Helping Patients with Diabetes during Ramadan

A chance encounter with a patient at the school gates last week reminded me that Ramadan has begun. Over the usual pleasantries, he mentioned that he had started fasting throughout April. I remarked how difficult that must be but was surprised that he regarded it as an extremely positive experience and explained just how important it was to him and his family.

In the past I am guilty of viewing the fasting period as medically inconvenient and hearing my patient’s enthusiasm I realised I actually needed to reframe my thinking: as this person’s doctor how can I support them effectively and safely to achieve what is important to them?

Ramadan this year started on April 1^st and continues until the evening of May 1^st. It falls in the ninth month of the Islamic calendar. As this is lunar Ramadan occurs 11 days earlier each year. Millions throughout the UK will fast - between sunrise (suhoor) and sunset (iftar) they will abstain from food, liquid and oral medications. 

For most conditions and most oral medications, this is simply managed by taking them before or after suhoor and iftar. Perhaps the most challenging condition to manage is diabetes, with various treatments relying on food intake to balance anti-glycaemic properties. 

Clear guidance from the British Islamic Medical Association details which clinical features make fasting more risky. 

For example, severe hypoglycaemia in the past 3 months makes fasting very high risk and patients should not fast; well-controlled type 1 diabetes is high risk and fasting is not recommended; uncomplicated type 2 diabetes with an HbA1c <64mmol/l (8%) indicates moderate risk and fasting may be undertaken with caution; well controlled type 2 diabetes is low risk. 

The International Diabetes Association provides more nuanced assessment of risk incorporating a wide range of factors such as which anti-gylcaemic agents, history of acute complications, presence of frailty, duration of daylight hours and previous difficulty with fasting. Many patients in a higher risk category may still choose to fast.

So how can we best support our patients with diabetes that want or need to fast?

Patient education is crucial. People need to know when they need to break their fast (e.g. BMs <3.9 or>16.7, Sx of hypo, acute illness), how to manage food and fluids around their fast, if and when blood glucose monitoring is indicated, and adjust diabetes medications. This last point can feel complicated but there is well established easy-to-follow guidance:

• Avoid initiating new medications or dose change in the weeks prior to Ramadan
• Metformin
  • Daily dose remains unchanged
  • OD take at iftar, BD take at iftar and suhoor, TDS - morning dose at suhoor and take lunchtime dose with evening dose at iftar
  • Slow-release - take at iftar
• Sulphonylureas
  • Avoid glibenclamide and switch to newer SU's if possible eg gliclazide
  • OD - take at iftar and consider dose reduction if good glycemic control
  • BD - reduce suhoor dose if good control; iftar dose unchanged
• SGLT2 inhibitors
  • Take with iftar, no dose change
  • Take extra fluids during non-fast period and use with caution in those at risk of fluid depletion and avoid starting immediately before or during Ramadan
• DPP4 inhibitors
  • No dose change
• Pioglitazone
  • Take with iftar, no dose change
• GLP1 agonists 
  • No dose change provided it has been dose-titrated at least 4 weeks before the start of Ramadan

Very helpful guidance for both patients and clinicians can be found at the International Diabetes Association and British Islamic Medical Association. 

For more detailed information on this and much more join us for our live Hot Topics Diabetes in Primary Care course on the 11^th June or you can check out our pre-recorded on demand edition at www.nbmedical.com.