The incidence of diabetic ketoacidosis during Ramadan fasting: A 10-year single-centre retrospective study

Incidence of diabetic ketoacidosis does not differ in Ramadan compared to other months and seasons: results from a 6-year multicenter study

BACKGROUND

Diabetic ketoacidosis (DKA) is a life-threatening adverse complication of patients with diabetes mellitus (DM). It is postulated that fasting during Ramadan can increase the risk of DKA; however, there are contradicting data in this regard. Furthermore, studies from Western countries have suggested a seasonal variation in the incidence of DKA. This study examines the differences in the number of DKA episodes during Ramadan compared to the rest of the year in patients with type 1 DM (T1D) and type 2 DM (T2D). Besides, we aim to examine the seasonal difference in the incidence of DKA.

METHODS

We included consecutive index-DKA admissions from 2015 to 2021 and used descriptive statistics to compare the episodes of DKA in Ramadan vs other months and seasons.

RESULTS

Of 922 patients, 480 (52%) had T1D, whereas 442 (48%) had T2D. The median age (IQR) was 35 (25-45) years, with the majority being Arab (N = 502, 54.4%). There were 94 DKA admissions in six collective Ramadan months, whereas the DKA admissions ranged from 61 to 88 episodes in other months (p = .3). The highest DKA admissions were observed in Autumn (N = 236) and the lowest in Spring (N = 226) with no statistically significant difference (p = .4). There were no differences in DKA severity or new-onset diabetes rates when analyzed based on Hiji months, Roman months, or seasons.

CONCLUSIONS

DKA occurrence is not increased during Ramadan. We found no evidence of seasonal variations in the rates of DKA in the State of Qatar.

Burden and Patterns of Medical Emergencies during Ramadan Fasting: A Narrative Review

Introduction Acute medical problems may occur more frequently during Ramadan fasting (RF). We aimed to provide a narrative overview of the global literature on medical emergencies during RF.

Methods This is a nonsystematic review of the international literature from one major medical online database (PubMed, National Institutes of Health, United States). The relevant literature was narrated in a concise thematic account.

Results There is a variable impact in the burden and time distribution of emergency services and hospitalization during RF that may require readjustment of resource allocation. Studies of the risk of accidents and injuries may be increased overall or at specified times, around Iftar time. A classical impact of emergencies has been the risk of worsening peptic ulcer disease. RF impacts diabetic emergencies such as severe hypoglycemia, hyperglycemia, and diabetic ketoacidosis, particularly in type 1 diabetes and poorly controlled patients. Glucocorticoid replacement therapy may represent a challenge to patients and physicians that require education and dose adjustment. Acute neurological conditions of interest include the “first day of Ramadan headache,” epilepsy, and strokes. Several studies evaluated the risk of the acute coronary syndrome and heart failure with inconsistent findings. RF may impact the renal and urological systems through stone disease, renal colic, and acute kidney. The impact on hematological conditions was mostly focused on the safety of anticoagulant therapy during Ramadan.

Conclusion The review addresses the emergency medical encounters of the fasting patient during Ramadan to allow a holistic and ethnically sensitive approach to medical care under circumstances where decisions have to be taken with no delay.

Effect of empagliflozin in patients with type 2 diabetes during Ramadan on volume status, ketonaemia, and hypoglycaemia

BACKGROUND AND AIMS

Patients with type 2 diabetes (T2D) carry higher risk of glycaemic variability during Ramadan. Glucose-lowering medications such as SGLT2 inhibitors are also associated with genitourinary infection, acute kidney injury, and euglycaemic diabetic ketoacidosis. Limited data is available on the effects of SGLT2 inhibitors on T2D patients during Ramadan. We investigated effects of empagliflozin use in fasting T2D patients.

METHODS

This was a prospective cohort study in a single diabetes centre in Malaysia. Empagliflozin group were on study drug for at least three months. For control group, subjects not receiving SGLT2 inhibitors were recruited. Follow-up were performed before and during Ramadan fasting. Anthropometric measurements, blood pressure, renal profile, and blood ketone were recorded during visits. Hypoglycaemia symptoms were assessed via hypoglycaemia symptom rating questionnaire (HypoSRQ).

RESULTS

We recruited a total of 98 subjects. Baseline anthropometry, blood pressure, and renal parameters were similar in two groups. No significant changes in blood pressure, weight, urea, creatinine, eGFR, or haemoglobin levels during Ramadan was found in either group. Likewise, no difference was detected in blood ketone levels (empagliflozin vs control, 0.17 ± 0.247 mmol/L vs 0.13 ± 0.082 mmol/L, p = 0.304) or hypoglycaemia indices (empagliflozin vs control, 19.1% vs 16%, p = 0.684).

CONCLUSIONS

Ramadan fasting resulted in weight loss and reduction in eGFR levels in patients with T2D. Empagliflozin use during Ramadan is safe and not associated with increased risk of dehydration, ketosis, or hypoglycaemia. Therefore, empagliflozin is a viable glucose-lowering drug for patients with T2D planning for Ramadan fasting.

Is Fasting Good When One Is at Risk of Liver Cancer?

Hepatocellular carcinoma (HCC), one of the leading causes of cancer-related deaths worldwide, is a multistep process that usually develops in the background of cirrhosis, but also in a non-cirrhotic state in patients with non-alcoholic fatty liver disease (NAFLD) or viral hepatis. Emerging evidence suggests that intermittent fasting can reduce the risk of cancer development and could improve response and tolerance to treatment through the metabolic and hormonal adaptations induced by the low energy availability that finally impairs cancer cells’ adaptability, survival and growth. The current review will outline the beneficial effects of fasting in NAFLD/NASH patients and the possible mechanisms that can prevent HCC development, including circadian clock re-synchronization, with a special focus on the possibility of applying this dietary intervention to cirrhotic patients.

The Association between Acute Myocardial Infarction-Related Outcomes and the Ramadan Period: A Retrospective Population-Based Study

Fasting throughout the Muslim month of Ramadan may impact cardiovascular health. This study examines the association between the Ramadan period and acute myocardial infarction (AMI)-related outcomes among a Muslim population. The data were retrospectively extracted from a tertiary hospital (Beer-Sheva, Israel) database from 2002–2017, evaluating Muslim patients who endured AMI. The study periods for each year were: one month preceding Ramadan (reference period (RP)), the month of Ramadan, and two months thereafter (1840 days in total). A comparison of adjusted incidence rates between the study periods was performed using generalized linear models; one-month post-AMI mortality data were compared using a generalized estimating equation. Out of 5848 AMI hospitalizations, 877 of the patients were Muslims. No difference in AMI incidence between the Ramadan and RP was found (p = 0.893). However, in the one-month post-Ramadan period, AMI incidence demonstrably increased (AdjIRR = 3.068, p = 0.018) compared to the RP. Additionally, the highest risk of mortality was observed among the patients that underwent AMI in the one-month post-Ramadan period (AdjOR = 1.977, p = 0.004) compared to the RP. The subgroup analyses found Ramadan to differentially correlate with AMI mortality with respect to smoking, age, sex, diabetes mellitus, and hypertension, suggesting the Ramadan period is a risk factor for adverse AMI-related outcomes among select Muslim patients.

Evidence-based risk factors for major complications during Ramadan fasting in people with diabetes grouped under IDF-DAR risk categories

AIM

To identify evidence-based risk factors for major complications during Ramadan fasting in people with diabetes grouped under IDF-DAR risk categories.

METHODS

This prospective observational multicenter study was conducted by Baqai Institute of Diabetology and Endocrinology (BIDE) between April-June 2019. People with diabetes having intention to fast during Ramadan were recruited. Demographic data collection along with risk categorization was done during pre-Ramadan visit. Structured education was given on one- to-one basis to each of the study participants. Assessment of complications was done during post Ramadan visit.

RESULTS

A total of 1045 people with diabetes participated with near equal gender distribution. Two thirds of study population was grouped into very high- and high-risk categories. Frequencies of major hypoglycemia, major hyperglycemia, hospitalization & need to break the fast were 4.4%, 10.8%, 0.8% & 3.1% respectively. On multivariate analysis, the risk factors found for major hypoglycemia during Ramadan were male gender, use of sedatives & antidepressants & having type1 diabetes mellitus, history of DKA/HHS during last 3 months for major hyperglycemia, major hypoglycemia & hospitalization for breaking of fast while older age, acute illness, and major hypoglycemia were identified factors for hospitalization.

CONCLUSION

In this prospective study evidence-based risk factors for fasting related major complications were identified in people with diabetes. It is imperative to recognize these factors during pre-Ramadan risk assessment visit.

Ramadan Fasting and Maternal and Fetal Outcomes in Pregnant Women with Diabetes Mellitus: Literature Review

There is an emerging Muslim and diabetic population in the United States and other Western countries and majority of pregnant women and patients with diabetes mellitus choose to fast during Ramadan. Fasting during Ramadan in pregnant women with diabetes may represent a 'perfect storm' of metabolic disturbances including hyperglycemia, hypoglycemia and ketosis. Recent continuous and flash glucose monitoring data suggests increased glycemic variability (fasting hypo- and post-Iftar hyperglycemia) in non-pregnant patients with diabetes during Ramadan. Only five small-scale studies, predominantly focused on women with gestational diabetes mellitus in Muslim-majority nations have explored maternal glycemic outcomes during Ramadan which is associated with lower mean blood glucose levels and higher frequency of fasting hypoglycemia. Data is limited however on important clinical outcomes such as symptomatic and serious hypoglycemia requiring hospitalization. Results have been conflicting regarding maternal Ramadan fasting and association with fetal outcomes in women without diabetes. Only one recently published study reported on perinatal outcomes in pregnant women with gestational diabetes which found no effect of Ramadan exposure on mean birthweight or macrosomia frequency but lower neonatal hypoglycemia prevalence, however a significant limitation was lack of documentation of maternal fasting status. At this stage, due to paucity of data, the current medical recommendation is against Ramadan fasting for pregnant Muslim women with diabetes. Large-scale population-based studies are warranted regarding maternal and fetal outcomes in pregnant fasting women with diabetes and such studies should characterize maternal fasting status and have meaningful and consistent clinical outcomes. High-quality data derived from these studies can assist clinicians in providing more evidence-based advice to safely navigate both mother and fetus through a potentially challenging pregnancy.

Diabetes emergencies around Ramadan study (DEARS) - A multi-center study of diabetes emergencies admitted before, during and after Ramadan in Malaysia

OBJECTIVE

The objective of this study was to determine admissions for diabetes emergencies among patients who fasted or planned to fast one month before, during and one month after Ramadan 2019 in public hospitals in Malaysia.

MATERIALS AND METHODS

This was a cross sectional prospective study done in 18 public hospitals in Malaysia from 7/4/2019 to 2/7/2019. Data was collected prospectively with universal sampling. All adult Muslim patients with previous diagnosis of diabetes, who were admitted for hypoglycemia, DKA or HHS were included if they had fasted and had intentions to fast.

RESULTS

295 admissions for diabetes emergencies were analyzed. The pre-Ramadan period recorded the highest number of admissions (119) followed by during (106) and post-Ramadan (70). Admissions for hyperglycemic emergencies accounted for 2/3 of total admissions. 37% of admissions for hypoglycemia occurred during pre-Ramadan period compared to 32.1% during Ramadan. Contributing factors included use of sulphonylurea (59.6%), presence of nephropathy (54.5%) and past history of hypoglycemia (45.5%). Admissions for DKA were more common than HHS (119 versus 77) and highest during Ramadan period (36.1%). Most of the admissions for hyperglycemic emergencies were among those with Type 2 diabetes (75.9% for DKA and 97.4% for HHS). Only 31.5% of patients admitted for diabetes emergencies recalled having received Ramadan advice in the past.

DISCUSSION

Admissions for diabetes emergencies were highest during pre-Ramadan period followed by Ramadan and post-Ramadan period. This suggests that fasting during Ramadan does not increase admissions for diabetes emergencies.

Ramadan fasting and diabetes 2019: The year in review

INTRODUCTION

The literature on health aspects of Ramadan fasting is widely spread in many journals making it not readily available to those interested in the subject.

MATERIALS AND METHODS

A narrative, non-systematic review of the international literature from two major online databases (viz. Scopus, PubMed) in one year (2019). The search term "Ramadan fasting AND Diabetes" was used, and relevant literature was narrated in a concise thematic account.

RESULTS

Research design included qualitative, quantitative, and mixed methods. Articles included controlled trials, critical appraisals, literature narrations, and systematic reviews, and meta-analyses. The publications spanned a vast array of topics related to Ramadan fasting, including assessments of current safety and efficacy profiles of newer diabetes therapies, modes of insulin delivery, and utilization of advanced technology for the treatment and monitoring of blood glucose during Ramadan fasting. Increased interest was particularly evident in capturing the experience element manifested by perceptions, attitudes, and practices of both patients and healthcare professionals during Ramadan. The current literature consolidates previous data on the safety of fasting practices amongst the well-controlled. On the other hand, it emphasizes the need for more aggressive interventions for high-risk patients, promoting the usage of newer anti-diabetic agents and advanced glucose monitoring technology for safer fasting practices.

CONCLUSIONS

The volume of global literature production related to Ramadan fasting and Diabetes remains modest. Observational studies of small size prevail. Greater improvements in both quality and quantity of research on Ramadan are needed.

Use of SGLT2 inhibitors during Ramadan: An expert panel statement

Fasting from dawn to sunset, during the holy month of Ramadan, constitutes one of the five main pillars in Islam and is observed by the majority of Muslims. Owing to important physiological changes, Ramadan fasting holds a crucial place in the context of diabetes management. Approximately one-fifth of the world's Muslim population resides in the Middle East and Africa (MEA) region. To discuss the challenges and management of diabetes during Ramadan fasting in the MEA region, a panel of 12 experts in the field of diabetes from across the MEA region attended two expert committee meetings held in Dubai. The key point of discussion was the safety and efficacy of the use of sodium-glucose co-transporter 2 inhibitors (SGLT2i) during Ramadan, based on outcomes of the recent clinical trials with SGLT2i. This is the first consensus recommendation on the management of diabetes with SGLT2i across the MEA region during Ramadan. The document summarizes expert views and opinions on the current management of diabetes with SGLT2i during Ramadan and aims to enhance the current knowledge and understanding on the issue of diabetes management during Ramadan. This will aid the physicians of the MEA region with appropriate decision-making for their patients during Ramadan.

Risk of diabetic ketoacidosis during Ramadan fasting: A critical reappraisal

OBJECTIVES

To evaluate the validity of the perceived increased risk and the actual occurrence of DKA observed during fasting in Ramadan.

METHODS

This is a non-systematic narrative review of the literature on the occurrence of DKA during Ramadan. Online databases (PubMed, Google Scholar, Cochrane Database, Medline OVID and CINAHL EBSCO) were searched. Three research questions are addressed 1. What is the basis of the expert opinion on the risk for DKA? 2. What is the likelihood that DKA is precipitated by Ramadan fast? and 3. What is the frequency of observed DKA during Ramadan?

RESULTS

The expert opinion suggesting a risk of DKA during Ramadan fasting was proposed with no evidence in the early writing on Ramadan fasting and has been reiterated and propagated since then. However, from first principles, DKA is not readily precipitated by the usual stress-free metabolic environment induced by Ramadan fasting with the exception of cases involved in the usual risk factors for metabolic decompensation. Furthermore, recent studies could not document any increase in observed DKA during Ramadan fasting in retrospective, prospective and database studies.

CONCLUSIONS

The current state of knowledge and evidence suggests the risk of DKA is not increased during Ramadan fasting.