Ramadan, a holy month of Islam varies between 29 and 30 days. Muslims who fast abstain from eating drinking smoking and use of oral medications.
Patients of diabetes mellitus who fast are at greater risk of complications which are hypoglycemia (low blood sugar), hyperglycemia (high blood sugar), Diabetic ketoacidosis, dehydration and thrombosis.
Medical recommendation most often for the patients is to not undertake fasting. But if they insist on fasting they must make such decision in consultation with their doctors understanding risks associated with it.
Management is individual centric.
General considerations
1. There should be frequent monitoring of blood glucose level.
2. Nutrition should be adequate enough to maintain a constant body mass. Avoid taking heavy sunset meals rich in carbohydrate and fats. Take plenty of fluids during non fasting hours and food containing complex carbohydrates at the predawn meal is advised.
3. Normal level of exercise. Avoid excessive exercise as it may cause hypoglycemia.
4. Breaking the fast. If blood sugar is less than 60mg/dl anytime or less than 70mg/dl within few hours of fast, or if blood sugar is in excess of 300mg/dl.
Management of Type 2 Diabetes mellitus
1. Patients controlled with lifestyle modification alone may distribute calories over 2 to 3 smaller meals to avoid hyperglycemia.
2. Patients on oral drugs- insulin sensitizers like metformin are preferred.
Those treated with metformin can safely fast. Dose needs to be modified - 2/3 of total dose should be given with sunset meal and 1/3 before predawn meal.
Pioglitazones are not independently associated with hypoglycemia but they can’t be substituted for any other OHA as it takes 2-4 weeks to exert its effects.
Sulfonylureas like glimepride, glyburide, glipizide are not recommended in view of hypoglycemia risk.
Glinides may be taken twice daily as it is short acting.
DPP 4 inhibitors (gliptins) are best tolerated drugs and can be taken. Alpha glucosidase inhibitors like acarbose miglitol and voglibose can be taken.
Patients treated with insulins :
One long or intermediate acting insulin injection along with short acting insulin before meal can be used. Use of 50:50 premixed insulin in evening and 30:70 insulin at early morning was also found useful.
Insulin pump is better option.
References :- ADA guidelines
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