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Ramadan is a period for worship, self-discipline, austerity and charity. Fasting is obligatory for all healthy adult Muslims, with no food or drink being consumed between dawn and sunset. There are only 2 meals a day pre-dawn and after sunset.

As the Islamic calendar year begins with the sighting of the new moon, Ramadan starts 10 days earlier each year. This year (2004) it runs from 15th October to 13th November.

Diabetes and Fasting

• Exemptions from fasting:
• Children under the age of puberty
• Those with learning difficulties
• The old and frail
• The acutely unwell
• Those with chronic illnesses for whom fasting may be detrimental to health

Patients with diabetes fall into this last category, but may prefer to meet their religious obligations by fasting.

Those Who Should Not Fast

• People with "brittle" type 1 diabetes
• Type 1 or type 2 patients with poor glycaemic control
• Individuals known to be non-compliant with diet or medication
• Patients with a history of recurrent DKA
• Pregnant women
• Patients with intercurrent infections
• Patients with renal impairment of any severity (risk of dehydration and uraemia)
• Elderly patients with reduced alertness
• Those who have previously experienced severe deterioration in glycaemic control during Ramadan

Hazards Of Fasting

The alteration of eating pattern without appropriate adjustment to the dosage and timing of insulin and/or oral medication may result in deterioration of glycaemic control. Insulin or sulphonylurea-treated patients run the risk of hypoglycaemia and some type 1 patients may risk DKA. When Ramadan occurs during the summer months prolonged fasting may create greater potential hazards. It is important therefore to discuss the management of hypo and hyperglycaemia. Patients must be advised to break their fast if there is severe deterioration in glycaemic control. It may be necessary to prescribe Hypostop (glucose gel) and/or Glucagon.

Precautions For Those Who Fast

The importance of continued compliance with dietary recommendations should be emphasized. Breaking the fast after sunset is not an excuse for over eating. Healthy eating guidelines should be followed - foods high in sugar and fats should be avoided. Regular meals/snacks with complex carbohydrate/starchy foods should be eaten. Patients need to monitor blood glucose with adjustment of medication as needed.

Patients who are treated with diet alone should not experience any problems with fasting during Ramadan.

Patients On Oral Medication

Patients taking Metformin alone are at no risk of hypoglycaemia and fasting poses little hazard. If a dose is usually taken at lunchtime it can be taken with the sunset meal.

Patients on a once-daily agent such as Glimepiride with breakfast, should be advised to take it with the sunset meal.

Patients taking a sulphonylurea should use a short acting agent i.e. Gliclazide and the morning and evening doses reversed during the fast. Long acting agents such as Glibenclamide are hazardous and should be avoided.

Patients On Insulin

There should be no need for a drastic reduction in the total dose of insulin. Many patients are insulin resistant and will still require large doses.

Many patients normally use premixed insulin (Mixtard, Humulin, Humalog Mix). It is advisable to reverse the morning and evening dose, if the doses are the same, the morning dose should be reduced by about 50% and a corresponding larger dose taken before the sunset meal.

Patients who are on a basal bolus regime should reverse their bedtime intermediate acting insulin (Insulatard, Humulin I) to the pre-dawn meal and then take their short acting insulin (Actrapid, Humulin S, Novorapid, Humalog) before each meal taken. Further adjustment to insulin dosages are likely to be needed after these initial suggestions have been instituted.

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