A Ramadan Experience of a Patient with Newly Diagnosed Diabetes

Özet

asting during holy month ramadan has always been a debate between doctors and patients. While some doctors and even other healthcare providers prohibit this duty which is a whole month period every year for muslims all over the world, anxiety being loaded and further causing emotional stress to humankind may increase blood glucose, deteriorating diabetes control, as well (1). A 36-year-old male who has been diagnosed with diabetes a few weeks before the onset of ramadan this year admitted to general internal medicine outpatient setting with 350 mg/dl of postprandial glucose and hbA1c which is 11%. Since dual antihyperglycaemic therapy with metformin and sitagliptin could not bring numbers to considerable levels, bedtime insulin glargine was added to his current pills. Patient refused unfasting and then he was invited to our diabetes awareness program many times so as to keep him knowledgable about prolonged fasting and possible problems that may occur during fasting period and soon after iftar (supper) meal. The new regimen was regulated dividing insulin into two, lesser amount (1/3) being applied on sahur between midnight and sunrise around 3.00 am. Feed back scores revealed brilliant results without any hypoglycaemia with never over 140 mg/dl level of blood glucose readings, postprandially. 20th day of the fasting month insulin glargine was stopped and rest of the oral medications still kept the diabetes in control. On the second day of the Eid Fiest after meal glucose levels were still good in numbers and need of insulin or a third oral medication was not present which had been attributed to possible antiinflammatory effect of early initiation of insulin and/or beta-cell regeneration –though C-peptide level, not measured- provided by sitagliptin. Striking number of people with diabetes is on the rise in the middle east and some North African countries where muslim population is located. Holy month Ramadan in muslim calender is important owing to fasting-permission dialogue of those patients with diabetes to their doctors. This dialogue is considerably worth evaluation since prohibition even will further cause anxiety leading to deterioration of sugar readings. Yet, with current medications we have, will not be capable of giving permission to all our diabetes patients for fasting during ramadan. Those who are type 1, type 2 and on insulin therapy are at least may seem to be more risky. But those who are on metformin, or on a diet only will be safer. The purpose will be avoiding hypoglycaemia during the day and high postprandials especially during supper (iftar). Glucose numbers advised for our patients in our clinic is between 100-180 mg/dl during all the ramadan period. In type 2 patients who have already lost beta cells after 15-20 years may not respond to a combination therapy such as metformin and sulphonylureas although metformin may remain. In such case, insulin will be necessary so as to cover a 24 hour optimal glucose level. The patient history may have some limitations to discuss deeply here i.e; measurements of insulin resistance (fasting insulin), C-peptide, anti-GAD anti-bodies (LADA), and BUN, creatinine levels, etc. However, compliance of patients, regardless of their prior education level is poor in many occasions and so are the availability of those serum markers in our instutution where we take care of our patients. Age of 36 is somewhere between type1 (LADA) and type2 so a closer follow-up is a must in case orals are prescribed. Here, early insulinization and a succesful combination with a DPP-IV (di-peptidyl peptidase) inhibitor is emphasized which are ready to take part of sulphonylurea class anti-glycaemic medications by some diabetologists. Lesser hypoglycaemia seen with metformin, longer acting insulin analogueinsulin glargine and DPP-IV inhibitor may push these medications forward during ramadan diabetes management (2-4). This paper is designed as a shorter communication or/and editorial, rather than a case report which I do believe readers may not be disappointed. If one day, we will be able to stimulate beta cell genesis invivo and stimulate their action physiologically then this will meet the needs of those muslim diabetes population who desire fasting which will help decrease A1c level by providing low stress hormones due to satisfaction of the religious obligatory of those who are willing to fast during holy month ramadan.