13/03/2023
Academic Post:
♦♦♦
Management of DM in Ramadan
⚛️⚛️⚛️
Introduction:
Fasting during Ramadan is one of the five pillars of Islam.
Fasting in Ramadan is mandatory for all Muslims who have reached puberty.
Ramadan has a major impact on the management of DM in the Muslim population.
Approx over 150 million Muslims with DM worldwide.
Clinical Guideline:
♦♦♦
Major risks associated with fasting in patients with diabetes
1) Hypoglycemia,
2) Hyperglycemia.
3) DKA
4) Dehydration and thrombosis.
♦️All individuals should break their fasting if:
1) Blood glucose < 70 mg/dl (3.9 mmol/L).
★ Re-check within 1 hour if blood glucose is Between 70-90 mg/dl (3.9-5.0 mmol/L)
2) Blood glucose >300 mg/dl (16.6 mmol/L).
3) Symptoms of hypoglycaemia, hyperglycaemia, dehydration or acute illness occur.
Hypoglycaemia:
i) Trembling.
ii) Sweating / chills.
iii) Palpitation.
iv) Hunger.
v) Altered mental status.
vi) Confusion.
vii) Headache.
Hyperglycaemia:
i) Extreme thrust.
ii) Hunger.
iii) Frequent urination
iv) Fatigue
v) Confusion
vi) Nausea / Vomiting
vii) Abdominal pain.
Dose Modification in Ramadan:
-------------------------------------------
Type I DM.
A) Basal Insulin:
a) Good glycaemic control ( HbA1C < 7.5):
★Reduce dose by 20-30%.
★Take at ifter or late evening. Or that of Pre-Ramadan bed time.
b) Poor glycaemic control ( HbA1C > 7.5%):
★Keep same dose and follow up.
★Take at ifter or late evening. Or that of Pre-Ramadan bed time.
B) Prandial Insulin:
★Patient on ICR/ISF Correction:
Continue same dose for Ifter and Suhoor (Sheheri).
★ Patient on Fix dose:
No dose change at Ifter,
But reduce dose at Suhoor ( Sheheri) by 20-30%.
Notes on prandial insulin:
i) For better post prandial control, it is advised to take bolus insulin 20 mints. prior to ifter.
ii) High blood glucose value may require extra correction doses based on insulin sensitivity ratio and target blood glucose.
iii) Correction doses must not be given frequently than every 3hours. (To avoid insulin stacking and hypoglycaemia.
The recommended use of MDI (Multiple dose insulin) therapy in adolescents with T1DM those are fasting during ramadan.
A) Once daily Long acting Basal analogue:
Measure Blood glucose in fasting (morning, mid-day and before ifter).
★ If blood glucose between 90-160 mg/dl ➡️ No dose adjustments needed.
★ If blood glucose between 160-250 mg/dl, ➡️ consider increasing basal insulin by 10-15%.
★ If blood glucose > 250 mg/dl, ➡️ consider increasing basal insulin by 20-30%.
★ If blood glucose 250 mg/dl, ➡️ consider increasing late evening basal insulin by 20-30%.
★ If blood glucose 250 mg/dl, ➡️ consider increasing ifter basal insulin by 20-30%.
★ If blood glucose 126 mg/dl (7.0 mmol/ L)
Basal insulin➡️ Increase by 2 unit.
5) >300mg/dl (16.7 mmol/L)
Basal insulin➡️ Increase by 4 unit.
Changes to SU (Sulphonylurea) dosing during Ramadan.
♦
Pre- Ifter / pre- Suhoor:
1) < 70 mg/dl: (3.9mmol)
★ Pre-Ifter/Post-suhoor
Short-acting insulin➡️ Reduce by 4 unit.
2) < 90 mg/ dl (5.0 mmol).
Short-acting insulin➡️ Reduce by 2 unit.
3) 90 - 126 mg/ dl (5.0 - 7.0 mmol/L).
Short-acting insulin➡️ No dose change required.
4) > 126 mg/dl (7.0 mmol/ L)
Short-acting insulin➡️ Increase by 2 unit.
5) >300mg/dl (16.7 mmol/L)
Short-acting insulin➡️ Increase by 4 unit.
❇️ Changes to Pre-mixed Insulin dosing during Ramadan.
A) Once daily dosing:
Take normal dose at Ifter.
B) Twice daily dosing:
i) Take normal dose at Ifter.
ii) Reduce Suhoor dose by 20-50%.
C) Three times Daily dosing:
i) Omit afternoon dose.
ii) Adjust Ifter and suhoor doses.
Changes to SU (Sulphonylurea) dosing during Ramadan.
--------------------------------------------------------------------------
❇️ Fasting / Pre-Ifter/ Pre Suhoor bl.glucose:
< 70mg/dl(3.9mmol/L)
➡️ Pre-Ifter insulin modifications:
Reduce by 4 units.
❇️Fasting / Pre-Ifter/ Pre Suhoor bl.glucose:
< 90mg/dl(5.0mmol/L)
➡️ Pre-Ifter insulin modifications:
Reduce by 2 units.
❇️Fasting / Pre-Ifter/ Pre Suhoor bl.glucose:
90-126mg/dl(5.0-7.0mmol/L)
➡️ Pre-Ifter insulin modifications:
No change required.
❇️Fasting / Pre-Ifter/ Pre Suhoor bl.glucose:
>126mg/dl(7.0mmol/L)
➡️ Pre-Ifter insulin modifications:
Increase by 2 units.
❇️Fasting / Pre-Ifter/ Pre Suhoor bl.glucose:
>300mg/dl(16.7mmol/L)
➡️ Pre-Ifter insulin modifications:
Increase by 4 units.
-----------*********----------@@@@@@-------------
Collected
Courtesy:
Dr. Raed Abu Taleb(Consultant Diabetologist)
