Saturday, July 19, 2014

Management of Diabetes Patients During the Fasting Month

I have quite a few Muslim patients, mainly those from the Middle East. And it always surprises them when I show a little awareness of what they have to go through during the month of Ramadan. After all, in the USA there is much ignorance about Islam, and being raised in Malaysia we've certainly had our share of exposure.
Obviously, the glycemic management of a person who is fasting for religious or medical reasons will change. And so, these perhaps might be some helpful tips:
  • When fasting, one should not take any oral hypoglycemics. This refers to the sulfonylureas like glyburide, glipizide and glimepiride. These are 'blind' secretagogues- you take the pill, you will make insulin- whether or not you need it
  • It should still be OK to continue metformin and incretimimetics like Sitagliptin, Linagliptin, or the injectables like Exenatide or Liraglutide. After all, one 'defect' in type 2 diabetes is excess hepatic gluconeogenesis even when one is fasting- so it is often helpful keeping patients on these. And recall these medications do not cause hypoglycemia (as even for the incretimimetics, the insulin secretion is glucose-dependent) so it will be safe, even if one is not taking any caloric intake
  • For insulin users, it is often OK to continue the basal insulin like Glargine or Detemir. If the dose was appropriate to begin with, there should be no need to even reduce the basal insulin though the truth is many overdose their basal insulin to partially compensate for meals. And so it might be prudent to advise a 10-20% reduction in the basal insulin dose when one is fasting
  • For rapid-acting insulin (Aspart, Glulisine, Lispro) users, recall there are two parts to this: the nutritional dose, and the 'sliding scale' or correctional dose (though in reality it's all given the same time). And so when one is fasting and not consuming any carbs, then it's logical to skip the nutritional portion- but if the blood glucose is high, then it's still OK to give the correctional dose of this
  • Same goes for insulin pump users: when one is fasting, just leave the pump running on basal insulin. May need to bolus for hyperglycemia; but obviously there should be no carb boluses. Again, in these patients there should be no need for reduction in the basal settings in the fasting state, though if one notices a decrease of >20 mg/dL/hour of glucose on the basal insulin alone, this suggests that the basal rate should be reduced anyway
And so, these are some tips that might be helpful in the management of patients with diabetes. It is also prudent to advise patients to carry glucose tabs even if one plans to fast, in case one experiences hypoglycemia.

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