insulin secretagogues and most sulfonylureas should be avoided or should be used with extreme caution during Ramadan fasting, the authors said, pointing to recent studies showing an increased risk of hypoglycemia during fasting with these agents.

“The risk of hypoglycemia increases exponentially in elderly patients and patients with renal failure and medical illnesses treated with sulfonylureas,” wrote the authors.

There were few studies examining the safety and efficacy of glucagon-like peptide 1 receptor agonists in patients with diabetes during Ramadan, they noted.

For patients with type 1 or type 2 diabetes who receive insulin injections, their total insulin dose will likely require frequent adjustment during Ramadan.

“The use of basal (glargine or detemir) and rapid-acting insulin analogs (lispro, aspart, and glulisine) has been shown to be superior to human insulin formulations (NPH and regular) during Ramadan by reducing the risk of hypoglycemia,” the authors wrote.

Insulin pump therapy is effective during fasting, providing a continuous basal rate of insulin, but is able to rapidly cover for the meal intake when the fast is broken.

Premixed insulin formulations are among the most frequently prescribed in many Muslim countries, but data from some studies suggest a higher risk of hypoglycemia than with basal insulin analogs, and their safety and efficacy during Ramadan fasting is not known.

Practical outlines on adjusting insulin levels during fasting are available, but the authors recommended a trial fast for 3 consecutive days before Ramadan to guide self-titration of the premix insulin dosage.

The authors also suggested structured diabetes education as an essential tool for managing diabetes during fasting and after breaking the fast, citing a retrospective study showing that patients who received diabetes education prior to Ramadan had less weight gain and fewer episodes of hypoglycemia compared to those who did not.

One author was supported by the American Diabetes Association and National Institutes of Health, and declared unrestricted research support, consulting fees, honoraria, and advisory board memberships from pharmaceutical companies.


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