Management of Glucose during fasting month.

Yesterday marked the starting of Ramadan ( a fasting month) for all Muslim.
Here is the brief account for management of diabetes during fasting month.
First we classify the diabetes patient to low , moderate to high risk.
Briefly low risk patient is the well controlled diabetes without target organ damage.
Very high risk patients are those with poorly controlled diabetes, recurrent hypoglycaemia, previous DKA (ketoacidosis), HHS (hyperosmolar ,hyperglycemia states), dialysis or pregnant lady.

Followed by knowing the potential complication they may face.
1-hypoglycemia
2-hyperglycemia
3-DKA
4-dehydration and thrombosis

Hypoglycaemia is due to reduced food intake.
Then why hyperglycemia ? accoding to the extensive EPIDIAR study which showed a fivefold increase in the incidence of severe hyperglycemia (requiring hospitalization) during Ramadan in patients with type 2 diabetes (from 1 to 5 events/100 people/ month_1) and an approximate threefold increase in the incidence of severe hyperglycemia with or without ketoacidosis in patients with type 1 diabetes (from 5 to 17 events /100 people/month_1) .
Hyperglycemia may have been due to
1.excessive reduction in dosages of medications to prevent hypoglycemia.
2.Patients who reported an increase in food and/or sugar intake had significantly higher rates of severe hyperglycemia

DKA particularly for those diabetic type 1. Particularly increased for those who reduced insulin injection with assumption food intake reduced during the month.

Dehydration and thrombosis
The dehydration may become severe as a result of excessive perspiration in hot and humid climates like Malaysia .It also happens among individuals who perform hard physical activities.
In addition, hyperglycemia produces a osmotic dieresis which further exacerbate the dehydration.
contraction of the intravascular space can further exacerbate the hypercoagulable state that is well demonstrated in diabetes .Increased blood viscosity secondary to dehydration may enhance the risk of thrombosis and stroke. Arab study found increase retinal vein occlusion during fasting month but not stroke and IHD.

General considerations

Individualization.

Frequent monitoring of glycemia

Nutrition.
It most likely to arise from inappropriate diet or as a consequence of over-eating and insufficient sleep. Therefore,the diet during Ramadan for diabetic patients should not differ significantly from a healthy and balanced diet.
ingesting large amounts of foods rich in carbohydrates and fats, especially at the sunset meal, should be avoided.

Exercise.
Normal levels of physical activity may be maintained. However, excessive physical activity may lead to a higher risk of hypoglycemia and should be avoided

Breaking the fast.
All patients should understand that they must always and immediately end their fast if hypoglycemia (3.3 mmol)

The fast should also be broken if blood glucose reaches (3.9 mmol/l)
in the first few hours after the start of the fast,

Type 2 Diabetis
Patients treated with oral agents. The choice of oral agents should be individualized.
In general, agents that act by increasing insulin sensitivity are associated with a significantly lower risk of hypoglycemia than compounds that act by increasing insulin secretion.

Metformin. Patients treated with metformin alone may safely fast because the
possibility of severe hypoglycemia is minimal.
2/3 of the total daily dose with the sunset meal and the other third before the
predawn meal.

Sulfonylureas.
It has been suggested that this group of drugs is unsuitable for use
during fasting because of the inherent risk of hypoglycemia. However, severe or fatal
hypoglycemia is a relatively rare complication of sulfonylurea use.
glyburide or glibenclamide may be associated with a higher risk of hypoglycemia than other
second-generation sulfonylureas, specifically gliclazide, glimepiride, and glipizide

Short-acting insulin secretagogues.
Members of this group (repaglinide and nateglinide) are useful because of their
short duration of action. They could be taken twice daily before the sunset and
predawn meals.

Incretin-based therapy.
Therapies that affect the incretin system include glucagon-like peptide-1 receptor agonists
(GLP-1ras) exenatide and liraglutide and dipeptidylpeptidase-4 inhibitors (DPP-4is) alogliptin, saxagliptin, sitagliptin,and vildagliptin. These classes of agents
are not independently associated with hypoglycemia.
Exenatide in particular can be dosed before meals to minimize appetite and promote weight loss.
With its short half-life of 2 h, it is not associated with a substantial effect on fasting
glucose.
DPP-4is are among the best tolerated drugs for the treatment of diabetes.
They are moderately less effective in A1C lowering than GLP-1ras and do not require titration.

alpha-Glucosidase inhibitors.
Acarbose,miglitol, and voglibose slow the absorption
of carbohydrates when taken with the first bite of a meal. Because they are
not associated with an independent risk of hypoglycemia, particularly in the fasting
state, they may be particularly useful during Ramadan
Insulin
judicious use of intermediate- or long acting insulin preparations plus a shortacting
insulin administered before meals.

Good luck to Dr during fasting month. It poses great challenge to keep Hbaic in target.