As-salamu alaykum and good afternoon. I'm going to talk about diabetes in Ramadan. So let's, without further ado, I'll just move on. This is my disclosure. So these are the presentation outlines I'm going to discuss about Ramadan overview, epidemiology of diabetes and fasting, pathophysiology, risk associated with fasting and the stratification, the pre-Ramadan assessment education, management of type 2 diabetes in Ramadan, in type 1 and type 2, management of diabetes in pregnancy in Ramadan, and cardiovascular, cerebrovascular, and renal implications of fasting. So it's a long topics, but I'm going to try to finish on time. So this is the, I mean, these guidelines of 2021 of Ramadan and diabetes guideline by IDF and D.A.R. is a very useful document and which really summarizes the management of this problem very nicely and with all the data that has, is there in the literature. So first the Ramadan overview. Ramadan is, fasting is one of the five pillars of Islam and is observed as a holy month and fasting during a month is compulsory for the adults who are healthy. The, this occurrence of Ramadan is about 10 year, 10 days earlier every year from the usual solar month, solar year that we follow. The adults who observe Ramadan fast from sunrise to sunset, we call it sahur, the sun, before the sun, sunrise and iftar it's sunset. And this duration, we can vary from up to two hours, 20 hours really in, in, in summer and can be shortened in the winter. So, and depends upon which part of the world you're residing. So there are about 150 million of Muslims worldwide as estimated to have type 2 diabetes. The global population is 1.9 billion of Muslims worldwide, which is about 25% of the global population. 8.8% of these populations estimated to have diabetes type 2. And 90% of these diabetes is type 2 of all, of all the types. So more than 150 million patients are there with Muslim patients who are likely to fast and those are in the adult age range of 20 to 79. If you see that the maximum population of Muslims are in the Asia-Pacific region, about 62 percent, followed by the MENA region, which is about 20 percent and then the sub-Saharan Africa. The Europe is 2.7 and the rest of the world is, has got a very small population of Muslim countries. So these are, this is sort of more of a problem of the developing world. So now coming on to this, this topic, the epidemiology of diabetes and fasting. There were hardly any studies before the start of this century. The first of this was to the Epidioris study, which was published in 2004, which is the largest with about 12,914 study participants. Then came the CREED study, which was published in 2015. This was only on type 2 diabetics with 3,777 participants, followed by DAR MENA and the DAR Global Survey. So these are the four important epidemiological studies of diabetes and fasting. I don't know whether you can see from there, from the back, but this is about type 2 diabetes. From these studies, the demographics and the clinical characteristics from these studies. Most of the patients who were fasting in type 2 diabetics, the duration of diabetes was about 7.6 to 8, up to 10 years of a duration of diabetes. The HbA1c were mostly 8, around 8 percentage. And the duration of fast that was more than 27 days of fasting in most of these studies. And they had some complications as well in this cohort of patients that were studied in these four studies. And if you come to type 1 diabetes, the numbers were much smaller. Obviously, type 1 diabetes is not that common. The fasting for 30 days was seen in a very small percentage of patients with diabetes type 1. The duration was about 10 to 14 years of diabetes duration. And those who fasted for more than 15 days were 23 and above. So there are a lot of patients who fasted in type 1 diabetes, despite that they come into the category of high-risk patients. So we need to understand this, that the type 1 diabetics are fasting, despite that we are not recommending at the moment, because of being at the high risk. If you look at the physiology of fasting in healthy individuals, because of the fasting, the insulin secretions decrease, and the glucagon secretion increase, which has an effect on the liver, which causes glycogenolysis and gluconeogenesis, leading to rise in the blood sugar levels to maintain it. And then because of the glucose levels can fall because of no eating, then the adrenal glands can secrete the epinephrine, which has an effect on the different parts of the body, including the liver, which stimulates the gluconeogenesis. So this is how fasting is affecting the physiology in healthy individuals. And if you look at the diabetics, both in type 1 and type 2, because of the deficiency of insulin or the insulin resistance, they are more likely to develop ketogenesis, particularly the type 1 diabetes, leading to ketoacidosis. So these are the changes that are happening in the physiological process in diabetics who are fasting. Now coming on to this 24-hour continuous glucose monitoring profile from a study in which there were 56 patients, and you can see that if you compare with those who were fasting as against those non-fasting, there were two peaks in these patients who are fasting. One is after iftar and the other is after sahur or sehr, so as compared to those who were non-fasting. So we need to be aware of this and this is very obvious. So basically pathophysiology of fasting in diabetics is we can lead to hyperglycemia or we can have ketoacidosis or we can have hypoglycemia because of the medications that the patient is on. How does fasting affect the metabolism in diabetes? This is from the Epidiary study. You can see that the weight, body weight, was unchanged in about 54 percent. Some of them had a loss about 27 and some of them also had a gain of weight. Increased risk of hyperglycemia and hyperglycemia was observed. Physical activity was unchanged in about more than 50 percent of the patients. Some of them decreased the physical activity during the month of fasting. And there were some positive effects on the lipids as well. So, I mean the prolonged fasting is a challenge in the treatment of patients with diabetes because of severe hypoglycemic risk, particularly in type 1, also in type 2, the dehydration and thrombosis and severe hyperglycemia is very rare and also the ketoacidosis. So these are the challenges of the treatment. So really for our patients to have a safe fasting, we need to do a risk calculation on them. This calculation can be based on the Ramadan related factors, for example, the length of the fasting hours. If somebody is staying in an area where the prolonged fasting of 20 hours is there, so that is an increase in the risk of these complications. There are diabetes related factors, for example, the type of diabetes, the duration of diabetes, the diabetic complications and so on and so forth. The factors concerning the individual, for example, if they have pregnancy or lactation is there or adolescence, gender, all these can have effects really in in the calculation of the risk. So the DARMINA and the IDF have come up with this calculation of risk or risk stratification on the basis of various factors that have been shown here. For example, if you see that the presence of hypoglycemic unawareness is given a 6.5 point. So this is a quite a good highest point that has been given to them and similarly pregnancy not within target is given a point of 6.5. So the numbers have been given to these various factors and when you add up these factors numbers, you give a score to the patient. If the patient has a score of less than 3, they are categorized as low risk group. If they have a score of 3.5 to 6, they are a moderate risk and if they have a score of more than 6, they are in the high risk category. So if you look at the medical and religious risk score recommendation, those who have got low risk medical recommendation is fasting is probably safe. Those who have got a moderate risk, the fasting safety is uncertain and those who have got a high risk fasting is probably unsafe and you can look at the religious recommendation as well, which has been provided by the Mufti. In which you can see that those who have got low risk of fasting is obligatory unless there is a specific reason not to fast. Those who have got moderate risk, fasting is preferred, but patients may choose not to fast if they are concerned about their health. If the patient does fast, they must follow the medical recommendations. That is what the religious leaders are recommending and those who are in the high categories, the religious recommendation is also advising them not to fast. So prior to Ramadan, we do a pre-Ramadan education to them. First an assessment followed by a stratification and then an assessment and the education is directed at not just the risk calculations, but the role of the self-monitoring blood glucose, when to break the fast, when to exercise, fluid and meal planning and medication adjustment is the most important part of this pre-Ramadan assessment. So that involves taking a detailed history and other details obtained from the patients on which you would give them advice prior to Ramadan. So education prior to Ramadan is on six key areas, which includes the risk, stratification, blood glucose monitoring, fluid and dietary advice, exercise advice, medication adjustment and when to break the fast. So these are the seven times of the day that has recommended, but it is not necessary that each and every patient has to do seven times blood glucose monitoring during the month. It depends upon which type of diabetes they have, what are the comorbidities they have. At least they should do one before the start of Suhoor, one two hours after the Suhoor, pre-iftar and two hours after iftar. That's the minimum that most experts and these guidelines are recommending but up to seven times and especially when they are not feeling well that is also the time that they should check their blood sugars and let and we need to tell our patients that by doing the testings their fast is not affected by any means from religious point of view. So when to break the fast when the blood sugars are less than 70 they are advised to break the fast if the blood sugars exceed 300 milligrams they should break the fast and if they have symptoms of hyperglycemia or suffering from an acute illness they should break the fast. So these are the recommendations and after this Ramadan is over they should have a post Ramadan assessment as well. I've discussed about the timings the symptoms of hyperglycemia which is well aware to all of you so I'm not going to dwell on it. So now let's talk about the approach to management of type 2 diabetes during fasting. We have dealt with all this and now let's go to the medication adjustment. The metformin is the most commonly used oral antidiabetics at the moment I think in the world. If somebody is taking once daily dosing take it at iftar. If they are taking twice daily no dose modification is to take at iftar and suhoor so no issues with that. Those who are taking three times they should combine the afternoon dose with a dose taken at iftar and take one at suhoor and those who are taking more a controlled release or extended release preparation they should take it at iftar. So this is the recommendation for metformin. A-carbose there has been no randomized controlled trial on A-carbose but because the way it works it is it is safe and no dose modification is required. They should take it at sehar and iftar during the month of Ramadan even if they are taking it two or three times a day. Glutazones due to the low risk of hyperglycemia with piaglutazone no dose modification is recommended. Individuals should not be switched to this class of medication close to Ramadan because it may take up to three months for the optimal anti-hyperglycemic effect to happen. So it is recommended that if you want to shift it to this medication do it many months before the start of Ramadan. GLP-1-aseptagon is as long as the dose modification and titration has been done a few weeks before the start of Ramadan no further treatment is recommended during the first fasting months and they can safely take it while they are fasting. GFP-4 inhibitors, as the previous speaker has already discussed, are very safe medications. Four are randomized controlled trials and five observational studies have examined the efficacy and safety of this group of drug and they do not require any adjustment or modification during Ramadan. SGLT-2, because SGLT-2 leads to volume depletion and increased urination, we have to be careful about this group of drug, particularly if your patient is in a area where there is a very hot climate. So be aware of that but generally speaking it is that it has a low risk of hyperglycemia and no dose adjustment is required during Ramadan, preferably to be taken at the time of iftar and increasing the fluid intake during the non-fasting hour is recommended for these patients. Sulfonylurea, once daily, if the patient has got very good control of diabetes, the dose may be reduced and they should take it at iftar. If they are taking twice daily dosing of the sulfonylureas, the dose that they are taking in the morning should be reduced, the evening dose should be the same for iftar time. Second generation and the third generation sulfonylureas are preferred. The older generation, like glimiculamide, should not be used for those who are fasting because of the risk of increased hyperglycemia. So now coming on to the insulin dosage, those who are on basal insulin, if the diabetes is well controlled, the dose should be reduced by about 15 to 30 percent and that has to be individualized and to be taken at iftar or the usual nighttime if they are taking it about 10 p.m. Most of my patients are taking it about 10 p.m. so that is okay. For those who are on twice a daily NPH as a basal insulin, the NPH at iftar should be the same as the evening one but the morning NPH should be reduced by 50 percent. Those who are on short acting insulin, they have to omit the one at lunch because they will not be taking lunch and the sehat dose may be reduced depending upon the amount of food that they are taking at sehat or sahur by about 25 to 50 percent and those changes to pre-mixed insulin because those who are on pre-mixed insulin usually taken twice a day but if somebody is taking once a day, it should be taken at iftar time. Those who are taking twice a day should reduce the morning dose which they should take at sehat by about 20 to 50 percent and those who are taking three times, some of them are taking three times, should omit the noon time pre-mixed insulin. Coming on to type one, fasting Ramadan for people with type 1 diabetes is generally associated with high risk of hyperglycemia and hyperglycemia. With well-structured pre-ramadan education program, the risk of fasting can be reduced and suitable individuals can be allowed to fast under strict monitoring after appropriate insulin dose adjustment. Insulin analogs are preferred over the regular insulins or conventional insulins if fasting is considered. Frequent self-monitoring of blood glucose is essential and if feasible through continuous glucose monitoring or flash glucose monitoring. Advanced insulin technologies such as the pumps is promising in allowing for safe fasting in type 1 diabetics. There is a lack of research and guidance for adults with type 1 diabetes that are seeking to fast during Ramadan and further research needs to be conducted in this age group. Those who are on insulin pump, their basal insulin dose should be reduced by 20 to 35 percent about four to five hours before iftar and increase the dose of the basal insulin by 10 to 30 percent after iftar up to midnight because that's the time when we are expecting the blood sugars to be higher. Prandial insulin should be calculated in the basis of the ICI insulin carbohydrate ratio and insulin sensitivity factor. Fasting in pregnancy, though the religion allows the pregnant ladies not to fast and they can do the fasting once after they have delivered, but if some of them insist we should be telling them and should be guiding them as well so that they have a safe fasting. Many pregnant women with pre-existing diabetes or GDM are considered a high risk for the fasting during Ramadan. Patient education prior to Ramadan is very important to ensure mother and fetus safety. Regular SMBG should be conducted at least once before the sunset meal, one to two hours after meals, once while fasting and any time feeling unwell. So this is the minimum that has to be done and the dose has to be adjusted prior to the onset of Ramadan. Pregnant women must understand that regardless of their fasting status they need to sustain the standard blood glucose levels of target of pregnancy, fasting of 70 to 95 and post-prandial of less than 120. So this is a tight target to achieve. Pregnant women must also understand that during pregnancy they should break their fast if any of the blood sugars fall below 70, feeling unwell or reduce fetal movement. So that's again something they should know that that is a recommendation that they should stop or break the fast. Coming on to the last part of my talk cardiovascular, cerebrovascular, renal implications of fasting. Congestive cardiac failure. A multi-center study in the Gulf region found no difference in hospital admission for heart failure in patients with diabetes who fast during Ramadan and outside of Ramadan. So that was a retrospective review from the same. So these are two studies that I'm quoting here. In a stroke there was a study in a cross-sectional and longitudinal study and found no difference in admission due to stroke in Ramadan and after Ramadan. But Yazdin et al found contrarily that fasting was associated with a higher risk. So there's one study that shows a higher risk of stroke as well. So by and large safety is there but hydration is very important for these group of patients so that they are because they have got increased risk of thrombosis. Coming on to acute coronary syndrome, evidence suggests no clear association between fasting during Ramadan and increase in ACS, acute coronary syndrome. In fact for us these two authors have found a significant reduction in acute coronary syndrome during Ramadan. Coming on to renal function, some studies showed that higher the stage of CKD the worse the renal outcome during Ramadan. But contrarily there's some studies showing improvement in EHFR. Meta-analysis conducted on mean difference of EGFR during and after the Ramadan found no clear difference between the EGFRs during the Ramadan and after the Ramadan. But during the calculation, the stratification and the calculation of the score, those who have got an EGFR of less than 30 have given a score of 6.5. So there comes into the high risk. So to summarize my talk, fasting in Ramadan is obligatory for all adults except elderly pregnant ladies and those who are not well. Metabolic benefits have been proven in the studies. Pre-Ramadan assessment is very vital for any patients who intend to fast. Risk stratification followed by education. Pre-Ramadan adjustment of oral antidiabetics and insulin is very important and the newer oral antidiabetics are associated with lower risk of hyperglycemia and may be preferred during Ramadan. Patient classified as high risk including type 1 and pregnant women with diabetes. If they insist on fasting, need close medical supervision and focused Ramadan-specific education, there is emerging evidence that newer technologies such as insulin pump particularly the hybrid closed pump can help the type 1 diabetic patients to fast with fewer complications. A post-Ramadan assessment is important by the healthcare professionals and it should be stressed to the patient with diabetes that a safe one-year fast does not automatically make them a low risk for the next year. So with this I would like to end my talk. Thank you very much for a patient listening.

diabetes management

Ramadan fasting

pre-Ramadan education

medication adjustments

hypoglycemia risks

post-Ramadan assessment