Real-world safety and effectiveness of insulin glargine 300 U/mL in participants with type 2 diabetes who fast during Ramadan: The observational ORION study

Real-World Outcomes of Individualized Targeted Therapy with Insulin Glargine 300 Units/mL in Insulin-Naïve Korean People with Type 2 Diabetes: TOBE Study

INTRODUCTION

The TOujeo BEyond glucose control (TOBE) study evaluated clinical outcomes with insulin glargine 300 units/mL (Gla-300) in insulin-naïve Korean people with type 2 diabetes mellitus (T2DM) in a real-world setting.

METHODS

This 24-week, prospective, non-interventional, multicenter, open-label, single-arm, observational study included adults aged ≥ 20 years with T2DM suboptimally controlled with oral hypoglycemic agents and/or glucagon-like peptide 1 receptor agonists who require basal insulin. Eligible participants were assigned to either general target glycated hemoglobin (HbA1c < 7%) or individualized target groups as per physician's discretion considering guidelines and participants' characteristics. The primary endpoint was the proportion of participants achieving the HbA1c target (individualized or general) at 24 weeks.

RESULTS

Among 369 participants, 19.5% (72/369) of participants achieved the HbA1c target at week 24; 37.5% (33/88) in the individualized and 13.9% (39/281) in the general target group. In both target groups, similar reductions in fasting plasma glucose and body weight were observed, with low incidence of hypoglycemia, and T2DM duration was significantly shorter in participants who did versus those who did not achieve the target HbA1c (individualized target group: 9.6 ± 8.0 versus 13.1 ± 8.4 years, P = 0.0454; general target group: 10.2 ± 8.6 versus 12.8 ± 7.4 years, P = 0.0378).

CONCLUSIONS

This study showed that initiation of insulin therapy with Gla-300 in people with T2DM using an individualized approach is more effective in achieving an HbA1c target. Moreover, earlier initiation of insulin therapy in people with suboptimally controlled T2DM may increase the success rate of glycemic control. A graphical abstract is available with this article.

Safety and effectiveness of iGlarLixi in adults with type 2 diabetes mellitus from Gulf countries during Ramadan holy month: A subgroup analysis of the SoliRam observational study

AIM

To investigate safety and effectiveness of iGlarLixi in adults with type 2 diabetes mellitus (T2DM) observing fast during Ramadan from Gulf countries.

METHODS

This planned subgroup analysis of the SoliRam - a multinational, prospective, non-interventional, real-world, observational study - focused on participants from Gulf countries. Primary endpoint was proportion of participants experiencing ≥1 episode of severe and/or symptomatic documented (<70 mg/dL [<3.9 mmol/L]) hypoglycemia.

RESULTS

A total of 241 individuals with T2DM (mean age: 58.1 years; male: 54.4%; mean duration of diabetes: 13.3 years) were included. All 234 eligible participants followed during Ramadan were able to fast for ≥25 days and no participants broke fast due to hypoglycemia. Primary endpoint was reported in one participant (0.5%) during fasting hours during Ramadan. Improvements (mean ± SD change) in HbA1c (-1.0 ± 1.0% [-11 ± 10 mmol/mol]), FPG (-22.5 ± 29.7 mg/dL), and body weight (-1.5 ± 2.0 kg) were observed from pre-Ramadan to post-Ramadan. Three participants (1.2 %) reported an adverse event (AE) of any cause and one (0.4%) reported a gastrointestinal AE.

CONCLUSIONS

iGlarLixi is an effective and well-tolerated treatment in people with T2DM from Gulf countries, including during Ramadan fasting, and is associated with low risk of hypoglycemia.

Real-world Safety and Effectiveness of Insulin Glargine 300 U/mL in Participants with Type 2 Diabetes Mellitus During the Period of Ramadan in Four Countries (Egypt, Jordan, Lebanon, and Turkey): A Prospective Observational Study

AIM

This non-interventional observational study aimed to describe the clinical outcomes of patients with T2DM treated with Gla-300 during the period of Ramadan.

BACKGROUND

Type 2 diabetes mellitus (T2DM) patients who decide to fast during the holy month of Ramadan face several challenges in achieving glycemic control without increasing the risk of hypoglycemia. Insulin glargine-300 (Gla-300) has well-established safety and efficacy in improving glycemic control in multiple randomized clinical trials (RCTs). However, limited evidence is available regarding its safety and effectiveness during fasting.

OBJECTIVE

The objective of this study was to assess the safety and clinical outcomes of insulin glargine-300 (Gla-300) in T2DM patients before, during, and after Ramadan.

METHODS

We conducted a prospective, observational, non-comparative, multicenter study on patients with T2DM currently treated with Gla-300 who planned to fast and continue on Gla-300 during Ramadan in four countries (Egypt, Jordan, Lebanon, and Turkey). The study outcomes included the change in glycemic parameters and incidence of hypoglycemia before, during, and after Ramadan.

RESULTS

One hundred and forty T2DM patients were included. Nearly 61% of the included patients had a duration of diabetes of <10 years. The mean Gla-300 daily doses during the pre-Ramadan, Ramadan, and post-Ramadan periods were 22.2 ±7.4, 20.4 ±7.5, and 22.5 ±4.7 IU, respectively. The mean change values from pre-Ramadan to Ramadan and post-Ramadan were -1.7 ±6.9 IU and 0.5 ±4.7 IU, respectively, among the included patients. The mean HbA1c decreased during the study period initiating from 7.9% ±1.4% pre-Ramadan to 6.9% ±0.4% post-Ramadan. The overall HBA1c target value was 6.9% ±0.4%, while the HbA1c target was achieved by 29 patients (21.9%). The mean fasting blood glucose (FPG) showed a reduction from baseline value in the post-Ramadan period by -0.9 ±2.3 mmol/L. Five patients (3.57%) had symptomatic documented hypoglycemia during Ramadan, and none was considered to have severe hypoglycemia.

CONCLUSION

Our study showed that insulin Gla-300 maintained the glycemic control of T2DM patients who decided to fast during the holy month of Ramadan without increasing the risk of hypoglycemia. Regular self-monitoring of blood glucose levels during Ramadan is highly recommended to avoid possible complications.

Management of diabetes during Ramadan: an update for Russian-speaking doctors

Fasting during the Islamic Ramadan month is one of the five obligatory pillars for each adult, healthy, and sane Muslim. People with severe illnesses, including type 1 and type 2 diabetes mellitus are exempt from fasting. However, many Muslims often insist on Ramadan participating despite any medical advises. It’s known that Muslims are the second largest religious group in Russia; thus, its crucial to have as much modern recommendation for management patients with type 1 and type 2 diabetes mellitus as possible. The aim of this narrative review is to evaluate physiological and pathophysiological metabolism changing during holy Ramadan month, to clarify the management of patients with type 1 and type 2 diabetes mellitus during Ramadan, to determine the frequency of glucose measuring during the day, and to understand when its time to interrupt the fasting. Moreover, we discuss specific recommendations in glucose-lowering therapy changing, nutrition, physical activities and education.

Real-world safety and effectiveness of iGlarLixi in people with type 2 diabetes who fast during Ramadan: The SoliRam observational study

BACKGROUND AND AIMS

To evaluate the safety and effectiveness of iGlarLixi in adults with type 2 diabetes (T2D) fasting during Ramadan.

METHODS

SoliRam was a multinational, prospective, single-arm, real-world observational study conducted during Ramadan 2020 and 2021 in adults with T2D treated with iGlarLixi ≥3 months at study entry. The primary endpoint was the percentage of participants experiencing ≥1 episode of severe and/or symptomatic documented hypoglycemia (<70 mg/dL [<3.9 mmol/L]).

RESULTS

Among the 409 eligible participants followed during Ramadan, 96.8% fasted for ≥25 days and 92.4% did not break fasting during Ramadan. Four participants broke their fast due to hypoglycemia. Minimal adjustments were seen in antihyperglycemic therapies from pre to during Ramadan. Documented symptomatic hypoglycemia was experienced by 1.0%, 2.3%, and 0.3% of participants, respectively, during the last month of pre-Ramadan, Ramadan, and first month post-Ramadan. Mean change in HbA_1c from pre-to post-Ramadan periods was -0.75% (-8.2 mmol/mol), and participants with HbA_1c <7% (<53 mmol/mol) increased from 7.9% pre-Ramadan to 28.6% post-Ramadan.

CONCLUSIONS

iGlarLixi is an effective and well-tolerated therapy for people with T2D, including those who intend to fast during Ramadan, and is associated with a low risk of hypoglycemia; benefits were observed both during and after Ramadan.

Clinical Evidence and Practice-Based Guidelines on the Utility of Basal Insulin Combined Oral Therapy (Metformin and Glimepiride) in the Current Era

BACKGROUND AND AIM

Basal insulin combined oral therapy consisting of insulin and oral anti-diabetic drugs (OADs) is recommended for type 2 diabetes uncontrolled on OADs. There is a lack of clear evidence and recommendations on the combined use of basal insulin analogues to more than one OADs (glimepiride plus metformin) in effective control of glycemic parameters and its safety in terms of reduced hypoglycemic events, weight gain and cardiovascular risk. In this context, a group of clinical experts discussed the utility of basal insulin combined oral therapy with metformin and glimepiride in the current era.

METHODS

The clinical experts discussed and provided their inputs virtually. The expert panel included clinical experts comprising endocrinologists and diabetologists from India and Nepal.

RESULTS

The panel thoroughly reviewed existing literature on the subject and proposed clinical evidence and practice-based guidelines.

CONCLUSION

These current clinical practice guidelines highlight the efficacy and safety of basal insulin combination therapy with various available basal insulins including neutral protamine hagedorn, detemir, glargine and degludec in addition to metformin and glimepiride therapy.

Use of Second-Generation Basal Insulin Gla-300 in Special Populations: A Narrative Mini-Review

BACKGROUND AND AIMS

Hypoglycemia and insulin-related adverse events are crucial barriers to effective diabetes management, particularly in the elderly, people with renal impairment, people with diabetes fasting during Ramadan, or people with type 1 diabetes mellitus (T1DM). There is a scarcity of clinical and real-world evidence assessing the effectiveness and safety of insulin glargine 300 U/mL (Gla-300) in these special populations. To understand the entirety of evidence, this mini-review elaborates on the use of Gla-300 in diabetes management among special populations.

METHODS

Clinical and real-world evidence related to the use of Gla-300 among special populations with diabetes were retrieved using PUBMED and Google Scholar.

RESULTS

Gla-300 has shown improved glycemic control with stable insulin action and low risk of hypoglycemia in diverse groups with diabetes. It also appears to have an acceptable safety profile during Ramadan fasting. However, adequate monitoring and adjustment of insulin dose on an individual basis should be considered.

CONCLUSION

Gla-300 is a second-generation basal insulin with proven benefits of reduced risk of hypoglycemia and improved glycemic control in special populations of people with diabetes.

Safety and effectiveness of newer antidiabetic medications during Ramadan fasting and safety of Ramadan fasting after bariatric surgery

Background

Fasting during Ramadan is mandatory for all adult healthy Muslims. International studies found that most Muslims with diabetes mellitus fast during Ramadan. The main risk factors are hypoglycemia, Hyperglycemia, diabetic ketoacidosis, and dehydration during fasting. Therefore, stratification of the risks for severe acute diabetes complications needs to be considered for each individual and strategies personalized to advert these complications. The advent of new diabetes medications which are effective yet with a better safety profile and monitoring of blood glucose levels during the day are important to reduce the risk of untoward effects of hypoglycemia and hyperglycemia during Ramadan fasting. Here we review the safety and effectiveness of the newer diabetes medications for Ramadan fasting and whether it is safe to perform fasting after bariatric surgery.

Methods

An extensive literature search using PubMed and Google Scholar was done using different search terms. The eligible studies were 48 randomized controlled trials, prospective observational studies, and reviews from January 2008 to June 2022 which were conducted in individuals living with diabetes.

Results and Conclusions

The newer diabetes medications such as GLP-1 agonists, DPP-4 inhibitors, SGLT-2 inhibitors, and new Insulin therapy are thought to be safe and effective during fasting of Ramadan. These medications are associated with a reduction in HbA1c, body weight, systolic blood pressure and risk of hypoglycemia during Ramadan fasting. However, further studies with larger sample size are needed to confirm the efficacy and safety of these newer medications during Ramadan fasting. Individuals with Bariatric surgery should seek advice and approval to fast from the bariatric dietician, physician, and surgeon before the beginning of the month of Ramadan.

Religious fasting and its impacts on individual, public, and planetary health: Fasting as a "religious health asset" for a healthier, more equitable, and sustainable society

Religious fasting is practiced by people of all faiths, including Christianity, Islam, Buddhism, Jainism, as well as Hinduism, Judaism, and Taoism. Individual/clinical, public, global, and planetary health has traditionally been studied as separate entities. Nevertheless, religious fasting, in conjunction with other religious health assets, can provide several opportunities, ranging from the individual to the population, environmental, and planetary levels, by facilitating and supporting societal transformations and changes, such as the adoption of healthier, more equitable, and sustainable lifestyles, therein preserving the Earth's systems and addressing major interconnected, cascading, and compound challenges. In this review, we will summarize the most recent evidence on the effects of religious fasting, particularly Orthodox and Ramadan Islamic fasting, on human and public health. Further, we will explore the potential effects of religious fasting on tackling current environmental issues, with a special focus on nutrition/food restriction and planetary health. Finally, specific recommendations, particularly around dietary intake during the fasting rituals, will be provided to ensure a sustainable healthy planet.

A Systematic Review of Insulin Management Recommendations to Improve Glycemic Control and Reduce Hypoglycemic Events During Ramadan Fasting in Patients With Insulin-Requiring Type 2 Diabetes

Background

Muslims with insulin-requiring type 2 diabetes are at high risk of hypo- and hyperglycemia while fasting during the month of Ramadan. Although a few reviews on diabetic management during Ramadan have been published, surveys reveal knowledge gaps remain among physicians.

Aim

This systematic review qualitatively analyzes what insulin dosing recommendations are likely to reduce hypoglycemic events and improve glycemic control during the Ramadan fasting for this high-risk group.

Methods

A comprehensive search in six databases and gray sources was performed from August 10, 2001, to August 10, 2021, for studies assessing which types of insulin and/or what dosing recommendations reduce hypoglycemic events and improve glycemic control during Ramadan. We excluded studies focusing mainly on oral antihyperglycemic medications, type 1 diabetes, persons with insulin pumps, and studies older than 20 years. Hypoglycemic event rates, pre-, and post-iftar blood glucose levels, overall average blood glucose, and hemoglobin A1c were analyzed, and a narrative synthesis was performed.

Results

Out of 1,101 collected articles, 14 eligible studies including 2,969 participants with an average age of 54.8 years, we found that insulin dose reduction may prevent hypoglycemia without causing subsequent hyperglycemia, and rapid-acting insulin analogs may improve post-iftar and overall blood glucose without incurring hypoglycemia.

Conclusions

Though initial findings are promising, more research is needed to confirm the benefits of insulin dose reduction, rapid-acting insulin analogs, and ultra-long-acting insulins.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021268943.

A Real-World Observational Study of Gla-300 in Adults with Type 2 Diabetes Who Fast During Ramadan in the South Asia Region: A Subgroup Analysis of the ORION Study

INTRODUCTION

In this ORION study subgroup analysis, the safety and effectiveness of insulin glargine 300 U/mL (Gla-300) was evaluated in people from the South Asia region with type 2 diabetes mellitus (T2DM) before, during, and after Ramadan, in a real-world setting.

METHODS

The ORION study was a real-world, prospective, observational, non-comparative study conducted across 11 countries. The current subgroup analysis included participants from the South Asia region (India and Pakistan) who fasted during Ramadan. The primary endpoint was the percentage of participants experiencing ≥ 1 event of severe and/or symptomatic documented hypoglycemia with self-monitored plasma glucose (SMPG) ≤ 70 mg/dL during Ramadan. Secondary endpoints analyzed were changes in glycated hemoglobin (HbA_1c), fasting plasma glucose (FPG), SMPG, insulin dose, and adverse events (AEs).

RESULTS

This subgroup analysis included 106 participants from the South Asia region with mean (standard deviation) age of 51.3 (10.9) years and mean number of 29.8 (4.0) fasting days. The number of severe and/or symptomatic documented hypoglycemia events was low in the pre-Ramadan (SMPG ≤ 70 mg/dL: 1 event [0.9%]; SMPG < 54 mg/dL: 1 event [0.9%]) and Ramadan periods (SMPG ≤ 70 mg/dL: 1 event [0.9%]; SMPG < 54 mg/dL: 0 events), and none in the post-Ramadan period. One participant reported severe hypoglycemia (any time of the day: nocturnal or daytime) throughout the pre-Ramadan period. A reduction in HbA_1c and FPG levels was seen during the pre- to post-Ramadan period; however, a slight increase in SMPG levels was reported during this same period. Gla-300 daily dose was reduced from 21.6 (9.6) U to 20.2 (8.9) U during the pre-Ramadan to Ramadan period. The incidence of AEs was 1.9%.

CONCLUSIONS

The real-world data from the ORION study indicate that Gla-300 is effective, with low risk of hypoglycemia, for the management of T2DM during Ramadan in the South Asian population.

TRIAL REGISTRATION

CTRI/2019/02/017636.

The Effect of Coronavirus Disease-19 Pandemic Lockdown and the Overlapping Ramadan Fasting Period on Glucose Control in Insulin-Treated Patients With Diabetes: A Flash Glucose Monitoring Study

Background

A strict lockdown was enforced during coronavirus disease (COVID-19) pandemic in many countries including the UAE. Lockdown period overlapped with Ramadan which is accompanied by its own drastic changes in lifestyle that include meal timings.

Aims

We report the impact of COVID-19 lockdown (between 22/3/2020 and 24/6/2020) on glucose control pre- and postlockdown and during Ramadan, in patients with type 1 diabetes (T1D) and type 2 diabetes (T2D) on insulin therapy.

Methods

A number of twenty-four patients (19 men, 6 women) who were monitoring their glucose levels using flash glucose monitoring (FGM) and remotely connected to the diabetes clinic in Imperial College London Diabetes Centre (ICLDC), Abu Dhabi, UAE were included. Using the international consensus on the use of continuous glucose monitoring guidelines, analyses of data were performed on glucose management indicator (GMI), time in range (TIR), time in hyperglycemia, time in hypoglycemia, low blood glucose index (LBGI) and high blood glucose index (HBGI). Variables were calculated for each period: 30 days before lockdown 14/2/2020-14/3/2020, 30 days into lockdown and pre-Ramadan 20/3/2020-18/4/2020, and 30 days into lockdown and Ramadan 24/4/2020-23/5/2020, using cgmanalysis package in R-studio software.

Results

Mean average glucose (MAG) remained steady before and during lockdown, and no significant differences were observed in TIR, time in hypoglycemia, and LBGI between prelockdown and lockdown periods. However, there was a statistically significant difference in GMI and percentage of time in hyperglycemia (>10.0 mmol/L) between Ramadan and pre-Ramadan during the lockdown period in p = 0.007, 0.006, and 0.004, respectively. Percentage of TIR (3.9-10.0 mmol/L) was significantly lower in Ramadan as compared to pre-Ramadan (50.3% vs. 56.1%; p = 0.026). Mean absolute glucose (MAG) (182.0 mmol/L vs. 166.6 mmol/L, p = 0.007) and HBGI (10.2 (6.8, 14.8) vs. 11.9 (7.9, 17.8), p = 0.037) were significantly higher in Ramadan compared to pre-Ramadan period. There was no statistically significant difference in percentage of time in hypoglycemia (<3.9 mmol/L) and LBGI between Ramadan and pre-Ramadan periods.

Conclusion

The lockdown period had no significant effects in the markers of glycemic control in the population studied. However, Ramadan fasting period embedded within this time was associated with several changes that include increase in GMI, HBGI, and glycemic variability similar to what has been reported in other Ramadan studies.

Safety and Effectiveness of Insulin Glargine 300 U/mL in Participants with Type 2 Diabetes Who Fast During Ramadan in The Gulf Region: A Subgroup Analysis of the Real-World ORION Study

INTRODUCTION

To evaluate the safety and effectiveness of insulin glargine 300 U/mL (Gla-300) in people with type 2 diabetes mellitus (T2DM) in the Gulf region who fast during Ramadan.

METHODS

ORION was a real-world, prospective, observational study in people with T2DM treated with Gla-300 during pre-Ramadan, Ramadan, and post-Ramadan periods. This subgroup analysis included 222 participants from the Gulf region (Kuwait, Saudi Arabia, United Arab Emirates, and Qatar). The primary endpoint was the percentage of participants experiencing severe and/or symptomatic documented hypoglycemia (self-monitored plasma glucose [SMPG] ≤ 70 mg/dL) during Ramadan. Changes in glycated hemoglobin (HbA_1c), fasting plasma glucose (FPG), SMPG, body weight, insulin dose, and adverse events (AEs) were also evaluated.

RESULTS

The primary endpoint was reported in one (0.5%) participant during Ramadan. The incidence rate of symptomatic documented hypoglycemia (SMPG ≤ 70 mg/dL) decreased from the pre-Ramadan (3.2%) to Ramadan period (0.5%), and no severe hypoglycemia events were reported during the study. Reductions were observed in HbA_1c (mean ± standard deviation: - 0.51 ± 0.95% [- 5.5 ± 10.4 mmol/mol]), FPG (- 13.9 ± 47.5 mg/dL), and SMPG (- 6.1 ± 27.1 mg/dL). No significant changes were observed in body weight or Gla-300 dose. AEs were reported in 11 (5.0%) participants.

CONCLUSION

In a real-world setting in the Gulf region, Gla-300 treatment in people with T2DM during Ramadan was associated with a low incidence of hypoglycemia and improved glycemic control.

TRIAL REGISTRATION

CTRI/2019/02/017636.

Ramadan Fasting in Germany (17-18 h/Day): Effect on Cortisol and Brain-Derived Neurotrophic Factor in Association With Mood and Body Composition Parameters

Ramadan fasting (RF) is a type of diurnal intermittent fasting. Previous studies reported the benefits of RF in healthy subjects on mood and health related to quality of life (QoL). Cortisol and brain-derived neurotrophic factor (BDNF) have been shown to play a role in mood, body composition parameters, and health-related QoL. This study aimed at elucidating the mechanism of the benefit of RF, particularly cortisol and BNDF and their association with mood and QoL. Insulin growth factor-1 (IGF-1), interleukin (IL)-8, matrix metalloproteinase (MMP)-9, and myoglobin were determined. Thirty-four healthy men and women were recruited. Serum from peripheral venous blood samples was collected at five time points: 1 week before RF (T1); mid of RF (T2), last days of RF (T3), 1 week after RF (T4), and 1 month after RF (T5). The amounts of biological mediators in the serum samples were determined by enzyme-linked immunosorbent assay (ELISA) and Luminex assays. BDNF and cortisol significantly decreased at T3 (p < 0.05) and T4 (p < 0.001) compared to T1, respectively. It seems the benefits of RF for mood-related symptoms are mediated by different biological mediators, particularly cortisol and BDNF.

Ramadan fasting and diabetes, latest evidence and technological advancements: 2021 update

Development of updated guidelines for management of diabetes in Ramadan Fasting is of paramount importance. Nonetheless, evidence-based guidelines in the field of Ramadan Fasting and Diabetes are scarce. Moreover, findings of some recent research such as effects of Ramadan fasting on microbiota, genetics and epigenetics, hormonal changes (such as adiponectin, leptin, testosterone…), and alternations in circadian rhythm should also be reviewed and included on a yearly basis. It is documented that self-monitoring of blood glucose (SMBG) is of vital importance for patients with type 1 diabetes who fast, and advantages of continuous glucose monitoring (CGM) or flash glucose monitoring (FGM) techniques should be highlighted. Moreover, the recent findings about applications of advanced insulin delivery technology in patients with diabetes who fast in Ramadan should also considered in the annual updates of the guidelines.

Ramadan fasting and diabetes, latest evidence and technological advancements: 2021 update

Development of updated guidelines for management of diabetes in Ramadan Fasting is of paramount importance. Nonetheless, evidence-based guidelines in the field of Ramadan Fasting and Diabetes are scarce. Moreover, findings of some recent research such as effects of Ramadan fasting on microbiota, genetics and epigenetics, hormonal changes (such as adiponectin, leptin, testosterone…), and alternations in circadian rhythm should also be reviewed and included on a yearly basis. It is documented that self-monitoring of blood glucose (SMBG) is of vital importance for patients with type 1 diabetes who fast, and advantages of continuous glucose monitoring (CGM) or flash glucose monitoring (FGM) techniques should be highlighted. Moreover, the recent findings about applications of advanced insulin delivery technology in patients with diabetes who fast in Ramadan should also considered in the annual updates of the guidelines.

Changes in fasting patterns during Ramadan, and associated clinical outcomes in adults with type 2 diabetes: A narrative review of epidemiological studies over the last 20 years

Although religious guidance exempts some Muslims with type 2 diabetes from fasting during Ramadan, many choose to fast. The associated risks for fasting adults with diabetes includes hypoglycemia, hyperglycemia, ketoacidosis, dehydration, and thrombosis. Thus, it is important that healthcare professionals support individuals who choose to fast to minimize risks. We reviewed three epidemiologic studies to understand how fasting patterns during Ramadan and associated clinical outcomes in adults with type 2 diabetes have evolved over two decades (2000-2020). Over a period of time people with diabetes choosing to fast during Ramadan are displaying increasingly complex profiles in terms of their diabetes, with increased disease duration, greater body mass index, and elevated pre-Ramadan mean glycated hemoglobin levels. Despite this, in the most recent study, >85% of adults with type 2 diabetes still chose to fast. Increased risk of hypoglycemia remains a major concern despite some improvements over time, which could be attributable to enhanced education programs, and changes in treatment type and/or dose prior to and/or during Ramadan. Our review highlights the evolution in fasting patterns over two decades and serves as an update for healthcare professionals to provide appropriate guidance to ensure that Ramadan fasting is safe and rewarding.

Impact of Ramadan Diurnal Intermittent Fasting on Hypoglycemic Events in Patients With Type 2 Diabetes: A Systematic Review of Randomized Controlled Trials and Observational Studies

Ramadan is the 9th month of the lunar calendar during which Muslims abstain from food and drink between dawn and sunset for 30 consecutive days. Ramadan fasting is observed by all healthy Muslim adults, as well many Muslims with type 2 diabetes (T2DM). Hypoglycemic events (HE) are a serious complication associated with diabetes management and are associated with increased cardiovascular disease risk. Conflicting results have been reported concerning the incidence of HE among people with T2DM observing Ramadan fasting. This review summarizes available scientific evidence on the occurrence of HE and the effects of different moderators on the incidence of HE among patients with T2DM during Ramadan. We conducted a systematic review of available observational studies and randomized controlled trials (RCTs) for patients with T2DM who fasted during Ramadan, with HE as the primary outcome. Ten databases were searched for relevant studies from inception until October 31, 2020. In total, 68 studies (35 RCTs and 33 observational studies) met the inclusion criteria. Non-sulfonylureas hypoglycemic medications showed superior effects in lowering the incidence of HE over sulfonylureas hypoglycemic medications. Variable moderators were associated with experiencing HE during Ramadan in both observational studies and RCTs, including sex, geographical location, body anthropometric indicators, season, dietary behaviors, fasting duration, time since diagnosis, and pre-fasting education. This comprehensive systematic review covered the largest number of observational and clinical studies investigating the impact of Ramadan on HE among patients with T2DM. The study highlights the significance of different moderators that influence the effect of Ramadan fasting on HE, including dietary behaviors, fasting time duration, sex, season, country, pre-fasting education, age, and time since diagnosis. The study also highlighted the impact of different hypoglycemic medications on HE and noted the superiority of non-sulfonylureas over sulfonylureas hypoglycemic medications in lowering the risk for hypoglycemia in people with T2DM during Ramadan fasting.

The Safety and Efficacy of Second-Generation Basal Insulin Analogues in Adults with Type 2 Diabetes at Risk of Hypoglycemia and Use in Other Special Populations: A Narrative Review

Hypoglycemia is a major barrier impeding glycemic control in persons with type 2 diabetes mellitus and creates a substantial burden on the healthcare system. Certain populations that require special attention, such as older adults and individuals with renal impairment, a longer duration of diabetes or those who have experienced prior hypoglycemia, may be at a higher risk of hypoglycemia, particularly with insulin treatment. Second-generation basal insulin analogues (insulin glargine 300 U/mL and degludec) have demonstrated reductions in hypoglycemia compared with insulin glargine 100 U/mL although evidence of this benefit across specific populations is less clear. In this review we summarize the literature with respect to the efficacy and safety data for second-generation basal insulin analogues in adults with type 2 diabetes mellitus who are at risk of hypoglycemia or who require special attention. Randomized controlled trials, meta-analyses and real-world evidence demonstrate that the use of second-generation basal insulin analogues is associated with less hypoglycemia compared with insulin glargine 100 U/mL without compromising glycated hemoglobin control. A reduced risk of hypoglycemia with second-generation basal insulin analogues was evident in older adults and in individuals with obesity, renal impairment, a history of cardiovascular disease or a long duration of insulin use. Further studies are needed in other populations, including those with more severe renal impairment or hepatic dysfunction, the hospitalized population and those with cognitive impairment. Overall, less hypoglycemia associated with second-generation basal insulin analogues may help reduce barriers for insulin use, improve adherence and offset the costs of hypoglycemia-related healthcare resource utilization.

Ramadan and Diabetes: A Narrative Review and Practice Update

Fasting in the Islamic month of Ramadan is obligatory for all sane, healthy adult Muslims. The length of the day varies significantly in temperate regions-typically lasting ≥ 18 h during peak summer in the UK. The synodic nature of the Islamic calendar means that Ramadan migrates across all four seasons over an approximately 33-year cycle. Despite valid exemptions, there is an intense desire to fast during this month, even among those who are considered to be at high risk, including many individuals with diabetes mellitus. In this review we explore the current scientific and clinical evidence on fasting in patients with diabetes mellitus, focussing on type 2 diabetes mellitus and type 1 diabetes mellitus, with brief reviews on pregnancy, pancreatic diabetes, bariatric surgery, the elderly population and current practice guidelines. We also make recommendations on the management of diabetes patients during the month of Ramadan. Many patients admit to a do-it-yourself approach to diabetes mellitus management during Ramadan, largely due to an under-appreciation of the risks and implications of the rigors of fasting on their health. Part of the issue may also lie with a healthcare professional's perceived inability to grasp the religious sensitivities of Muslims in relation to disease management. Thus, the pre-Ramadan assessment is crucial to ensure a safe Ramadan experience. Diabetes patients can be risk-stratified from low, medium to high or very high risk during the pre-Ramadan assessment and counselled accordingly. Those who are assessed to be at high to very high risk are advised not to fast. The current COVID-19 pandemic upgrades those in the high-risk category to very high risk; hence a significant number of diabetes patients may fall under the penumbra of the 'not to fast' advisory. We recognize that fasting is a personal choice and if a person chooses to fast despite advice to the contrary, he/she should be adequately supported and monitored closely during Ramadan and for a brief period thereafter. Current advancements in insulin delivery and glucose monitoring technologies are useful adjuncts to strategies for supporting type 1 diabetes patients considered to be high risk as well as 'high-risk' type 2 patients manage their diabetes during Ramadan. Although there is a lack of formal trial data, there is sufficient evidence across the different classes of therapeutic hypoglycaemic agents in terms of safety and efficacy to enable informed decision-making and provide a breadth of therapeutic options for the patient and the healthcare professional, even if the professional advice is to abstain. Thus, Ramadan provides an excellent opportunity for patient engagement to discuss important aspects of management, to improve control in the short term during Ramadan and to help the observants understand that the metabolic gains achieved during Ramadan are also sustainable in the other months of the year by maintaining a dietary and behavioural discipline. The application of this understanding can potentially prevent long-term complications.

ELECTRONIC SUPPLEMENTARY MATERIAL

The online version of this article (10.1007/s13300-020-00886-y) contains supplementary material, which is available to authorized users.

A Prospective Clinical Trial of Prolonged Fasting in Healthy Young Males and Females-Effect on Fatigue, Sleepiness, Mood and Body Composition

Fasting during a long period (17–18 h/day) may affect daily performance. Fatigue is one of important parameters to observe for this effect. This study aimed to determine the effect of Ramadan fasting (RF)—particularly on fatigue in both young males and females. Sleepiness, mood-related symptoms (MRSs) and body composition (BC) were determined, too. Thirty-four young males and females were recruited and performed RF. They were assessed for fatigue, sleepiness, MRS and BC at T1 (one week before RF), T2 (mid of RF), T3 (last days of RF), T4 (one week after RF) and T5 (one month after RF). The assessments were done in the morning, except for fatigue and sleepiness, which were also assessed in the afternoon and evening of T1 to T5. This study observed numerous positive effects to RF. After they began fasting and compared to T1, participants experienced (1) significantly less fatigue; (2) small to large improvement of MRSs; and (3) positive changes relating to BC. RF did not appear to have a significant effect on participants’ sleepiness scores. Ultimately, this study illustrates how prolonged fasting, like RF, benefits the youth, particularly by decreasing fatigue, improving MRSs and positively impacting BC.