FAQ 7: As a Pharmacist what is your recommendation for a patient who is taking Insulin for diabetes melitus and would like to be fasting during the day for a particular period of time to perform his/her religious direction during Holy Ramadaan?

Ramadan is the holy month of fasting in which Muslims refrain from food, fluids, oral medications and smoking from sunrise until sunset. The Koran specifically exempts from fasting those for whom it may have harmful consequences, such as pregnant women, the elderly and those with medical conditions. Fasting is not recommended for type 1 diabetes patients, those who are non-adherent to therapy or who have poor glycemic control [1]. These individuals in particular are at increased risk of hypo- and hyperglycemic episodes as well as metabolic complications associated with dehydration [2]. However, many diabetes patients choose to participate despite the medical and religious advice excusing them from the Ramadan fast [3, 4, 5].

Fortunately, diabetes management strategies during Ramadan have been proposed by international medical and religious bodies [1, 6, 7, 8, 9]. General considerations include pre-Ramadan medical assessment and patient education regarding meal planning; physical activity; the need for increased frequency of blood glucose monitoring and the recognition and management of acute complications. Recommendations for diabetes medication dosing adjustments tailored for both type 1 and type 2 diabetes patients are also outlined. Despite availability of such resources, studies have identified gaps in prescribed diabetes patient care, notably inappropriate health professional discouragement towards fasting and lack of counseling regarding medications or instructions for breaking the fast  [10, 11, 12].

Pharmacists as the front desk healthcare provider has a tremendous role in managing diabetic patients during ramadan.

Pharmacists Recommendations:
At least 1 – 2 months before Ramadan
  • Pre – Ramadan medical assessment
  • Speak to your physician for insulin dose adjustment if needed and individualized advice so as to minimize the risk associated with fasting.
During fasting, especially daytime
  • Monitor your blood sugar levels more frequently especially if you are on insulin therapy or multiple anti-diabetic medications. Test your blood sugar immediately if you experience hypoglycemic symptoms or are feeling unwell.
During Iftar (sunset meal) or Suhur (predawn meal)

Avoid eating too much carbohydrates and fat, especially during Iftar.

  • Drink more water during non-fasting hours
When exercising
  • Avoid excessive rigorous exercise especially before Iftar (sunset meal).
  • Change your exercise timing to about 2 hours after Iftar.

What symptoms to look out for?

  • Chest pain
  • Confusion
  • Dizziness
  • Fruity odour on breath
  • Heart palpitation
  • Muscle cramps
  • Nausea & vomiting
  • Weakness
When you feel unwell/ experience the symptoms above
  • Break your fast
  • Check your blood glucose immediately
  • Seek medical advice immediately if:
    • blood glucose < 3.3 mmol/L (60 mg/dL)
    • blood glucose < 3.9 mmol/L (70 mg/dL) in first few hours after starting of fast
    • Blood glucose > 16.7 mmol/L (300mg/ dL)
  • Call emergency medical service

Avoid fasting on sick days.

Reference:

  1. American Diabetes Association Workgroup Report: Recommendations for diabetes management during Ramadan. Update 2010. Diab Care. 2010, 33: 1895-1902. 10.2337/dc10-0896.View ArticleGoogle Scholar
  2. Alkandari JR, Maughan RJ, Roky R, Aziz AR, Karli U: The implications of Ramadan fasting for human health and well-being. J Sports Sci. 2012, 30 (Suppl 1): S9-S19.View ArticlePubMedGoogle Scholar
  3. Salti I, Benard D, Detournay B, Bianchi-Biscay M, le Brigand C, Voinet C, Jabbar A, EPIDIAR study group: 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: 2306-2311. 10.2337/diacare.27.10.2306.View ArticlePubMedGoogle Scholar
  4. Robinson T, Raisler J: “Each one is a doctor for herself”: Ramadan fasting among pregnant Muslim women in the United States. Ethn Dis. 2005, 15 (1 Suppl 1): S99-S103.Google Scholar
  5. Hui E, Reddy M, Bravis V: Fasting among pregnant women with diabetes during Ramadan. Int J Clin Pract. 2012, 66: 910-911.View ArticlePubMedGoogle Scholar
  6. Hui E, Bravis V, Hassanein M, Hanif W, Malik R, Chowdhury TA, Suliman M, Devendra D: Management of people with diabetes wanting to fast during Ramadan. BMJ. 2010, 340: 1407-1411.View ArticleGoogle Scholar
  7. Al Maatouq MA: Pharmacological approaches to the management of type 2 diabetes in fasting adults during Ramadan. Diab Metab Syndr Obes. 2012, 5: 109-119.View ArticleGoogle Scholar
  8. Hussanein M: Diabetes and Ramadan: how to achieve a safer fast for Muslims with diabetes. Br J Diab Vasc Dis. 2010, 10: 246-250. 10.1177/1474651410380150.View ArticleGoogle Scholar
  9. Beshyah SA: Fasting during the month of Ramadan for people with diabetes: medicine and Fiqh united at last. Ibonsina J Med Biomed Sci. 2009, 1: 58-60.Google Scholar
  10. Gaborit B, Dutour O, Ronsin O, Atlan C, Damon P, Gharsalli R, Pradel V, Dadoun F, Dutour A: Ramadan fasting with diabetes: an interview study of inpatients’ and general practitioners’ attitudes in the South of France. Diab Metab. 2011, 37: 395-402. 10.1016/j.diabet.2010.12.010.View ArticleGoogle Scholar
  11. Pinelli NR, Jaber LA: Practices of Arab American patients with type 2 diabetes mellitus during Ramadan. J Pharm Pract. 2011, 24: 211-215. 10.1177/0897190010367432.View ArticlePubMedGoogle Scholar
  12. Peeters B, Mehuys E, van Tongelen I, van Bever E, Bultereys L, Avonts D, Yildiz G, Remon JP, Boussery K: Ramadan fasting and diabetes: an observational study among Turkish migrants in Belgium. Prim Care Diab. 2012, 6: 293-296. 10.1016/j.pcd.2012.02.003.View ArticleGoogle Scholar
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