Management of Diabetes Mellitus in Islamic Fasting

Document Type: Review Article

Authors

1 Dubai Health Authority, Dubai, UAE

2 Senior Specialist Registrar, Dubai health authority, UAE

3 Senior Specialist Registrar, Dubai Health Autority, UAE

Abstract

Introduction: Millions of Muslims across the globe fast during the holy month of Ramadan, as well as on the other specific dates of the lunar calendar. Although the Islamic law exempts patients from fasting, more than 50 million Muslim patients with diabetes mellitus fast during Ramadan. Ramadan fasting in diabetic patients may increase the risk of various complications, such as hypoglycemia, hyperglycemia, diabetic ketoacidosis, hypovolemia, and thrombosis. This study aimed to review the safe management of blood glucose in the diabetic patients willing to fast during Ramadan. Methods: This literature review was conducted via searching in databases such as Medline, PubMed, PMC, Google Scholar, ScienceDirect, Cochrane Library, and the reference lists of relevant articles. Results: The diabetic patients who are willing to fast during Ramadan should be prepared within at least 1-2 months prior to the beginning of Ramadan through Ramadan-focused advice, medical assessment before Ramadan, modifications in their medication protocol, balanced diet, physical activity plans, and advice on the self-monitoring of blood glucose. Conclusion: According to the results, safe Ramadan fasting in diabetic patients could be achieved with the help of healthcare providers, including physicians and pharmacists.

Keywords


1. Abuznaid S. Islam and management: What can be learned?. Thunderbird International Business Review. 2005; 48(1): 125-39.

2. Bakhit AA, Kurdi AM, Wadera JJ, Alsuwaida AO. Effects of Ramadan fasting on moderate to severe chronic kidney disease. A prospective observational study. Saudi Med J. 2017; 38(1): 48-52.

3. Boucher NA, Siddiqui EA, Koenig HG. Supporting Muslim Patients During Advanced Illness. Perm J. 2017; 21: 16-190.

4. Ali S, Davies MJ, Brady EM, Gray LJ, Khunti K, Beshyah SA, et al. Guidelines for managing diabetes in Ramadan. Diabet Med. 2016; 33(10): 1315-29.

5. Al-Arouj M, Assaad-Khalil S, Buse J, Fahdil I, Fahmy M, Hafez S, et al. Recommendations for management of diabetes during Ramadan: update 2010. Diabetes Care. 2010; 33(8): 1895-902.

6. Mohamed N, Maideen P, Jumale A, Alatrash JI, Sukkur A, Ahamed A, et al. Health Benefits of Islamic Intermittent Fasting. Journal of Nutrition, Fasting and Health. 2017; 5(4): 162-71.

7. Mohamed N, Maideen P, Jumale A, Balasubramaniam R. Adverse health effects associated with Islamic fasting-A literature review. Journal of Fasting and Health. 2017; 5(3):113-8.

8. Almalki MH, Alshahrani F. Options for controlling type 2 diabetes during Ramadan. Front Endocrinol (Lausanne). 2016; 7: 32.

9. Loke SC, Rahim KF, Kanesvaran R, Wong TW. A prospective cohort study on the effect of various risk factors on hypoglycaemia in diabetics who fast during Ramadan. Med J Malaysia. 2010; 65(1): 3-6.

10. Salti I, Bénard E, Detournay B, Bianchi-Biscay M, Le Brigand C, Voinet C, et al. A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care. 2004; 27(10): 2306-11.

11. Ibrahim M, Al Magd MA, Annabi FA, Assaad-Khalil S, Ba-Essa EM, Fahdil I, et al. Recommendations for management of diabetes during Ramadan: update 2015. BMJ Open Diabetes Res Care. 2015; 3(1): e000108.

12. Philip E, Cryer MD, Stephen N, Davis MD, Harry Shamoon MD. Hypoglycemia in diabetes. Diabetes Care. 2003; 26(6): 1902-12.

13. AlMaatouq MA. Pharmacological approaches to the management of type 2 diabetes in fasting adults during Ramadan. Diabetes Metab Syndr Obes. 2012; 5: 109-19.

14. Elmehdawi R, Ehmida M, Elmagrehi H. Incidence of diabetic ketoacidosis during Ramadan fasting in Benghazi-Libya. Oman Med J. 2009; 24(2): 99-102.

15. Jaleel MA, Raza SA, Fathima FN, Jaleel BN. Ramadan and diabetes: as-saum (the fasting). Indian J Endocrinol Metab. 2011; 15(4): 268-73.

16. Ahmedani MY, Ahsan S, Haque MSU. Role of Ramadan specific diabetes education (RSDE); A prospective study. Pak J Med Sci. 2017; 33(3): 586-93.

17. Tourkmani AM, Hassali MA, Alharbi TJ, Alkhashan HI, Alobikan AH, Bakhiet AH, et al. Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes. Patient Prefer Adherence. 2016; 10: 1709-17.

18. McEwen LN, Ibrahim M, Ali NM, Assaad-Khalil SH, Tantawi HR, Nasr G, et al. Impact of an individualized type 2 diabetes education program on clinical outcomes during Ramadan. BMJ Open Diabetes Res Care. 2015; 3(1): e000111.

19. Bravis V, Hui E, Salih S, Mehar S, Hassanein M, Devendra D. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-31.

20. Hassanein M. Ramadan focused diabetes education; a much needed approach. J Pak Med Assoc. 2015; 65(5 Suppl 1): S76-8.

21. Almalki MH, Hussen I, Khan SA, Almaghamsi A, Alshahrani F. Assessment of Ramadan Education and Knowledge Among Diabetic Patients. Clin Med Insights Endocrinol Diabetes. 2018; 11: 1179551417751611.

22. Hui E, Bravis V, Hassanein M, Hanif W, Malik R, Chowdhury TA, et al. Management of people with diabetes wanting to fast during Ramadan. Bmj. 2010; 340: c3053.

23. Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010; 103(4): 139-47.

24. Chaudhury A, Duvoor C, Dendi R, Kraleti S, Chada A, Ravilla R, et al. Clinical review of antidiabetic drugs: Implications for type 2 diabetes mellitus management. Front Endocrinol (Lausanne). 2017; 8: 6.

25. Maideen NMP, Jumale A, Balasubramaniam R. Drug Interactions of Metformin Involving Drug Transporter Proteins. Adv Pharm Bull. 2017; 7(4): 501-5.

26. Gray LJ, Dales J, Brady EM, Khunti K, Hanif W, Davies MJ. Safety and effectiveness of non‐insulin glucose‐lowering agents in the treatment of people with type 2 diabetes who observe Ramadan: a systematic review and meta‐analysis. Diabetes Obes Metab. 2015; 17(7): 639-48.

27. Aravind SR, Ismail SB, Balamurugan R, Gupta JB, Wadhwa T, Loh SM, et al. Hypoglycemia in patients with type 2 diabetes from India and Malaysia treated with sitagliptin or a sulfonylurea during Ramadan: a randomized, pragmatic study. Curr Med Res Opin. 2012; 28(8): 1289-96.

28. Al Sifri S, Basiounny A, Echtay A, Al Omari M, Harman‐Boehm I, Kaddaha G, et al. The incidence of hypoglycaemia in Muslim patients with type 2 diabetes treated with sitagliptin or a sulphonylurea during Ramadan: a randomised trial. Int J Clin Pract. 2011; 65(11): 1132-40.

29. Hassanein M, Abdallah K, Schweizer A. A double-blind, randomized trial, including frequent patient–physician contacts and Ramadan-focused advice, assessing vildagliptin and gliclazide in patients with type 2 diabetes fasting during Ramadan: the STEADFAST study. Vasc Health Risk Manag. 2014; 10: 319-26.

30. Hassanein M, Hanif W, Malik W, Kamal A, Geransar P, Lister N, et al. Comparison of the dipeptidyl peptidase-4 inhibitor vildagliptin and the sulphonylurea gliclazide in combination with metformin, in Muslim patients with type 2 diabetes mellitus fasting during Ramadan: results of the VECTOR study. Curr Med Res Opin. 2011; 27(7): 1367-74.

31. Hassoun AA, Pathan MF, Medlej RC, Alarouj M, Shaltout I, Chawla MS, et al. Effects of vildagliptin relative to sulfonylureas in Muslim patients with type 2 diabetes fasting during Ramadan: influence of age and treatment with/without metformin in the VIRTUE study. Diabetes Metab Syndr Obes. 2016; 9: 225-31.

32. Khattab M, Mahmoud K, Shaltout I. Effect of Vildagliptin Versus Sulfonylurea in Muslim Patients with Type 2 Diabetes Fasting During Ramadan in Egypt: Results from VIRTUE Study. Diabetes Ther. 2016; 7(3): 551-60.

33. Mahar SA, Hasan MI, Khan MI, Fawwad A, Hussain S, Maheshwary N, et al. Comparison of hypoglycaemia episodes in people with type-2 diabetes fasting in Ramazan, treated with vildaglipton or sulphonylurea: results of the Pakistani cohort of the VIRTUE study. J Pak Med Assoc. 2014; 64(11): 1297-302.

34. Al‐Arouj M, Hassoun AA, Medlej R, Pathan MF, Shaltout I, Chawla MS, et al. The effect of vildagliptin relative to sulphonylureas in Muslim patients with type 2 diabetes fasting during Ramadan: the VIRTUE study. Int J Clin Pract. 2013; 67(10): 957-63.

35. Halimi S, Levy M, Huet D, Quéré S, Dejager S. Experience with vildagliptin in type 2 diabetic patients fasting during Ramadan in France: insights from the VERDI study. Diabetes Ther. 2013; 4(2): 385-98.

36. Aziz KM. Fasting during Ramadan: efficacy, safety, and patient acceptability of vildagliptin in diabetic patients. Diabetes Metab Syndr Obes. 2015; 8: 207-11.

37. Schweizer A, Halimi S, Dejager S. Experience with DPP-4 inhibitors in the management of patients with type 2 diabetes fasting during Ramadan. Vasc Health Risk Manag. 2014; 10: 15-24.

38. Hanif W, Malik W, Hassanein M, Kamal A, Geransar P, Andrews C, et al. Treatment adherence with vildagliptin compared to sulphonylurea as add-on to metformin in Muslim patients with type 2 diabetes mellitus fasting during Ramadan. Curr Med Res Opin. 2013; 29(7): 807-11.

39. Shete A, Shaikh A, Nayeem KJ, Rodrigues L, Ali MSS, Shah P, et al. Vildagliptin vs sulfonylurea in Indian Muslim diabetes patients fasting during Ramadan. World J Diabetes. 2013; 4(6): 358-64.

40. Mudher Mikhael E. Effectiveness and Safety of Newer Antidiabetic Medications for Ramadan Fasting Diabetic Patients. J Diabetes Res. 2016; 2016: 1-11.

41. Azar ST, Echtay A, Wan Bebakar WM, Al Araj S, Berrah A, Omar M, et al. Efficacy and safety of liraglutide compared to sulphonylurea during Ramadan in patients with type 2 diabetes (LIRA‐Ramadan): a randomized trial. Diabetes Obes Metab. 2016; 18(10): 1025-33.

42. Brady EM, Davies MJ, Gray LJ, Saeed MA, Smith D, Hanif W, et al. A randomized controlled trial comparing the GLP‐1 receptor agonist liraglutide to a sulphonylurea as add on to metformin in patients with established type 2 diabetes during Ramadan: the Treat 4 Ramadan Trial. Diabetes Obes Metab. 2014; 16(6): 527-36.

43. Bashier A, Khalifa AA, Abdelgadir EI, Al Saeed MA, Al Qaysi AA, Bayati MBA, et al. Safety of Sodium-Glucose Cotransporter 2 Inhibitors (SGLT2-I) During the Month of Ramadan in Muslim Patients with Type 2 Diabetes. Oman Med J. 2018; 33(2): 104-10.

44. Hassanein M, Echtay A, Hassoun A, Alarouj M, Afandi B, Poladian R, et al. Tolerability of canagliflozin in patients with type 2 diabetes mellitus fasting during Ramadan: Results of the Canagliflozin in Ramadan Tolerance Observational Study (CRATOS). Int J Clin Pract. 2017; 71(10).

45. Kelwade J, Sethi BK, Vaseem A, Nagesh VS. Sodium glucose co transporter 2 inhibitors and Ramadan: Another string to the bow. Indian J Endocrinol Metab. 2014; 18(6): 874-5.

46. Maideen NMP, Balasubramaniam R. Pharmacologically relevant drug interactions of sulfonylurea antidiabetics with common herbs. J Herbmed Pharmacol. 2018; 7(3): 200-10.

47. Maideen NMP. Pharmacokinetic and Pharmacodynamic Interactions of Sulfonylurea Antidiabetics. Eur J Med. 2018; 6(2): 83-96.

48. Aravind SR, Al Tayeb K, Ismail SB, Shehadeh N, Kaddaha G, Liu R, et al. Hypoglycaemia in sulphonylurea-treated subjects with type 2 diabetes undergoing Ramadan fasting: a five-country observational study. Curr Med Res Opin. 2011; 27(6): 1237-42.

49. Ahmed MH, Husain NE, Elmadhoun WM, Noor SK, Khalil AA, Almobarak AO. Diabetes and Ramadan: A concise and practical update. J Family Med Prim Care. 2017; 6(1): 11-8.

50. Pakkir Maideen NM, Manavalan G, Balasubramanian K. Drug interactions of meglitinide antidiabetics involving CYP enzymes and OATP1B1 transporter. Ther Adv Endocrinol Metab. 2018: 9(8): 259-68.

51. Hassanein M, Al-Arouj M, Hamdy O, Bebakar WMW, Jabbar A, Al-Madani A, et al. Diabetes and Ramadan: practical guidelines. Diabetes Res Clin Pract. 2017; 126: 303-16.

52. Pakkir Maideen NM. Thiazolidinediones and their Drug Interactions involving CYP enzymes. American Journal of Physiology, Biochemistry and Pharmacology. 2018; 8(2): 47-54.

53. Almalki MH, Alshahrani F. Options for controlling type 2 diabetes during Ramadan. Front Endocrinol (Lausanne). 2016; 7: 32.

54. Ahmed MH, Husain NE, Elmadhoun WM, Noor SK, Khalil AA, Almobarak AO. Diabetes and Ramadan: A concise and practical update. J Family Med Prim Care. 2017; 6(1): 11-8.

55. Vasan S, Thomas N, Bharani AM, Abraham S, Job V, John B, et al. A double-blind, randomized, multicenter study evaluating the effects of pioglitazone in fasting Muslim subjects during Ramadan. Int J Diabetes Dev Ctries. 2006; 26(June): 70-6.

56. Kalra S. Alpha glucosidase inhibitors. J Pak Med Assoc. 2014; 64(4): 474-6.

57. Pan C, Yang W, Barona JP, Wang Y, Niggli M, Mohideen P, et al. Comparison of vildagliptin and acarbose monotherapy in patients with Type 2 diabetes: a 24‐week, double‐blind, randomized trial. Diabet Med. 2008; 25(4): 435-41.

58. Pathan MF, Sahay RK, Zargar AH, Raza SA, Khan AK, Ganie MA, et al. South Asian Consensus Guideline: use of insulin in diabetes during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 499-502.

59. Benbarka MM, Khalil AB, Beshyah SA, Marjei S, Awad SA. Insulin pump therapy in Moslem patients with type 1 diabetes during Ramadan fasting: an observational report. Diabetes Technol Ther. 2010; 12(4): 287-90.

60. Akbani MF, Saleem M, Gadit WU, Ahmed M, Basit A, Malik RA. Fasting and feasting safely during Ramadan in the patient with diabetes. Pract Diabetes Int. 2005; 22(3): 100-4.

61. Niazi AK, Kalra S. Patient centred care in diabetology: an Islamic perspective from South Asia. J Diabetes Metab Disord. 2012; 11(1): 30.

62. Beshyah SA, Benbarka MM, Sherif IH. Practical management of diabetes during Ramadan fast. Libyan J Med. 2007; 2(4): 185-9.

63. Hossain K, Zehra T. Diabetes and diet in Ramadan. JPMA. J Pak Med Assoc. 2015; 65(5 Suppl 1): S72-5.

64. Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010; 103(4): 139-47.

65. Qureshi B. Diabetes in Ramadan. J R Soc Med. 2002; 95(10): 489-90.

66. Masood SN, Sheikh MA, Masood Y, Hakeem R, Shera AS. Beliefs of people with diabetes about skin prick during Ramadan fasting. Diabetes Care. 2014; 37(4): e68-9.

67. Eid YM, Sahmoud SI, Abdelsalam MM, Eichorst B. Empowerment-based diabetes self-management education to maintain glycemic targets during Ramadan fasting in people with diabetes who are on conventional insulin: a feasibility study. Diabetes Spectr. 2017; 30(1): 36-42.

68. Zainudin SB, Abu Bakar KNB, Abdullah SB, Hussain AB. Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan. Ther Adv Endocrinol Metab. 2018: 9(8): 231-40.

69. Ahmedani MY, Hashmi BZ, Ulhaque MS. Ramadan and diabetes-knowledge, attitude and practices of general practitioners; a cross-sectional study. Pak J Med Sci. 2016; 32(4): 84650.

70. Al Slail FY, Rashid HU, Fadl SM, Kheir OO. Physician Awareness in Diabetes Management During Ramadan 2015—A Focus Group Discussion. US Endocrinol. 2017; 13(1): 30-4.

71. Ibrahim OH. Pharmacist Role in Pharmaceutical Care during Ramadan. Pharmacol Pharm. 2015; 6(12): 589.

72. Bukhari N. How pharmacists can support and advise patients during Ramadan. Pharm J. 2016; 15: 05.

73. Wilbur K, Al Tawengi K, Remoden E. Diabetes patient management by pharmacists during Ramadan. BMC Health Serv Res. 2014; 14(1): 117.

74. Adnan M, Khaliq A, Fahad M, Hussaini SA, Karim S. Pharmacists’ Management of Diabetes during Ramadan Fasting. Ibnosina Journal of Medicine and Biomedical Sciences. 2016; 8(5): 160-7.

75. Amin ME, Chewning B. Community pharmacists’ knowledge of diabetes management during Ramadan in Egypt. Int J Clin Pharm. 2014; 36(6): 1213-21.

76. Hassanein M, Al-Arouj M, Hamdy O, Bebakar WMW, Jabbar A, Al-Madani A, et al. Diabetes and Ramadan: practical guidelines. Diabetes Res Clin Pract. 2017; 126: 303-16.

77. Bajaj HS, Abouhassan T, Ahsan MR, Arnaout A, Hassanein M, Houlden RL, et al. Diabetes Canada Position Statement for People With Types 1 and 2 Diabetes Who Fast During Ramadan. Can J Diabetes. 2019; 43(1): 3-12.