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Fasting during Ramadhan is obligatory for all healthy Muslims.1 Fasting will result in hypoinsulinemia and hyperglucagonemia.
Fasting can lead to excessive glycogenolysis, increased lipolysis and This can lead to excessive glycogenolysis, lipolysis and ketone
ketogenesis especially in patients with Type 1 Diabetes Mellitus body formation and eventually development of DKA.4
(T1DM).1 Gluconeogenesis &
The risk of Diabetic Ketoacidosis (DKA) in T1DM patient are increased ketogenesis Peripheral tissues
during fasting.1 Increased glucose uptake
Liver
The International Diabetes Federation – Diabetes and Ramadan (IDF-
Glucose
DAR) Practical Guidelines categorised T1DM patient in very high risk
group, so they must be advised not to fast.2
Glycogen stores depleted
Excessive breakdown Pancreas
A 24-year-old male was brought to emergency department with a Insulin secretion
gradual decreased of consciousness, vomit, and shortness of breath. decreased or absent
He had T1DM since 15 years ago and routinely used Detemir 12 iu at
night and Aspart 6 iu three times daily before meal. IDF-DAR Practical Guidelines categorised people with diabetes into
He performed Ramadhan fasting for 10 days and decreased the three risk groups (very high, high, and moderate/low risk).2
dosage of the insulin by himself.
He had experienced a similar incident (DKA) 3 months before • Severe hypoglycemia within 3 months prior to
Ramadan
Ramadan with poor glycemic control (HbA1C 12.7%).
• Unexplained DKA within 3 months prior to
Ramadan
• Hyperosmolar hyperglycemic coma within 3
Very months prior to Ramadan
High • History of recurrent hypoglycemia
Weight : 57 kg Risk • Poorly controlled T1DM
Height : 162 cm Groups • Acute Illness
BMI : 21,72 kg/m2 • Pregnancy in pre-existing diabetes or Gestational
Diabetes
Somnolence, GCS 345 • Chronic dialysis or CKG stage 4 & 5
Blood pressure 120/70 mmHg
• Advanced macrovascular complications
• Old age with ill health
Tachycardia 112 bpm
People with poorly controlled T1DM must be advised not to fast.
Tachypneu 26 tpm (kussmaul) If they insist on Ramadhan fasting, then they should :
Receive structured education
Be followed by a qualified diabetes team
Laboratory Result Laboratory Result Check their blood glucose regularly (Self Monitored Blood
Glucose)
Hb 13.7 g/dL Natrium 126 mmol/L
Adjust medication dose as per recommendation
Leucocyte 19,720 /µL Kalium 5,13 mmol/L Be prepared to break the fast in case of hypo- or
Random blood 1,130 Chloride 75 mmol/L hyperglycemia
glucose mg/dL Be prepared to stop the fast in case of frequent hypo- or
HbA1c 13.6% Osmolality 328 mOsm/L hyperglycemia or worsening of other related medical
6.3 conditions.2
Keton Serum
BGA : Ph 7.18 ; HCO3 7.4 mmol/L ; PCO2 19.4 mmHg Recommended Timings to Check Blood Glucose Levels during
Anion Gap 43.6 Ramadan Fasting3
3
Conclusion : High anion gap metabolic acidosis 1. Pre-dawn meal (suhoor) DAY 4
2. Morning 2
Diagnosis : Type 1 diabetes with severe DKA 3. Midday Suhoor 5 Iftar
7
precipitating factor : Ramadhan Fasting 4. Mid-afternoon 1
6
5. Pre-sunset meal (iftar)
Rehydration NIGHT
6. 2-hour after iftar
Continuous IV insulin 7. At any time when there are
Kalium Correction symptoms of hypoglycemia/
Subcutaneous insulin basal bolus hyperglycemia or feeling
unwell
DKA was resolved All patients should break their fast if :
25 1,130 1,250
20.5 •Blood glucose <70mg/dl (re-check within 1 hour)
20 1,000 •Blood glucose >300mg/dl
15
15 750 •Symptoms of hypoglycemia or acute illness occur.2
13
10 500
7.4
5 3.47 250
5.13 137
0 •A pre-Ramadhan assessment is vital for patient with poorly-
Day 1 Day 2 Day 3 Day 4 Discharged controlled T1DM, who are classified as very high risk group.
•They must be advised not to fast. Close medical supervision is
GCS Blood glucose (mg/dL) HCO3 (mmol/L) Potassium (mmol/L)
needed if they insist on Ramadan fasting.
1. Hassanein M, Al-Arouj M, Hamdy O, Bebakar W, Jabbar A, Al-Madani A, et al Diabetes and Ramadan: Practical guidelines. International Diabetes Federation (IDF), in
collaboration with the Diabetes and Ramadan (DAR) International Alliance. 2016:1-141
2. Hui E, Bravis V, Hassanein M, Hanif W, Malik R, Chowdury T, et al. Management of people with Diabetes wanting to fast during Ramadan. BMJ 2010;340:c3053. doi:
10.1136/bmj.c3053
3. Ibrahim M, Abu Al, Magd M, Annabi FA, Asaad-Khalil S, Ba-Essa E, et al. Recommendations for management of diabetes during Ramadan: update 2015. BMJ Open Diabetes
Research and Care 2015;3: e000108. doi:10.1136/bmjdrc-2015-000108
4. Karamat M, Syed A, Hanif W. Review of Diabetes management and guidelines during Ramadan. J R Soc Med 2010: 103: 139-147.