What is the best advice for patients with diabetes who want to observe the fast during Ramadan?
When patients have reasonable diabetic control, it is better to try to make the diabetes fit around the fast. Ramadan is the ninth month in the Islamic calendar, which has a twelve-month lunar cycle. This means that the month changes from year to year. In the winter, the fast lasts around 12 hours; in the summer, it can be as long as 18 hours.
During Ramadan, Muslims take a dawn meal (Suhor) and then no food or drink is allowed until the sunset meal (Iftar). At the Iftar, there is a tendency to gorge traditional foods that are high in fat and sugar. In the daytime, physical activity tends to be reduced and some patients do not perform glucose monitoring.
The main aims of manipulating therapy are to avoid hypoglycaemia and to prevent deterioration in glycaemic control. Hypoglycaemia should not be an issue for patients on metformin monotherapy, although they may experience more nausea and gastrointestinal side-effects. Patents who normally take the drug three times a day should usually combine the lunchtime dose with the pre-meal dose at night.
For patients on sulphonylureas, long-acting agents such as glibenclamide should not be used. When the sulphonylurea is taken twice daily, the larger dose should be given in the evening (the opposite of standard practice).
The post-prandial glucose regulators repaglinide and nateglinide can be given as usual, but omitting the lunchtime dose.
The situation is more complicated for patients on insulin, and advice depends on the regime used and acquiescence with blood glucose monitoring. Short-acting insulin analogues used with long-acting insulins such as glargine (in a basal-bolus regime) provide the most flexibility. Here the lunchtime analogue dose will be omitted, the pre-breakfast dose reduced and the evening dose increased according to blood glucose readings.
For the many patients with poor control who are on a twice-daily fixed mixture, simply reducing the pre-breakfast dose or reversing the morning and evening doses may be enough to see them through the fast.
Dr Steve Bain, reader in diabetic medicine, Birmingham Heartlands Hospital. Source/acknowledgment: GP Magazine, 13 October 2003, p.76