Insulin lispro (Lys(B28), Pro(B29) in the treatment of diabetes during the fasting month of Ramadan. Ramadan Study Group

Ramadan fasting and diabetes, latest evidence and technological advancements: 2021 update

Development of updated guidelines for management of diabetes in Ramadan Fasting is of paramount importance. Nonetheless, evidence-based guidelines in the field of Ramadan Fasting and Diabetes are scarce. Moreover, findings of some recent research such as effects of Ramadan fasting on microbiota, genetics and epigenetics, hormonal changes (such as adiponectin, leptin, testosterone…), and alternations in circadian rhythm should also be reviewed and included on a yearly basis. It is documented that self-monitoring of blood glucose (SMBG) is of vital importance for patients with type 1 diabetes who fast, and advantages of continuous glucose monitoring (CGM) or flash glucose monitoring (FGM) techniques should be highlighted. Moreover, the recent findings about applications of advanced insulin delivery technology in patients with diabetes who fast in Ramadan should also considered in the annual updates of the guidelines.

Ramadan fasting and diabetes, latest evidence and technological advancements: 2021 update

Development of updated guidelines for management of diabetes in Ramadan Fasting is of paramount importance. Nonetheless, evidence-based guidelines in the field of Ramadan Fasting and Diabetes are scarce. Moreover, findings of some recent research such as effects of Ramadan fasting on microbiota, genetics and epigenetics, hormonal changes (such as adiponectin, leptin, testosterone…), and alternations in circadian rhythm should also be reviewed and included on a yearly basis. It is documented that self-monitoring of blood glucose (SMBG) is of vital importance for patients with type 1 diabetes who fast, and advantages of continuous glucose monitoring (CGM) or flash glucose monitoring (FGM) techniques should be highlighted. Moreover, the recent findings about applications of advanced insulin delivery technology in patients with diabetes who fast in Ramadan should also considered in the annual updates of the guidelines.

Ramadan fasting in insulin-treated patients is associated with potentially unfavourable changes in glucose metrics: A flash glucose monitoring (FGM) study

AIM(S)

Ramadan fasting (RF) can represent various challenges to glycaemic control especially in insulin-treated patients with diabetes. We aimed to assess the effect of RF on several glucose metrics using flash glucose monitoring (FGM).

METHODS

Complete FGM data for 29-30 days before, during and after Ramadan were available for 40 patients with type 1 (n = 13) and type 2 diabetes (n = 27) on insulin (with or without oral hypoglycaemic) treatment. Indicators of mean glucose, glucose variability (GV) and time in different glycaemic ranges were analysed.

RESULTS

RF was associated with increase in time in hyperglycaemia (38.5 ± 18.2 vs 48.7 ± 20.7%; P < 0.001) and decrease in time in hypoglycaemia (3.2 ± 2.8 vs 2.1 ± 2.1%; P = 0.003), and time in target range (56.3 ± 17.2 vs 47.9 ± 19.7%, P < 0.001). There were no significant differences in markers of GV with RF; however, RF was associated with a significant reduction in GV during the day but not night time with an increase in the ensuing non-fasting period.

CONCLUSIONS

In insulin-treated patients, RF is associated with an increase in time in hyperglycaemia, a reduced time in target range and nocturnal increase in GV, indicating a need for more refined management algorithms.

Impact of Ramadan Diurnal Intermittent Fasting on Hypoglycemic Events in Patients With Type 2 Diabetes: A Systematic Review of Randomized Controlled Trials and Observational Studies

Ramadan is the 9th month of the lunar calendar during which Muslims abstain from food and drink between dawn and sunset for 30 consecutive days. Ramadan fasting is observed by all healthy Muslim adults, as well many Muslims with type 2 diabetes (T2DM). Hypoglycemic events (HE) are a serious complication associated with diabetes management and are associated with increased cardiovascular disease risk. Conflicting results have been reported concerning the incidence of HE among people with T2DM observing Ramadan fasting. This review summarizes available scientific evidence on the occurrence of HE and the effects of different moderators on the incidence of HE among patients with T2DM during Ramadan. We conducted a systematic review of available observational studies and randomized controlled trials (RCTs) for patients with T2DM who fasted during Ramadan, with HE as the primary outcome. Ten databases were searched for relevant studies from inception until October 31, 2020. In total, 68 studies (35 RCTs and 33 observational studies) met the inclusion criteria. Non-sulfonylureas hypoglycemic medications showed superior effects in lowering the incidence of HE over sulfonylureas hypoglycemic medications. Variable moderators were associated with experiencing HE during Ramadan in both observational studies and RCTs, including sex, geographical location, body anthropometric indicators, season, dietary behaviors, fasting duration, time since diagnosis, and pre-fasting education. This comprehensive systematic review covered the largest number of observational and clinical studies investigating the impact of Ramadan on HE among patients with T2DM. The study highlights the significance of different moderators that influence the effect of Ramadan fasting on HE, including dietary behaviors, fasting time duration, sex, season, country, pre-fasting education, age, and time since diagnosis. The study also highlighted the impact of different hypoglycemic medications on HE and noted the superiority of non-sulfonylureas over sulfonylureas hypoglycemic medications in lowering the risk for hypoglycemia in people with T2DM during Ramadan fasting.

Comparison of Human Premixed and Basal Plus Short-Acting Insulin Regimens for Individuals With Type 2 Diabetes During Ramadan Fasting

Background Premixed insulin and basal insulin plus short-acting insulin regimens may be of value for treating individuals with type 2 diabetes (T2DM) who are fasting during Ramadan due to simplicity and better compliance. The objective of this study was to compare the effectiveness of human premixed insulin to basal plus short-acting insulin regimens in the management of fasting individuals with T2DM during Ramadan. Methods We conducted a prospective observational study in Basrah (southern Iraq) on 30 individuals with T2DM who fast during Ramadan. The enrolled patients were assigned into two groups at random: one group received a human premixed insulin regimen, the other received a basal plus short-acting insulin regimen. A baseline clinical and biochemical analysis was gathered for all patients at recruitment two weeks before fasting and within four weeks after the end of fasting. Patients were assessed twice during fasting month for insulin dose adjustment and documentation for any hyperglycemia or hypoglycemia. Results Fourteen patients were assigned to the premixed group, and 16 patients were assigned to the basal plus short-acting insulin group. The mean patient age was 53 ± 8 years, and the mean T2DM duration was 9.3 ± 4.2 years. The two groups were matched by age, body mass index, and glycated hemoglobin (HbA1c). There was no significant difference between the initial and final mean HbA1c in both groups. However, there was more non-significant HbA1c reduction in the premixed group as compared to the basal plus short-acting insulin group. The number of hypoglycemic events and weight changes among the two groups was not significant. Conclusions Both human premixed and basal plus short-acting insulin regimens are equally useful for glycemic control for patients with T2DM who choose to fast in observance of the month-long holiday of Ramadan.

Ramadan and Diabetes: A Narrative Review and Practice Update

Fasting in the Islamic month of Ramadan is obligatory for all sane, healthy adult Muslims. The length of the day varies significantly in temperate regions-typically lasting ≥ 18 h during peak summer in the UK. The synodic nature of the Islamic calendar means that Ramadan migrates across all four seasons over an approximately 33-year cycle. Despite valid exemptions, there is an intense desire to fast during this month, even among those who are considered to be at high risk, including many individuals with diabetes mellitus. In this review we explore the current scientific and clinical evidence on fasting in patients with diabetes mellitus, focussing on type 2 diabetes mellitus and type 1 diabetes mellitus, with brief reviews on pregnancy, pancreatic diabetes, bariatric surgery, the elderly population and current practice guidelines. We also make recommendations on the management of diabetes patients during the month of Ramadan. Many patients admit to a do-it-yourself approach to diabetes mellitus management during Ramadan, largely due to an under-appreciation of the risks and implications of the rigors of fasting on their health. Part of the issue may also lie with a healthcare professional's perceived inability to grasp the religious sensitivities of Muslims in relation to disease management. Thus, the pre-Ramadan assessment is crucial to ensure a safe Ramadan experience. Diabetes patients can be risk-stratified from low, medium to high or very high risk during the pre-Ramadan assessment and counselled accordingly. Those who are assessed to be at high to very high risk are advised not to fast. The current COVID-19 pandemic upgrades those in the high-risk category to very high risk; hence a significant number of diabetes patients may fall under the penumbra of the 'not to fast' advisory. We recognize that fasting is a personal choice and if a person chooses to fast despite advice to the contrary, he/she should be adequately supported and monitored closely during Ramadan and for a brief period thereafter. Current advancements in insulin delivery and glucose monitoring technologies are useful adjuncts to strategies for supporting type 1 diabetes patients considered to be high risk as well as 'high-risk' type 2 patients manage their diabetes during Ramadan. Although there is a lack of formal trial data, there is sufficient evidence across the different classes of therapeutic hypoglycaemic agents in terms of safety and efficacy to enable informed decision-making and provide a breadth of therapeutic options for the patient and the healthcare professional, even if the professional advice is to abstain. Thus, Ramadan provides an excellent opportunity for patient engagement to discuss important aspects of management, to improve control in the short term during Ramadan and to help the observants understand that the metabolic gains achieved during Ramadan are also sustainable in the other months of the year by maintaining a dietary and behavioural discipline. The application of this understanding can potentially prevent long-term complications.

ELECTRONIC SUPPLEMENTARY MATERIAL

The online version of this article (10.1007/s13300-020-00886-y) contains supplementary material, which is available to authorized users.

A systematic review on the safety of Ramadan fasting in high-risk patients with Diabetes

INTRODUCTION

Fasting the holy month of Ramadan is passionately practiced by all Muslim population around the world. Patients with diabetes are generally considered to have a higher risk of fasting. The current international guidelines have risk-stratified the patients with diabetes and other comorbidities to different categories, and the decision of fasting or not is made based on this categorization. Many studies looked at the impact of Ramadan fasting on those high-risk patients, and many are currently being in progress.

METHODS

In this systematic review, we conducted an extensive search in PubMed and google scholar engines. Studies filtration focused only on the Randomized controlled trial (RCT) and prospective observational studies accomplished between the year 2007 up to March2019 on impact of Ramadan on patients with diabetes at high risk of fasting.

RESULTS

The global dissemination and implementation of the guidelines for the management of diabetes during Ramadan broke the inertia among health care providers. Additionally, the concept of pre-Ramadan assessment for risk categorization, therapeutic doses modification in hand with self -monitoring blood glucose; have markedly reduced the risk and hospitalisation during Ramadan.

CONCLUSIONS

There is still limited data on fasting Ramadan by high risk patients with diabetes. There was minimal diversity in the published results, however, Generally and despite the education, self-titration; the incidences of complications during Ramadan is minimally higher than other times of the year in this group.

Comparison of analog insulin mix 50:50 with human insulin mix 30:70 in persons with type 2 diabetes during Ramadan

AIM OF THE STUDY

To test if changing the Iftar insulin to a 50:50 mixed analog insulin from a 30:70 human insulin at the same total dose leads to improvement in the postprandial blood glucose (taken as after the main meal). Since the intermediate acting insulin dose is effectively lowered, the pre-Suhur blood glucose is also tested to see if this rises.

METHODS

The Iftar human 30:70 mixed insulin is substituted for a 50:50 one using insulin lispro protamine suspension and 50% insulin lispro (Humalog^® Mix50/50™), whilst maintaining the same total dose. The participants were also changed to 75% insulin lispro protamine suspension and 25% insulin lispro (Humalog^® Mix75/25™) at the same pre-Ramadan dose for their Suhur injection (Experimental group). A similar number of controls continued their 30:70 mixed human insulin at the same dose during Ramadan (Control group). Pre-Ramadan and during Ramadan fasting and postprandial (3 hours) and pre-Suhur blood glucose (BG) are tested in 20 subjects and 20 controls by the patients using home glucose meters. Hypoglycaemia, defined as a BG of ≤ 70 mg%, was tested for by the patients and noted if they experience symptoms of it. Severe hypoglycaemia occurred if the patient needed assistance for recovery. No insulin dose adjustments are made in either group and any other anti-diabetic treatment was continued. Pre- and post-Ramadan HbA₁ c and body weight are measured. The number of days fasted and baseline characteristics are age, gender, and duration of diabetes are also noted. Differences between groups in parameters were assessed using ANCOVA to adjust for pre-Ramadan values of age, gender, and duration of diabetes.

RESULTS

All the participants fasted for at least 29 days. The 2 groups were not significantly different at baseline. During Ramadan, mean postprandial BG in the Experimental group was lower by 21.1 mg% (1.2 mmol/l) (95% CI 12.6, 29.7; P < 0.001). Similarly, after Ramadan mean HbA₁ c in the Experimental group was lower by 0.4% (95% CI 0.1%, 0.8%; P = 0.01). No significant differences between the groups were detected in mean bodyweight after Ramadan (P = 0.86) or mean fasting BG during Ramadan (P = 0.07). There was no difference in incidence of hypoglycaemia.

CONCLUSIONS

Switching from human insulin mix 30:70 to analog insulin mix 50:50 results in better post main meal control in Ramadan, without affecting HbA1c, or increasing the incidence of hypoglycaemia.

Impact of optimum diabetes care on the safety of fasting in Ramadan in adult patients with type 2 diabetes mellitus on insulin therapy

AIM

We aimed at evaluating the safety of fasting Ramadan for insulin treated type 2 diabetes patients by assessing the biochemical, biometric parameters, flash glucose monitoring (FGM) data as compared to pre-Ramadan and hospital admissions with diabetes or non-diabetes conditions. The risks of fasting between those treated with basal insulin vs intensive insulin during Ramadan was also assessed.

METHODS

We included insulin treated patients with type 2 diabetes and we excluded those with co-morbidities. Patients were provided with Ramadan-focused education, FGM before and during Ramadan and medical advice for treatment adjustment. We measured biologic and biometric data before and after Ramadan.

RESULTS

HbA1c reduced from 7.9 ± 1.20 pre-Ramadan to 7.7 ± 1.5% post Ramadan (p = 0.023). Average peak glucose reading was 330.1 ± 79.8 mg/dl before Ramadan improved significantly to reach 289.3 ± 77.7 mg/dl (p = 0.013). Average number of hypoglycemic episodes was higher in intensive insulin group between 1200 and 1800 h (p = 0.028).

CONCLUSION

People with type 2 diabetes treated with insulin who fast Ramadan and who are provided with Ramadan focused patient education, individualized treatment adjustment and FGMS were not at increased safety risks as measured by biochemical, biometric and FGM data.

A systematic review on efficacy and safety of the current hypoglycemic agents in patients with diabetes during Ramadan fasting

The fasting in the holy month of Ramadan is passionately practised among the Muslims population around the world. Patients with diabetes are generally considered to have various risks with fasting. The recent pharmacologic and technical advances in the management of diabetes may have enabled these patients to practice safe fasting. The purpose of this review is to scientific evidence on the safety and efficacy of the current hypoglycemic agents during Ramadan. METHODS: An extensive Electronic search via PubMed and Google scholar was accomplished through using different search terms. The eligible studies were limited to only published Randomised controlled trial (RCT) and prospective observational studies from 2007 to 2018 on patients with all types of diabetes on any pharmacological management, who intended to fast in Ramadan. RESULTS AND CONCLUSIONS: The current era witnessed a gradual shift in the management of these patients with diabetes who elected to fast in Ramadan, despite the variable health-related risks with fasting. Results from available RCTs and observational studies in patients with type 2 diabetes showed lower risk of hypoglycemia, similar or better efficacy for glycemic and weight control with SGLT2 inhibitors, incretin mimetics and the newer insulin analogues compared to Sulfonylurea. Gliclazide is a relatively safer option among all sulfonylurea. Patients requiring insulin did better with insulin analogues, especially the newer premixed formulation at the time of breaking fast compared to the former insulin formulation. Current commonly used newer hypoglycemic agents are generally safe during Ramadan, however, their safety in the higher risk diabetes patients is highly needed.

EADSG Guidelines: Insulin Therapy in Diabetes

A diagnosis of diabetes or hyperglycemia should be confirmed prior to ordering, dispensing, or administering insulin (A). Insulin is the primary treatment in all patients with type 1 diabetes mellitus (T1DM) (A). Typically, patients with T1DM will require initiation with multiple daily injections at the time of diagnosis. This is usually short-acting insulin or rapid-acting insulin analogue given 0 to 15 min before meals together with one or more daily separate injections of intermediate or long-acting insulin. Two or three premixed insulin injections per day may be used (A). The target glycated hemoglobin A1c (HbA1c) for all children with T1DM, including preschool children, is recommended to be < 7.5% (< 58 mmol/mol). The target is chosen aiming at minimizing hyperglycemia, severe hypoglycemia, hypoglycemic unawareness, and reducing the likelihood of development of long-term complications (B). For patients prone to glycemic variability, glycemic control is best evaluated by a combination of results with self-monitoring of blood glucose (SMBG) (B). Indications for exogenous insulin therapy in patients with type 2 diabetes mellitus (T2DM) include acute illness or surgery, pregnancy, glucose toxicity, contraindications to or failure to achieve goals with oral antidiabetic medications, and a need for flexible therapy (B). In T2DM patients, with regards to achieving glycemic goals, insulin is considered alone or in combination with oral agents when HbA1c is ≥ 7.5% (≥ 58 mmol/mol); and is essential for treatment in those with HbA1c ≥ 10% (≥ 86 mmol/mol), when diet, physical activity, and other antihyperglycemic agents have been optimally used (B). The preferred method of insulin initiation in T2DM is to begin by adding a long-acting (basal) insulin or once-daily premixed/co-formulation insulin or twice-daily premixed insulin, alone or in combination with glucagon-like peptide-1 receptor agonist (GLP-1 RA) or in combination with other oral antidiabetic drugs (OADs) (B). If the desired glucose targets are not met, rapid-acting or short-acting (bolus or prandial) insulin can be added at mealtime to control the expected postprandial raise in glucose. An insulin regimen should be adopted and individualized but should, to the extent possible, closely resemble a natural physiologic state and avoid, to the extent possible, wide fluctuating glucose levels (C). Blood glucose monitoring is an integral part of effective insulin therapy and should not be omitted in the patient's care plan. Fasting plasma glucose (FPG) values should be used to titrate basal insulin, whereas both FPG and postprandial glucose (PPG) values should be used to titrate mealtime insulin (B). Metformin combined with insulin is associated with decreased weight gain, lower insulin dose, and less hypoglycemia when compared with insulin alone (C). Oral medications should not be abruptly discontinued when starting insulin therapy because of the risk of rebound hyperglycemia (D). Analogue insulin is as effective as human insulin but is associated with less postprandial hyperglycemia and delayed hypoglycemia (B). The shortest needles (currently the 4-mm pen and 6-mm syringe needles) are safe, effective, and less painful and should be the first-line choice in all patient categories; intramuscular (IM) injections should be avoided, especially with long-acting insulins, because severe hypoglycemia may result; lipohypertrophy is a frequent complication of therapy that distorts insulin absorption, and therefore, injections and infusions should not be given into these lesions and correct site rotation will help prevent them (A). Many patients in East Africa reuse syringes for various reasons, including financial. This is not recommended by the manufacturer and there is an association between needle reuse and lipohypertrophy. However, patients who reuse needles should not be subjected to alarming claims of excessive morbidity from this practice (A). Health care authorities and planners should be alerted to the risks associated with syringe or pen needles 6 mm or longer in children (A).

Safety of Sodium-Glucose Cotransporter 2 Inhibitors (SGLT2-I) During the Month of Ramadan in Muslim Patients with Type 2 Diabetes

Objectives

Sodium-glucose cotransporter 2 inhibitors (SGLT2-I) are a new class of antidiabetic drugs that might increase the risk of dehydration and hypoglycemia, particularly during the month of Ramadan in which Muslims abstain from eating and drinking for 14-16 hours daily. We aimed to provide real-life evidence about the safety of SGLT2-I during Ramadan.

Methods

All patients over the age of 18 years on SGLT2-I before Ramadan 2016 who would be fasting during Ramadan were included. Demographic data, detailed medical history including comorbidities and medication profile, and laboratory results were collected before and after Ramadan. We also conducted a phone interview to evaluate the frequency and severity of hypoglycemia and dehydration.

Results

Of the total of 417 patients, 113 (27.0%) experienced hypoglycemic events, and 93 of these (82.3%) checked their blood glucose using a glucometer. Confirmed hypoglycemia (< 70 mg/dL) was observed in 78 (83.8%). The hypoglycemic events were significantly more frequent in the SGLT2-I plus insulin-treated group than in those treated with SGLT2-I plus oral hypoglycemic agents group (p < 0.001). Confirmed hypoglycemic events were more frequent in those using SGLT2-I plus intensive insulin compared to those using SGLT2-I plus basal insulin (p = 0.020). Symptoms of dehydration were seen in 9.3% (n = 39) of the total population. We observed statistically significant reductions in glycated hemoglobin and weight by the end of Ramadan (p < 0.001). There were no significant changes in lipid profile and creatinine levels by the end of the study.

Conclusions

The use of insulin in combination with SGLT2-I increases the risk of hypoglycemia during Ramadan. Hypoglycemic events were mild and did not require hospital admission. However, careful monitoring during prolonged fasting is warranted. No significant harmful effects on renal function result from treatment with SGLT2-I during Ramadan.

Diabetes, driving and fasting during Ramadan: the interplay between secular and religious law

A large proportion of the Muslim population fasts during Ramadan. The risk of hypoglycemia is increased with fasting during Ramadan in people with diabetes who are on insulin and insulin secretagogues. Therefore, the combination of fasting with diabetes and driving presents a challenging situation, with legal implications for such individuals and their healthcare professionals. This novel, narrative, non-systematic review discusses the importance of addressing hypoglycemia in fasting with reference to secular legal guidance on driving with diabetes. We discuss religious aspects relating to fasting and driving in Islam. While there is no clear guidance or legal position on diabetes and driving for individuals who are fasting, Islamic law provides a logical framework to address this. Healthcare professionals need to raise and facilitate discussions on this often-overlooked topic with people with diabetes who are planning on fasting to minimize the potential for public harm. For some individuals fasting perhaps should be avoided when driving and that this religiously compatible position would best be adopted when one is dependent on driving for livelihood. Ultimately further research on glycemic control and management when fasting and driving, as well as a formal legal guidance on this topic, is required to safeguard healthcare professionals and the public from the potential dangers of driving with diabetes and fasting.

Original paper: Efficacy and safety analysis of insulin degludec/insulin aspart compared with biphasic insulin aspart 30: A phase 3, multicentre, international, open-label, randomised, treat-to-target trial in patients with type 2 diabetes fasting during Ramadan

AIMS

To compare the efficacy and safety of insulin degludec/insulin aspart (IDegAsp) and biphasic insulin aspart 30 (BIAsp 30) before, during and after Ramadan in patients with type 2 diabetes mellitus (T2DM) who fasted during Ramadan.

METHODS

In this multinational, randomised, treat-to-target trial, patients with T2DM who intended to fast and were on basal, pre- or self-mixed insulin ± oral antidiabetic drugs for ≥90 days were randomised (1:1) to IDegAsp twice daily (BID) or BIAsp 30 BID. Treatment period included pre-Ramadan treatment initiation (with insulin titration for 8-20 weeks), Ramadan (4 weeks) and post-Ramadan (4 weeks). Insulin doses were reduced by 30-50% for the pre-dawn meal (suhur) on the first day of Ramadan, and readjusted to the pre-Ramadan levels at the end of Ramadan. Hypoglycaemia was analysed as overall (severe or plasma glucose <3.1 mmol/L [56 mg/dL]), nocturnal (00:01-05:59) or severe (requiring assistance of another person).

RESULTS

During the treatment period, IDegAsp (n = 131) had significantly lower overall and nocturnal hypoglycaemia rates with similar glycaemic efficacy, versus BIAsp 30 (n = 132). During Ramadan, despite achieving significantly lower pre-iftar (meal at sunset) self-measured plasma glucose (estimated treatment difference: -0.54 mmol/L [-1.02; -0.07]_{95% CI}, p = .0247; post hoc) with similar overall glycaemic efficacy, IDegAsp showed significantly lower overall and nocturnal hypoglycaemia rates versus BIAsp 30.

CONCLUSIONS

IDegAsp is a suitable therapeutic agent for patients who need insulin for sustained glucose control before, during and after Ramadan fasting, with a significantly lower risk of hypoglycaemia, versus BIAsp 30, an existing premixed insulin analogue.

Predetermined Anti-Diabetic Drug Regimen Adjustments during Ramadan Fasting: An Observational Study of Safety

BACKGROUND

Many Muslim type 2 diabetes mellitus (T2DM) patients choose to fast the month of Ramadan despite the possible adverse health effects brought about by the change in dietary habits, among other things. Clinical data regarding the safety of multi-drug regimens during fasting are particularly scarce. The aim of the study was to evaluate the safety of a drug protocol devised by the authors to accommodate Ramadan's dietary changes, involving dose adjustments of four anti-diabetic drug regimens in T2DM patients fasting Ramadan.

METHODS

In this prospective, observational, open-label study, 301 T2DM patients who wished to fast Ramadan were followed during Ramadan and the preceding month. The incidence of hypoglycemia, diabetic ketoacidosis (DKA) and non-ketotic hyperosmolar state (NKHS) was monitored. Patients were classified into four groups: A group (those taking metformin, sulfonylurea and insulin [n=33]); B group (metformin and sulfonylurea [n=89]); C group (metformin and insulin [n=96]); and D group (premixed 70/30, glargine or regular insulin [n=82]). During Ramadan, drug doses were adjusted as percentages of their pre-Ramadan values: 75% for sulfonylureas, 75% for glargine, 75% for premixed insulin 70/30 in two doses, and 75% for regular insulin. Metformin was adjusted to a twice-daily regimen.

RESULTS

No cases of DKA or NKHS were reported. Hypoglycemia occurred at a lower rate than pre-Ramadan values in groups C, and D; and a similar rate in groups A, and B.

CONCLUSION

The data suggested that using the above protocol to adjust the doses of anti-diabetic drugs is safe in T2DM patients in regards to hypoglycemia, DKA, and NKHS.

Diabetes and Ramadan: Practical guidelines

Ramadan fasting is one of the five pillars of Islam and is compulsory for all healthy Muslims from puberty onwards. Exemptions exist for people with serious medical conditions, including many with diabetes, but a large number will participate, often against medical advice. Ensuring the optimal care of these patients during Ramadan is crucial. The International Diabetes Federation (IDF) and Diabetes and Ramadan (DAR) International Alliance have come together to deliver comprehensive guidelines on this subject. The key areas covered include epidemiology, the physiology of fasting, risk stratification, nutrition advice and medication adjustment. The IDF-DAR Practical Guidelines should enhance knowledge surrounding the issue of diabetes and Ramadan fasting, thereby empowering healthcare professionals to give the most up-to-date advice and the best possible support to their patients during Ramadan.

Strategies to Make Ramadan Fasting Safer in Type 2 Diabetics: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials and Observational Studies

Ramadan is the holy month for Muslims whereby they fast from predawn to after sunset and is observed by all healthy Muslim adults as well as a large population of type 2 diabetic Muslims.To determine the comparative effectiveness of various strategies that have been used for type 2 diabetic Muslim who fast during Ramadan.A systematic review and network meta-analysis of randomized controlled studies (RCT) as well as observational studies for patients with type 2 diabetes who fasted during Ramadan was conducted. Eight databases were searched from January 1980 through October 2015 for relevant studies. Two reviewers independently screened and assessed study for eligibility, assessed the risk of bias, and extracted relevant data. A network meta-analysis for each outcome was fitted separately, combining direct and indirect evidence for each comparison.Twenty-nine studies, 16 RCTs and 13 observational studies each met the inclusion criteria. The most common strategy used was drug changes during the Ramadan period, which found that the use of DPP-4 (Dipeptidyl peptidase inhibitor -4) inhibitors were associated with a reduction in incidence of experiencing hypoglycemia during Ramadan in both RCTs (pooled relative risk: 0.56; 95% confidence interval: 0.44-0.72) as well as in observational studies (pooled relative risk: 0.27; 0.09-0.75). Ramadan-focused education was shown to be beneficial in reducing hypoglycemia in observational studies but not RCTs (0.25 versus 1.00). Network meta-analyses suggest that incretin mimetics can reduce the risk of hypoglycemia by nearly 1.5 times.The newer antidiabetic agents appear to lower the risk of hypoglycemia and improved glycemic control when compared with sulfonylureas. Ramadan-focused education shows to be a promising strategy but more rigorous examination from RCTs are required.

Options for Controlling Type 2 Diabetes during Ramadan

The Muslim population is about 1.5 billion worldwide. Based on a global diabetes prevalence of 4.6%, it is estimated that there are about 50 million Muslims with diabetes around the world who observe fasting during the month of Ramadan each year. Ramadan, one of the five pillars of Islam, and which takes place during the ninth month of the Islamic calendar, involves fasting from sunrise to sunset. During the fast, Muslims are required to refrain from eating food, drinking, using medications, and smoking from dawn until after sunset, with no restrictions on food or fluid intake between sunset and dawn. Islam exempts people from the duty of fasting if they are sick, or if fasting may affect their health, as fasting for patients with diabetes carries a risk of an assortment of complications, including hypoglycemia, postprandial hyperglycemia, and metabolic complications, associated with dehydration. Nevertheless, a large number of people with diabetes who still choose to fast during Ramadan despite the advice of their doctor, and the permission received from religious authorities thus create medical challenges for themselves and their health-care providers. It is thus important for patients with diabetes who wish to fast during Ramadan to make the necessary preparations to engage in fasting as safely as possible. This review presents a guide to the care of diabetic patients during Ramadan to help them fast safely if they wish to do so.

Glucagonocentric restructuring of diabetes: a pathophysiologic and therapeutic makeover

The hormone glucagon has long been dismissed as a minor contributor to metabolic disease. Here we propose that glucagon excess, rather than insulin deficiency, is the sine qua non of diabetes. We base this on the following evidence: (a) glucagon increases hepatic glucose and ketone production, catabolic features present in insulin deficiency; (b) hyperglucagonemia is present in every form of poorly controlled diabetes; (c) the glucagon suppressors leptin and somatostatin suppress all catabolic manifestations of diabetes during total insulin deficiency; (d) total β cell destruction in glucagon receptor-null mice does not cause diabetes; and (e) perfusion of normal pancreas with anti-insulin serum causes marked hyperglucagonemia. From this and other evidence, we conclude that glucose-responsive β cells normally regulate juxtaposed α cells and that without intraislet insulin, unregulated α cells hypersecrete glucagon, which directly causes the symptoms of diabetes. This indicates that glucagon suppression or inactivation may provide therapeutic advantages over insulin monotherapy.

Ramadan and diabetes: As-Saum (The fasting)

Ramadan, the ninth month of Islamic lunar calendar, is marked by religious ritual of fasting from early dawn till sunset by Muslims. Islam has allowed many categories of people to be exempt totally or temporarily from fasting. Patients with uncontrolled diabetes face possible major metabolic risks including hypoglycemia, hyperglycemia with or without the risk of impending ketosis, dehydration, and thrombosis. Diabetics can be stratified into four categories based on their level of risk associated with fasting. The recommended ruling for persons in categories 1 and 2 is that they are prohibited from fasting to prevent harming themselves based on the certainty or the preponderance of probability that harm will occur, whereas the recommended ruling for those in categories 3 and 4 is that they should fast. The strategies to ensure safety of diabetics who are planning to fast include Ramadan-focused patient education, pre-Ramadan medical assessment, following a healthy diet and physical activity pattern, physician-recommended modifications in medication protocol and therapeutic recommendations and checking blood glucose as and when required.

Efficacy and safety of insulin glargine and glimepiride in subjects with Type 2 diabetes before, during and after the period of fasting in Ramadan

AIMS

To determine the safety and efficacy of insulin glargine and glimepiride in patients with Type 2 diabetes before and after Ramadan and during fasting for Ramadan.

METHODS

In this open, descriptive, multi-centre, prospective study, insulin-naïve (n = 100) or previously insulin-treated (n = 249) patients with Type 2 diabetes received insulin glargine [titrated from 10 U daily according to fasting blood glucose (FBG)] and glimepiride (4 mg daily). The number and type of hypoglycaemic episodes and glycaemic control were assessed before, during and after Ramadan. Bivariate logistic regression analyses were used to identify factors which predicted hypoglycaemia during Ramadan.

RESULTS

Only one episode of severe hypoglycaemia occurred in each time period before, during and after Ramadan. Mild hypoglycaemic episodes increased from 156 pre-Ramadan to 346 during Ramadan (P < 0.001) and decreased to 153 post-Ramadan (P = 0.0002).The increase during Ramadan was mainly attributed to increased symptomatic hypoglycaemic episodes. FBG and glycated haemoglobin improved during the titration period and did not change during the rest of the study. Risk of hypoglycaemic events during Ramadan was higher in countries where fasting is strict [odds ratio (OR) 3.69 (2.06-6.63), P < 0.0001]. Lower weight [< 70.0 kg; OR 2.56 (1.46-4.48), P = 0.001] and waist circumference [< 90 cm; OR 3.06 (1.62-5.78), P = 0.001] increased the risk of hypoglycaemia during Ramadan whilst FBG > 6.7 mmol/l [OR 0.3 (0.17-0.54), P < 0.0001] had a protective effect.

CONCLUSIONS

Combination of insulin glargine and glimepiride may be used during Ramadan in patients with Type 2 diabetes who wish to fast, provided glimepiride is given at the time of breaking the fast and insulin glargine titrated to provide FBG > 6.7 mmol/l.

Does the seizure frequency increase in Ramadan?

During Ramadan, the ninth month of the Islamic lunar calendar, adult Muslims are required to refrain from taking any food, beverages, or oral drugs, as well as from sexual intercourse between dawn and sunset. In this study, we aimed at discovering alterations in drug regimens and the seizure frequency of epileptic patients during Ramadan (15 October 2004-13 November 2004). In the 3 months following Ramadan in the year 2004, 114 patients with epilepsy who were fasting during Ramadan were examined at our Epilepsy Department. Of the 114 patients who were included in the study, 38 patients had seizures and one of these patients developed status epilepticus during Ramadan. When the seizure frequency of these patients during Ramadan was compared to that in the last 1 year and last 3 months period just prior to Ramadan, a statistically significant increase was observed (p<0.001). Moreover, there was an important increase in the risk of having seizures in the patients who changed their drug regimens compared with those who did not (p<0.05). In the patients who received monotherapy or polytherapy, no difference in the frequency of seizures during Ramadan was seen (p>0.05). During Ramadan, an increase in the seizure frequency of patients with epilepsy was observed. The most important reason for this situation was the alteration in the pharmacokinetics and pharmacodynamics of drugs, and consequently, in their efficacy. We believe that in the patients who received monotherapy and who did not change their drug regimes, the increase in seizure frequency may have been related to the changes in their daily rhythms, emotional stress, tiredness and their day-long fasting.

Tratamiento de la diabetes mellitus durante el Ramadán

In the treatment of patients with diabetes mellitus it is fundamental that the therapeutic schemes are adapted to each's patient characteristics such as age, associated diseases and diabetes complications. This therapeutic individualization must also include lifestyles and socio-cultural and religious factors as the celebration of Ramadan. Although Muslin diabetics are theoretically free from Ramadan, they commonly wish to fast in practice. It is therefore needed a right approach of the patient during this period. In this Review, we analyze the prevalence of diabetes among different ethnicities, the possible complications of the disease in relation to fasting's pathophysiology, and the studies performed to rightly manage type 1 and 2 diabetic patients during Ramadan. It is necessary to adapt the therapeutic scheme both for patients treated with dietetic measures or oral drugs and for patients receiving insulin. It is also important the involvement of health professionals in the advice, orientation and adaptation of the therapeutic regimen of Muslin people with diabetes.

A comparison of glycemic effects of glimepiride, repaglinide, and insulin glargine in type 2 diabetes mellitus during Ramadan fasting

Although diabetics may be exempted from Ramadan fasting, many patients still insist on this worship. Aim of the present study is to compare the effects of glimepiride, repaglinide, and insulin glargine in type 2 diabetics during Ramadan fasting on the glucose metabolism. Patients, who were willing to fast, were treated with glimepiride (n=21), repaglinide (n=18), and insulin glargine (n=10). Sixteen non-fasting control type 2 diabetics matched for age, sex, and body mass index were also included. Fasting blood glucose (FBG), post-prandial blood glucose (PBG), HbA1c, and fructosamine as well as lipid metabolism were evaluated in pre-Ramadan, post-Ramadan, and 1-month post-Ramadan time points. There was no significant change from pre-Ramadan in FBG, PBG, and HbA1c variables in fasting diabetics at post-Ramadan and 1-month post-Ramadan. However, PBG was found higher in non-fasting control diabetics at post-Ramadan and 1-month post-Ramadan (p<0.05 and p<0.001, respectively). In fructosamine levels, a significant increase was noted both in fasting group and non-fasting group at 1-month post-Ramadan (p<0.01 for all). However, no significant difference was found in the comparison of the changes in fructosamine levels between fasting group and non-fasting group. Risk of hypoglycemia did not significantly differ between fasting and non-fasting diabetics. There was no significant difference between three drug therapies regarding glucose metabolism and rate of hypoglycemia. No adverse effects on plasma lipids were noted in fasting diabetics. In this fasting sample of patients with type 2 diabetes, glimepiride, repaglinide, and insulin glargine did not produce significant changes in glucose and lipid parameters.

Diabetes and Ramadan: review of the literature

During the month of Ramadan, Muslims fast every day from dawn to sunset. In the healthy subject, this fasting does not have any harmful consequences on health. However, it can induce several complications for patients with diabetes. The aim of this review twofold: first, it seeks to give some clues about methodological aspect of research during Ramadan and to show the impact of various diabetes monitoring and treatment, including biochemical and clinical parameters, diet and caloric intake, drug intake when fasting. Second, it intends to determine whether or not Ramadan fasting induces complications in patients with types 1 and 2 diabetes and ultimately to elaborate some advice as to the management of fasting patients. Several studies have shown that Ramadan fasting did not alter biochemical parameters in patients with type 2 diabetes. However, other studies have shown that there is either an increase or a decrease in biochemical parameters during Ramadan. Ramadan fasting would be acceptable for patients with well-balanced type 2 diabetes who are conscious of their disease and compliant with their diet and drug intake. If patients with type 1 diabetes wish to fast, it is necessary to advise them to undertake control of their glycaemia several times a day. Patients with type 1 diabetes who will fast during Ramadan may be better managed with fast absorption insulin.

[Clinical case: beliefs, Ramadan and diabetes mellitus]

From the clinical case of a 52-Year old, type 2 diabetic obese woman, muslim algerian native, an endocrinologist and a religious representative discuss the influences of religion, beliefs and environment, on compliance to the diabetes diet and therapeutic management, with a particular emphasis on the Ramadan period. Inadequate behaviours, result in a worsening in glucose control. This, should be avoided through an appropriate patient's education, all along the Year, not only through the healthcare team, but involving patient's family and friends too, as well as the community and religious Authorities.

The implementation of nutritional advice for people with diabetes

These consensus-based recommendations emphasize the practical implementation of nutritional advice for people with diabetes, and describe the provision of services required to provide the information. Important changes from previous recommendations include greater flexibility in the proportions of energy derived from carbohydrate and monounsaturated fat, further liberalization in the consumption of sucrose, more active promotion of foods with a low glycaemic index, and greater emphasis on the provision of nutritional advice in the context of wider lifestyle changes, particularly physical activity. Monounsaturated fats are now promoted as the main source of dietary fat because of their lower susceptibility to lipid peroxidation and consequent lower atherogenic potential. Consumption of sucrose for patients who are not overweight can be increased up to 10% of daily energy provided that this is eaten in the context of a healthy diet and distributed throughout the day [corrected]. Evidence is presented for the effectiveness of advice provided by trained dieticians. The increasing evidence for the importance of good metabolic control and the growing requirement for measures to prevent Type 2 diabetes in an increasingly obese population will require major expansion of dietetic services if the standards in National Service Frameworks are to be successfully implemented.

Novel insulins: expanding options in diabetes management

Management of type 1 and type 2 diabetes mellitus with intensive insulin therapy usually includes an intermediate- or long-acting basal component for between-meal and nocturnal glycemic control, together with preprandial bolus injections of a short-acting insulin for control of meal-stimulated increases in serum glucose levels. Although the ideal basal/bolus insulin combination has yet to be found, recent developments may provide safer and more effective options. Two new short-acting semisynthetic analogs--insulin lispro and insulin aspart--can be administered as preprandial bolus injections closer to mealtime than regular human insulin, thereby synchronizing insulin administration and food absorption. In clinical trials, postprandial increases in blood glucose levels were significantly less after treatment with insulin lispro or insulin aspart than with premeal regular insulin. Because of their short duration of action, a slightly greater basal insulin supply may be needed when insulin lispro or insulin aspart is used. Inhalation devices for aerosolized regular human insulin offer another alternative to premeal subcutaneous bolus injections. Inhaled insulin is absorbed more rapidly than subcutaneous regular insulin and may therefore be given closer to mealtime. For basal therapy, insulin glargine, a new long-acting analog, is absorbed more slowly after subcutaneous administration than are conventional neutral protamine Hagedorn (NPH) and ultralente insulin, and has a relatively flat metabolic effect. Clinical trials indicate that insulin glargine is at least as effective as NPH insulin and ultralente insulin, and is associated with a reduced risk of nocturnal hypoglycemia. Other long-acting analogs, such as fatty acid acylated insulins, have been tested in animal models and are being evaluated in clinical studies.

Insulin lispro: a pharmacoeconomic review of its use in diabetes mellitus

Insulin lispro is a recombinant insulin analogue with transposed amino acids (proline and lysine) at positions 28 and 29 near the C-terminus of the B-chain. The most prominent practical advantage of insulin lispro over human soluble insulin lies in its very rapid onset of action. This property allows it to be injected immediately before meals and minimises the demands made on patients with type 1 diabetes mellitus, and those with type 2 disease who require insulin, by the ongoing need for careful meal planning and timing. Numerous clinical studies have shown significant improvements in postprandial glycaemic control, with some evidence of reduced rates of severe or nocturnal hypoglycaemia, relative to conventional human insulin in patients receiving lispro-based insulins. Quality-of-life studies show consistent preferences by patients for and increased treatment satisfaction with insulin lispro over human soluble insulin, particularly with variations of the Diabetes Treatment Satisfaction Questionnaire. Willingness of patients and taxpayers to pay additional costs for insulin lispro or a premixed lispro-based formulation over conventional human insulins, and cost benefits favouring formulary inclusion, have been shown in well designed studies carried out in Australia and Canada. Spanish data suggest cost effectiveness in terms of episodes of severe hypoglycaemia avoided, and preliminary German resource utilisation data indicate cost savings related to reduced hospitalisation and general practice costs, with insulin lispro relative to human soluble insulin.

CONCLUSIONS

Insulin lispro and premixed formulations of lispro-based insulins offer quality-of-life improvements relative to conventional human insulins in patients with diabetes mellitus. Participants in well designed studies have expressed a preference for lispro-based insulins and have been shown to be willing to pay for the advantages they offer, and current cost-benefit data favour the inclusion of these insulins in formularies and their reimbursement by third party payers. Further research into the pharmacoeconomic implications of insulin lispro use in the long term is needed, particularly with respect to effects on indirect costs and those associated with complications of diabetes mellitus.

The challenge of culturally competent health care: applications for asthma

To better serve the increasingly diverse ethnic and racial communities in the United States, health care professionals must develop a knowledge base of cultural health practices. In asthma, a common disease, ethnic minority populations experience poorer outcomes when compared with whites. It is, therefore, imperative that providers have an improved understanding of how patients make decisions concerning their health. Cultural health practices, in concert with conventional treatments, often form a comprehensive asthma management strategy for the patient. The potential implication of alternative explanations for disease, as well as the role of diet and botanical supplements, is explored in this article in an effort to increase providers' sensitivity to nonbiomedical models of disease causality. This sensitivity is the first step in developing cultural competency.