Impact of provision of optimum diabetes care on the safety of fasting in Ramadan in adult and adolescent patients with type 1 diabetes mellitus

BACKGROUND

All diabetes and Ramadan guidelines advice against fasting for people with type 1 diabetes, however, many insist on fasting. Consequently, this causes a challenge due to the risk of hypoglycaemia, hyperglycemia ± diabetic ketoacidosis.

AIM

To assess the impact of optimum care, which includes Ramadan-focused education, flash glucose monitoring, dietary advice and treatment adjustment on the safety of Ramadan fasting in people with type 1 diabetes.

METHODS

Thirty persons with type 1 diabetes who insisted to fast during Ramadan were recruited to the study. At pre-Ramadan visit, all patients received Ramadan focused education and Freestyle Libre (FSL) sensor insertion and training. Patients used the sensor for 6 weeks (pre-Ramadan and during Ramadan). The physical and biological parameters were collected 2-4 weeks before and after Ramadan.

RESULTS

22 patients on basal bolus insulin and 2 on an insulin pump had FSL data. Average number of days fasted were 24. Learning benefits was reported by 95% of patients following pre-Ramadan educational session. There was no clinically significant change in physical and/or biological data between pre and post-Ramadan. 63% reported making insulin dose adjustments in Ramadan. Flash glucose monitoring data showed 46.7% of patients had more than 10 hypoglycemic episodes in the 2 weeks prior to Ramadan compared to 29.2% during Ramadan. However, none of the data were statistically significant apart from HbA1c which reduced from prior to RamadanHbA1c of 8.2% to 7.9% post Ramadan (P 0.010). There was one DKA on 2nd day of Ramadan, reported due to missing insulin dose to avoid hypoglycemia.

CONCLUSION

Optimal care of selective patients with type 1 diabetes with a low complication rate may allow Ramadan fasting with improvement in glycemic control and without an increase in hypoglycemia, biometric or metabolic parameters. Larger, randomized controlled trials are required to be able to generalize this as a recommendation.

The use of Free Style Libre Continues Glucose Monitoring (FSL-CGM) to monitor the impact of Ramadan fasting on glycemic changes and kidney function in high-risk patients with diabetes and chronic kidney disease stage 3 under optimal diabetes care

AIM

To understand the risk of hypoglycaemia during Ramadan fasting by use of CGM, as well as to observe the Glycemic control and renal functions in patients with diabetes and chronic kidney disease stage 3 (CKD-3).

METHOD

A prospective interventional study conducted in the Dubai Hospital, a tertiary care centre in the United Arab Emirates, during the month of Ramadan 1437 AH (Hijri), which corresponded to June 6th till July 5th, 2016. 25 patients with type 2 diabetes and stage 3 chronic kidney disease (CKD stage 3) were included in the study, who intended to fast during Ramadan. The aim was to observe the serum glucose level through 24 h FreeStyle Libre flash continuous glucose monitor (FSL-CGM). Most patients had three sensors during the study, covering an average three weeks during Ramadan and three weeks outside Ramadan (Sha'ban and shawal). We also monitored the change in, BP, HBA1c, kidney functions and BMI before and after Ramadan.

RESULTS

This study included 25 adults with a mean age of 60 (±14 years). Fasting Ramadan did not result in any significant change in biophysical and biochemical profile of these patients. Data from FSL-CGM showed significantly longer duration (101.9 ± 119.1 Vs. 45.9 ± 47.6 min, p < 0.033) and more frequent hypoglycemic episodes (4.4 ± 4.7 Vs. 2.3 ± 3.0, p < 0.047) during Ramadan compared tonon-Ramadan respectively. The mean blood glucose readings were also significantly lower (70.7 ± 29.3 Vs.93.7 ± 57.9 mg/dl p < 0.011) during Ramadan compared to non -fasting period. The renal function mean ± SD (serum creatinine 1.48 ± 0.37, 1.44 ± 0.37 and eGFR, 49.0 ± 18.4, 48.9 ± 17.5 p 0.9) showed no significant change due to fasting.

CONCLUSION

In patients with diabetes and CKD-stage 3 Ramadan fasting under close supervision and optimal diabetes care, was not associated with worsening of HBA1c and renal function. Patients had significantly more frequent and prolonged hypoglycemic episodes during Ramadan.

Impact of optimum diabetes care on the safety of fasting in Ramadan in adult patients with type 2 diabetes mellitus on insulin therapy

AIM

We aimed at evaluating the safety of fasting Ramadan for insulin treated type 2 diabetes patients by assessing the biochemical, biometric parameters, flash glucose monitoring (FGM) data as compared to pre-Ramadan and hospital admissions with diabetes or non-diabetes conditions. The risks of fasting between those treated with basal insulin vs intensive insulin during Ramadan was also assessed.

METHODS

We included insulin treated patients with type 2 diabetes and we excluded those with co-morbidities. Patients were provided with Ramadan-focused education, FGM before and during Ramadan and medical advice for treatment adjustment. We measured biologic and biometric data before and after Ramadan.

RESULTS

HbA1c reduced from 7.9 ± 1.20 pre-Ramadan to 7.7 ± 1.5% post Ramadan (p = 0.023). Average peak glucose reading was 330.1 ± 79.8 mg/dl before Ramadan improved significantly to reach 289.3 ± 77.7 mg/dl (p = 0.013). Average number of hypoglycemic episodes was higher in intensive insulin group between 1200 and 1800 h (p = 0.028).

CONCLUSION

People with type 2 diabetes treated with insulin who fast Ramadan and who are provided with Ramadan focused patient education, individualized treatment adjustment and FGMS were not at increased safety risks as measured by biochemical, biometric and FGM data.

Assessment of risk of fasting during Ramadan under optimal diabetes care, in high-risk patients with diabetes and coronary heart disease through the use of FreeStyle Libre flash continuous glucose monitor (FSL-CGMS)

AIM

Most of Muslims patients with diabetes and Coronary Heart Disease (CHD) elect to fast in Ramadan, but the actual risk in this subset of patients with diabetes is largely unknown. We aimed to understand the safety of fasting in CHD patients with diabetes insisting on fasting Ramadan under optimal care. We also monitored the change in biophysical and biochemical parameters of these patients before and after Ramadan. We conducted this prospective study in a tertiary care hospital in Dubai during Ramadan 2016, (June 6th till July 5th).

PATIENTS AND METHODS

21 Patients with T2DM with stable known CHD during the three months prior to study and insisted on fasting despite advice against it were recruited for the study. All patients received continuous glucose monitoring with free style libre monitoring device (FSL-CGM) during and outside Ramadan period. We recorded DM or CVD-related emergency visit or hospitalisation, change in BMI, systolic and diastolic BP, lipids profile, e-GFR, HBA1c, and frequency of hypoglycemia during Ramadan fasting and not -fasting period.

RESULTS

This is first study using CGM in CHD patients with diabetes who observe fast in Ramadan. Patients had a significantly higher incidence (3.2 ± 2.8 vs 1.1 ± 1.6 episodes, p = 0.033) and prolonged duration of hypoglycemia (117.8 ± 87.2, 49.1 ± 59.1 min p 0.022) during fasting compared to non-fasting respectively. No significant alteration was seen in BMI, SBP and DBP, lipid profile and renal function. There is a significant improvement in HBA1c during Ramadan.

CONCLUSION

We could not associate any adverse cardiovascular effects with fasting Ramadan in patients with stable CHD under optimal diabetes care. FSL-CGMS data showed higher frequency of hypoglycemia during Ramadan fasting. Studies with larger sample size are needed for further validation of these findings.

Safety of Sodium-Glucose Cotransporter 2 Inhibitors (SGLT2-I) During the Month of Ramadan in Muslim Patients with Type 2 Diabetes

Objectives

Sodium-glucose cotransporter 2 inhibitors (SGLT2-I) are a new class of antidiabetic drugs that might increase the risk of dehydration and hypoglycemia, particularly during the month of Ramadan in which Muslims abstain from eating and drinking for 14-16 hours daily. We aimed to provide real-life evidence about the safety of SGLT2-I during Ramadan.

Methods

All patients over the age of 18 years on SGLT2-I before Ramadan 2016 who would be fasting during Ramadan were included. Demographic data, detailed medical history including comorbidities and medication profile, and laboratory results were collected before and after Ramadan. We also conducted a phone interview to evaluate the frequency and severity of hypoglycemia and dehydration.

Results

Of the total of 417 patients, 113 (27.0%) experienced hypoglycemic events, and 93 of these (82.3%) checked their blood glucose using a glucometer. Confirmed hypoglycemia (< 70 mg/dL) was observed in 78 (83.8%). The hypoglycemic events were significantly more frequent in the SGLT2-I plus insulin-treated group than in those treated with SGLT2-I plus oral hypoglycemic agents group (p < 0.001). Confirmed hypoglycemic events were more frequent in those using SGLT2-I plus intensive insulin compared to those using SGLT2-I plus basal insulin (p = 0.020). Symptoms of dehydration were seen in 9.3% (n = 39) of the total population. We observed statistically significant reductions in glycated hemoglobin and weight by the end of Ramadan (p < 0.001). There were no significant changes in lipid profile and creatinine levels by the end of the study.

Conclusions

The use of insulin in combination with SGLT2-I increases the risk of hypoglycemia during Ramadan. Hypoglycemic events were mild and did not require hospital admission. However, careful monitoring during prolonged fasting is warranted. No significant harmful effects on renal function result from treatment with SGLT2-I during Ramadan.