Ramadan fasting in patients with type 2 diabetes mellitus: Experience from a teaching hospital.

Sir,

We read the review article on the topic “Ramadan and fasting” by Jaleel et al.,[1] in the current issue with great interest. We would like to share our experiences of managing this cohort of patients with type 2 diabetes mellitus during Ramadan fasting.

Though the safety of fasting in patients with diabetes has been well demonstrated by bulk of literature, it carries a risk of an assortment of complications. Many patients with diabetes insist on fasting against medical advice, thereby creating a challenge for themselves and physicians.

We conducted a prospective observational study in which 179 patients with type 2 diabetes were enrolled, who decided to fast even after they had been explained about the associated risks. One month before the start of Ramadan, weight and blood pressure were recorded, and glucose/HbA1c, lipids, electrolytes, liver and renal function tests performed. The seriously ill or patients with severe complications (33) were excluded. At their first visit (2-4 weeks before Ramadan fasting), patients along with their family members were educated and counseled about self-care, signs and symptoms of hypo and hyperglycemia, diet and hydration, glucose monitoring and physical activity. Necessary changes in the diet and medications were done as per the recommendations.[23] Out of 146 patients,14 were on diet control, 90 on oral hypoglycemic agents (OHA) , 20 on OHA with insulin, and 22 on insulin alone. None of the patients on glibenclamide was allowed to fast. Most of the patients were on glimepiride, extended release gliclazide/glipizide with metformin, metformin alone or in combination with pioglitazone and alpha glucosidase inhibitors. These drugs were given before sunset meal and predawn meal as required. Insulin therapy was given in the form of premixed 30/70 administered twice daily, or NPH (Neutral Protamine Hagedorn) /Glargine at bedtime in conjunction with OHA. They were called for second visit during Ramadan (second half) and for third visit 2-4 weeks after Ramadan, for detailed assessment.

13/22 patients on insulin alone, 16/20 on insulin with OHA, 72/90 on OHA and all 14 on diet and exercise could complete fasting >15 days. The weight gain (range 1-2.6 kg) was recorded in 83/146 patients. Mean change in HbA1c was 0.5±0.3%, which was not statistically significant. No significant change in blood pressure, lipids or renal profile could be demonstrated. Hypoglycemia and hyperglycemia were the most frequent complications. The tolerance of fasting was good this year since it was during rainy season. There was significant increase in the number of mild symptomatic hypoglycemic events (164 events before Ramadan, 302 during Ramadan and 147 after Ramadan). None of the patients required hospitalization. The increase in hypoglycemic episodes was related to age (>60 years), good glycemic control before fasting (<8%), skipping of predawn meal and more vigilant and cautious attitude for hypoglycemia. Medical advice was ignored just because of religious reasons at certain occasions.

In India, we have sizeable Muslim population with diabetes who decide to fast. Ramadan fasting can be facilitated for safer outcomes and lesser adverse events with intense education and counseling. Actually, increased awareness and education is not the only marker on which safe and successful fasting depends, it is the attitude of the patient and personal determination that help patient break, skip or continue fasting.[4]