Introduction: Fasting and Islamic Legal Concessions for Diabetic Patients
Today, we discuss a vital and beneficial topic for everyone, especially with the increasing cases of diabetes and the frequent questions patients ask before Ramadan about whether they can fast or not. We always mention the noble verse in Surah Al-Baqarah: "The month of Ramadan in which was revealed the Qur'an, a guidance for mankind and clear proofs of guidance and distinction. So whoever sights [the new moon of] the month, let him fast it; and whoever is ill or on a journey - then an equal number of other days." (2:185)
Allah, the Most High, wants ease for us and does not want hardship for us. Religion came to make things easier, not to make them difficult. As it was said in the hadith: "No one has made the religion burdensome but it will overcome him." Therefore, if there are Islamic legal concessions for the sick, it is better to take them, and this is the essence of this lecture.
Statistics on Fasting for Diabetic Patients (DAR Study)
Studies (such as the "Diabetes and Ramadan - DAR" group) indicate that in 2010, there were approximately 132 million Muslim diabetics, and it was found that around 100 million of them fast during Ramadan, with the vast majority fasting for more than 15 days.
Therefore, global medical associations strive to issue medical guidelines to ensure "safe fasting" without harm. One of the important studies is the EPIDIAR study, which was conducted in 13 Islamic countries and showed that 43% of type 1 diabetics and 80% of type 2 diabetics fast during Ramadan, placing a great responsibility on doctors to guide these patients.
Benefits and Risks of Fasting for Diabetic Patients
Fasting is essentially "intermittent fasting," a system that Muslims have practiced for 1400 years. If the patient follows healthy principles, fasting can lead to:
- Weight loss.
- Improved blood sugar control and HbA1C levels.
- Improved cholesterol levels and liver fats.
However, there are obstacles and risks facing patients, especially those taking insulin or medications that stimulate its release. Studies have shown that patients over the age of 65 are the most likely to visit the emergency room due to hypoglycemia, reaching up to 12%.
Potential Complications During Fasting:
- Hypoglycemia: Medically known as blood sugar levels dropping below 70 mg/dL. It is dangerous for the heart and brain.
- Hyperglycemia: If blood sugar exceeds 300 mg/dL, which may lead to dehydration.
- Diabetic Ketoacidosis (DKA): Especially in type 1 diabetes.
- Dehydration and Blood Clots: Fasting for long hours (13-14 hours) in hot weather increases blood viscosity. Since diabetes is a condition that increases the likelihood of clotting (hypercoagulable state), dehydration can lead to venous or cerebral clots.
Risk Assessment: Who Should Break Their Fast?
Global associations categorize diabetic patients into risk categories based on the danger of fasting for them using tools such as the DAR Risk Score:
1. Very High-Risk Category (Should Not Fast):
- Those who have experienced severe hypoglycemia leading to hospitalization shortly before Ramadan.
- Those suffering from "hypoglycemia unawareness."
- Those who have experienced DKA or ketoacidosis within 3 months before Ramadan.
- Uncontrolled type 1 diabetics.
- Patients with acute illnesses (recent stroke, kidney failure, dialysis).
- Pregnant women with diabetes who are treated with insulin.
2. Moderate and Low-Risk Categories:
- Patients whose blood sugar is well-controlled (HbA1C less than 8%).
- Those treated with medications that do not cause hypoglycemia (such as metformin or DPP-4 inhibitors).
Importance of Health Education Before Ramadan (Diabetes Education)
Studies, such as the READ Program, have shown that educating patients four weeks before Ramadan on how to check blood sugar, adjust medications, and manage their diet, reduces the incidence of hypoglycemia by 44%. In contrast, the rate of complications increases by 75% in patients who did not receive this education.
Unfortunately, a study in 2014 showed that doctors' own knowledge about fasting advice was inconsistent, with 63% of doctors advising type 1 diabetics to fast despite the risks. This necessitated the launch of global awareness campaigns for both doctors and patients to ensure "safe fasting."
When and How Should Patients Check Their Blood Sugar During Ramadan?
Measuring blood sugar is crucial for managing diabetes during fasting. We advise patients to check their blood sugar at the following critical times:
- Immediately before breaking the fast: If blood sugar is less than 70 mg/dL, the patient should break their fast immediately, even if there is only one hour left until the call to prayer, to avoid severe hypoglycemia.
- After Taraweeh prayer: As it is a physical activity that may lead to a drop in blood sugar.
- Upon waking up in the morning (around 10 AM): If the patient finds their blood sugar between 70 and 90 mg/dL and they are taking medications that stimulate insulin, it is best for them to break their fast as they will certainly experience hypoglycemia before the end of the day.
- At any time they feel symptoms of hypoglycemia: Such as shaking, sweating, headache, or blurred vision.
Golden Rule: The patient should break their fast immediately if their blood sugar is less than 70 mg/dL or more than 300 mg/dL (to avoid dehydration and diabetic ketoacidosis).
Physical Activity and Exercise
Light exercise is acceptable and considered part of the recommended physical activity, especially in countries that perform 20 rak'ahs of Taraweeh prayer, which involves bowing, prostrating, and movement. However, intense sports and running should be completely avoided during fasting hours and are best practiced two hours after breaking the fast.
Adjusting Oral Medication Doses During Ramadan
Based on the 2020 guidelines published in the BMJ, here is how to handle different drug groups:
1. Safe Medications (Do Not Cause Hypoglycemia):
- Metformin: Does not require dose adjustment, but if the patient takes 3 tablets a day, it is preferable to take 2 (one at iftar and one at suhoor). For the extended-release type (XR), it is taken once at iftar.
- DPP-4 Inhibitors (e.g., Januvia, Galvus, Trajenta): Very safe and do not require dose adjustment. They can be started even just before Ramadan.
- SGLT2 Inhibitors (e.g., Forxiga, Jardiance): Do not cause hypoglycemia, but it is preferable to take them at iftar rather than suhoor to reduce urination and dehydration during the day. (Note: Do not start them for the first time just before Ramadan).
2. Insulin-Stimulating Medications (Sulfonylureas):
These medications (such as Amaryl and Diamicron) carry a high risk of hypoglycemia:
- If blood sugar is well-controlled, it is preferable to switch the patient to safer medications.
- If continued, the suhoor dose should be reduced by 50% or completely stopped if the dose is small, while maintaining the full iftar dose.
Adjusting Insulin Doses During Ramadan
Adjusting insulin requires extreme caution:
- Long-acting insulin (Base Insulin such as Lantus, Toujeo): The dose is reduced by 15% to 30% and taken at suhoor (pre-dawn meal).
- Pre-mixed insulin (such as Mixtard): If the patient takes two doses, they take the full suhoor dose and reduce the iftar (sunset meal) dose by 50%.
- Rapid-acting insulin: Taken with meals (iftar and suhoor), and the lunch dose is completely canceled.
Final advice: It is always preferable to switch from pre-mixed (cloudy) insulin to a Base-Bolus system, i.e., long-acting insulin with rapid-acting insulin at meals, as it is safer and causes less frequent hypoglycemia.
[All praise is due to God]