Objectives: This paper reviews available information on insulin regimens that may enable patients with type 1 diabetes mellitus to fast during the month of Ramadan with minimal complications. It also provides guidance for health care professionals in managing patients who wish to observe the fast.
Methods: Relevant English-language articles were identified through searches of the MEDLINE, EMBASE, and Index Medicus Eastern Mediterranean Region databases (all, 1980-2008) conducted in February 2008 using the terms Ramadan, fasting, type 1 diabetes mellitus, hypoglycemia, and hypotension. Only original research and review articles related to adult patients with type 1 diabetes were considered for review, excluding pregnant women and patients with poorly controlled disease.
Results: The literature review identified 5 clinical trials relevant to type 1 diabetes and fasting. Two main meals are eaten during Ramadan, one before dawn (Suhur) and the other at sunset (Iftar). Suggested adjustments to the insulin regimen during fasting include using 70% of the pre-Ramadan dose, divided as follows: 60% as insulin glargine given in the evening and 40% as an ultra-short-acting insulin (insulin aspart or lispro) given in 2 doses, 1 at Suhur and 1 at Iftar. Alternatively, 85% of the pre-Ramadan dose may be divided as 70% Ultralente and 30% regular insulin, both given in 2 doses, 1 at Suhur and 1 at Iftar. Another option is to give 100% of the pre-Ramadan morning dose of 70/330 premixed insulin at Iftar and 50% of the usual evening dose at Suhur. Patients who observe the fast should be advised to monitor their blood glucose regularly,avoid skipping meals or overeating,and maintain contact with their physician throughout the fast. The fast should be broken immediately if blood glucose drops below 60 mg/dL (3.3 mmol/L). Breaking the fast should be considered when blood glucose drops below 80 mg/dL (4.4 mmol/L), and the fast should be interrupted if blood glucose rises above 300 mg/dL (16.7 mmol/L) to avoid diabetic ketoacidosis. Fasting is contraindicated in patients with poorly controlled type 1 diabetes,including those with a history of severe hypoglycemia and/ or diabetic ketoacidosis at least 3 months before Ramadan; those with comorbid conditions (eg, unstable angina, uncontrolled hypertension, advanced macrovascular complications, infections, renal insufficiency);; those who are noncompliant with diet and medication; those who engage in intense physical activity; pregnant women; and the elderly.
Conclusion: Patients with type 1 diabetes who wish to fast during Ramadan should follow specific recommendations and be closely monitored by their physician.