Safety of Ramadan fasting in young patients with type 1 diabetes: A systematic review and meta‐analysis

Abstract

Aims/IntroductionAlthough patients with type 1 diabetes are medically exempt, many insist on fasting during Ramadan. Multiple daily insulin injections (MDI), premixed insulin and continuous subcutaneous insulin infusion (CSII) are commonly used. To date, little is known about the safety of Ramadan fasting in these patients.Materials and MethodsWe pooled data from 17 observational studies involving 1,699 patients treated with either CSII or non‐CSII (including premixed and MDI) regimen. The study outcomes were the frequencies of hypoglycemia, hyperglycemia and/or ketosis. Given the lack of patient‐level data, separate analyses for premixed and MDI regimen were not carried out.ResultsThe CSII‐treated group (n = 203) was older (22.9 ± 6.9 vs 17.8 ± 4.0 years), and had longer diabetes duration (116.7 ± 66.5 vs 74.8 ± 59.2 months) and lower glycated hemoglobin (7.8 ± 1.1% vs 9.1 ± 2.0%) at baseline than the non‐CSII‐treated group (n = 1,496). The non‐CSII‐treated group had less non‐severe hypoglycemia than the CSII‐treated group (22%, 95% CI 13–34 vs 35%, 95% CI 17–55). Of the non‐CSII‐treated group, 7.1% (95% CI 5.8–8.5) developed severe hypoglycemia, but none from the CSII‐treated group did. The non‐CSII‐treated group was more likely to develop hyperglycemia (12%, 95% CI 3–25 vs 8.8%, 95% CI 0–31) and ketosis (2.5%, 95% CI 1.0–4.6 vs 1.6%, 95% CI 0.1–4.7), and discontinue fasting (55%, 95% CI 34–76 vs 31%, 95% CI 9–60) than the CSII‐treated group.Conclusions The CSII regimen had lower rates of severe hypoglycemia and hyperglycemia/ketosis, but a higher rate of non‐severe hyperglycemia than premixed/MDI regimens. These suggest that appropriate patient selection with regular, supervised fine‐tuning of the basal insulin rate with intensive glucose monitoring might mitigate the residual hypoglycemia risk during Ramadan.

Ramadan fasting in people with type 1 diabetes during COVID-19 pandemic: The DaR Global survey

“…About 62% participants with T1DM (64% for the <18 years and 61% for those 18 or older) fasted for at least 15 days in this survey. Several studies indicated that some people with T1DM, including many adolescents, can fast when empowered with the appropriate patient education, blood glucose monitoring, insulin dose adjustment, and support by experts in the field, which collectively can lead to safer fasting during Ramadan [12] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] .…”

Ramadan and Diabetes: A Narrative Review and Practice Update

“…Continuous subcutaneous insulin infusion (CSII) via insulin pumps enables different levels of basal insulin delivery to be programmed and for smaller bolus doses, thereby allowing for flexibility in settings, such as for fasting, as well as small changes for those are insulin sensitive. A multicentre study comparing CSII with multiple dose insulin (MDI) and a recent systematic review comparing CSII with MDI/premixed insulin regimens have shown lower rates of severe hyperglycaemia/ hypoglycaemia and ketosis with CSII [108,109], better glucose variability and better adherence to fasting [108]. Other studies have demonstrated that patients on CSII can safely fast during Ramadan if they have adequate pre-Ramadan education [110], with minimal adverse events such as hypoglycaemia or DKA [83,111,112].…”

Type 1 diabetes mellitus in children: experience in Indonesia

“…If hypoglycemia occurs, the child should break the fast regardless of the time (28). Aside from changes in meal schedules, other changes in the patients' daily routines such as sleep-wake cycles also need to be considered in disease management during Ramadan (29).…”