|Year : 2017 | Volume
| Issue : 1 | Page : 11-18
Diabetes and Ramadan: A concise and practical update
Mohamed H Ahmed1, Nazik Elmalaika Husain2, Wadie M Elmadhoun3, Sufian K Noor4, Abbas A Khalil5, Ahmed O Almobarak6
1 Department of Medicine and HIV Metabolic Clinic, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes, Buckinghamshire, UK
2 Department of Pathology, Faculty of Medicine and Health Sciences, Omdurman Islamic University, Khartoum, Sudan
3 Department of Pathology, Faculty of Medicine and Health Sciences, Nile Valley University, Atbara, Sudan
4 Department of Medicine, Faculty of Medicine and Health Sciences, Nile Valley University, Atbara, Sudan
5 Department of Surgery, Whiston Hospital, Merseyside, UK
6 Department of Pathology, Faculty of Medicine, University of Medical Sciences and Technology, Khartoum, Sudan
|Date of Web Publication||18-Sep-2017|
Mohamed H Ahmed
Department of Medicine and HIV Metabolic Clinic, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes, Buckinghamshire
Source of Support: None, Conflict of Interest: None
Despite the fact that the month of Ramadan includes 29–30 days and the duration of fasting for each day can last for between 12 and 16 h, it was estimated that a large number of individuals with diabetes do fast during Ramadan. In light of recent advancement of new pharmacological agents, drugs such as vildagliptin, sitagliptin, and liraglutide were found to be safe to use during this month of fasting. These therapeutic agents can also be used in combination with metformin. The use of sulfonylureas, in most of the recent guidelines about diabetes and Ramadan, seems not to gain much support due to the risk of hypoglycemia. In this review, we also addressed the use of insulin injection, insulin pump, and education before, during, and after Ramadan. Further research is needed to determine (i) the therapeutic benefit of new antidiabetic agents and (ii) the benefit of new technologies for the treatment of diabetes.
Keywords: Diabetes, fasting, Ramadan
|How to cite this article:|
Ahmed MH, Husain NE, Elmadhoun WM, Noor SK, Khalil AA, Almobarak AO. Diabetes and Ramadan: A concise and practical update. J Family Med Prim Care 2017;6:11-8
|How to cite this URL:|
Ahmed MH, Husain NE, Elmadhoun WM, Noor SK, Khalil AA, Almobarak AO. Diabetes and Ramadan: A concise and practical update. J Family Med Prim Care [serial online] 2017 [cited 2020 Feb 18];6:11-8. Available from: http://www.jfmpc.com/text.asp?2017/6/1/11/214964
| Introduction|| |
The month of Ramadan is a special occasion for all Muslims worldwide as it is the month of fasting. During fasting, Muslims abstain from all sort of oral intakes including medication. The duration of fasting starts before the beginning of dawn and ends with dusk, and this would explain the difference in hours of fasting in different parts of the world. Importantly, it was estimated that around 79% of individuals with type 2 diabetes are likely to fast. It is important to mention that the Quran has made a clear exemption for the sick, elderly, travelers, children, expectant, and breastfeeding mothers not to fast during Ramadan.
Due to the complexity of the management of diabetes during Ramadan, the understanding of the pathophysiology of fasting with diabetes is important for the treating physician. The main concerns in fasting are hypoglycemia, hyperglycemia, dehydration, and ketoacidosis. Therefore, education about physical activity, food consumption, and medication adjustment is crucial to guard against complications. Before addressing the issues of treatment and patient education, we provide a comprehensive review of the major biochemical and physiological changes associated with fasting.
| Biochemical and Physiological Changes during Fasting|| |
Several studies have shown that fasting is associated with significant changes in the biochemical parameters among individuals with diabetes. For example, among 1301 participants with diabetes in one study, HbA1c, lipid profile, arterial blood pressure, and uric acid were significantly lower during Ramadan as compared to other periods of the year. One may conclude from the above that fasting may, in fact, be beneficial for the health of some individuals with diabetes.
Interestingly, no marked changes were observed in the mean glucose level, episodes of hypoglycemia, and mean glycemic excursion changes when continuous glucose monitoring among individuals with diabetes during Ramadan was applied. Furthermore, fasting in individuals with diabetes was shown to have improved leptin, adiponectin, and insulin sensitivity.,,, Inflammatory markers were also shown to have diminished with plasma homocysteine, D-dimer level, C-reactive protein, interleukin-6, and fibrinogen being reduced during fasting., The improvement in cardiovascular and inflammatory markers may be in part attributed to decrease total calorie intake and, hence, weight reduction.,, The incidence of significant hypoglycemia and hyperglycemia in Type 2 diabetics is low as demonstrated in the study that continuously monitored blood glucose levels in Type 2-affected individuals. However, any individuals with diabetes should be educated to remain vigilant for these complications.
Ramadan is considered a month of celebration for many Muslims globally. It is with this state of ecstasy that the month carries the paradoxical risk of food excess after the hours of fasting. This is of particular importance to those individuals with fasting with diabetes. Therefore, its not surprising that excess intake of fat and carbohydrate during the night coupled with the decreased physical activity during the day were found to be associated with weight gain during Ramadan. [Table 1] displays the physiological and biochemical changes associated with fasting.
|Table 1: Summary of the biochemical and physiological changes associated with Ramadan fasting|
Click here to view
Understanding the physiological and biochemical changes associated with fasting Ramadan allows a better understanding of the management approaches and application of new therapeutic agents.
| Patient Education before, during, and after Ramadan|| |
The purpose of patient education, clinical evaluation, and open reflections is, thus, to ensure patient's safety while fasting.,, It is important to emphasize that dietary counseling and education of patients are associated with a significant reduction of acute complications. For instance, the impact of individualized education before Ramadan was evaluated in individuals with Type 2 diabetes (774 individuals, from Egypt, Iran, Jordan, and Saudi Arabia). In this study, 67% received an individualized education (about nutrition, physical activity, drug adjustment, and glucose monitoring) and 33% received usual care. It was concluded that this particular study showed that individualized education improved safety during Ramadan in terms of decreasing hypoglycemic events, improved diabetes control, and prompted weight loss. Interestingly, in a small pilot study, telemonitoring was also shown to be of potential benefit in decreasing metabolic complications associated with Ramadan fasting, particularly hypoglycemia. The physician can also educate patient about that exemption from fasting is possible in case fasting will worsen the health of the individuals and this in-line with Islamic Fiqh (Islamic jurisprudence). Therefore, patient education is very important to achieve safe fasting and health-care providers are required to pass necessary information (guidelines, leaflets translated into different languages, and use of telemedicine)., Involvement of all health practitioners may be another mean of providing safe education. For instance, pharmacists well trained about the management of diabetes during Ramadan may also contribute to patient education, especially in heavily populated or remote areas. An integrated approach addressing the management of Type 1 and Type 2 diabetes is provided in [Table 2].
|Table 2: Summary of management of both Type 1 and 2 diabetes during Ramadan|
Click here to view
The International Group for Diabetes and Ramadan recommended (2015 guidelines) that Taraweeh prayers should be regarded as a physical exercise with the potential to induce dehydration and hypoglycemia. The Taraweeh prayers are long night prayers that last for 1–2 h and are performed during each day of the entire month of Ramadan. Therefore, individuals with diabetes are advised to drink plenty of water and to guard against hypoglycemia. Dates, a customary fruit that Muslims break their fast with, are regarded as having a low glycemic index and may result in possible improvement of glucose and lipid profile and possible reduction in cardiovascular risk factors.,,, It is important that physicians should advise individuals with diabetes about the risk of developing hyperglycemia after Ramadan. Ramadan is followed by a 3-day festival known as Eid al-Fitr. This festival is usually celebrated with sweets and gifts and the potential for high calorific intake. It is, therefore, important that physicians should also emphasize the importance of resuming medications as normal and not in reduced doses.
Type 2 diabetes
The main concern with therapeutic agents during Ramadan was hypoglycemia.,, Therefore, individualized education and medication adjustment are crucial to ensure safe fasting. In the following discussion, we have included tables that provide a quick summary of medications and related studies, while in the text, we have provided the general consensus about whether to use or not to use these medications during Ramadan. [Table 3] provides a list of studies about the use of sulfonylureas, biguanides, alpha-glucosidase inhibitors, thiazolidinediones, and meglitinides while [Table 4] provides a list of studies about the use of incretins and glucagon-like peptide-1 (GLP-1) agonists.
|Table 3: Summary of studies about the use of sulfonylureas, biguanide, alpha-glucosidase inhibitors, thiazolidinediones, and meglitinides during the fasting month of Ramadan|
Click here to view
|Table 4: The recent therapeutic agents introduced for treatment of Type 2 diabetes|
Click here to view
| General Consensus about Therapeutic Agents during Ramadan|| |
We have included this guide consensus reached by the International Group for Diabetes and Ramadan published periodically in 2005, 2010, and 2015.,, We have also included recommendations from the South Asian Consensus Guidelines published in 2012. In addition, we also searched MEDLINE for clinical trials during Ramadan, clinical reviews, and systemic reviews. For ease of reading, we have summarized the majority of these studies in the [Table 2],[Table 3],[Table 4] and only included general consensus in the following discussion.
Due to the risk of hypoglycemia associated with sulfonylureas, some guidelines did not recommend them and others suggested to use them with caution during Ramadan. The only sulfonylurea associated with a minimum risk of hypoglycemia is gliclazide.
There is general agreement in all published studies that metformin can be safely used during Ramadan; however, dose reduction is needed [Table 2].
Despite the low incidence of hypoglycemia with glitazones during Ramadan, their use is not widely recommended due to their side effects, for example, water retention, risk of heart failure, and weight gain.
Meglitinides are safe to be used during Ramadan, and there is no risk of hypoglycemia.
Hypoglycemia is not a serious issue but is limited use due to gastrointestinal side effects. There were no randomized clinical trials available.
Dipeptidyl peptidase-4 inhibitors
There is general agreement that vildagliptin or sitagliptin as monotherapy is safe during fasting. They can be added to metformin and very low risk of hypoglycemia.
Glucagon-like peptide-1 mimetics
Due to the absence of hypoglycemia associated with the injection of exenatide and liraglutide, they can have a potential for safe use during Ramadan. In a randomized controlled trial, liraglutide in comparison to sulfonylurea is well tolerated during Ramadan and may be an effective therapy in combination with metformin in achieving glycemic control, with low risk of hypoglycemia and adequate weight loss. It is plausible to suggest that emerging evidence supports the use of GLP-1 receptor agonists during fasting, albeit further evidence is needed.
Insulin and type 2 diabetes
The administration of long-acting insulin and mixed insulin is shown to be safe in individuals with Type 2 diabetes. For instance, premixed insulin (25% insulin lispro and 75% neutral protamine lispro) can be given with the sunset meal and half the usual evening dose to be used with the predawn meal (suhoor)., Long-acting insulin-like glargine can be given as a single injection and this can be administered with short-acting insulin or metformin.
Type 1 diabetes
Due to the high risk of hypoglycemia, hyperglycemia, and diabetic ketoacidosis, individuals with Type 1 diabetes may find fasting challenging, especially those with poor diabetes control and comorbidities., Long-acting insulin use such as glargine is associated with fewer episodes of hypoglycemia, and the use of basal bolus regimen is preferred as compared with the conventional twice daily insulin regimen.,, However, studies have shown that NovoMix insulin has been used in Ramadan with some success. For instance, 100% of the pre-Ramadan dose of 70/30 mix insulin corresponding with the sunset meal (iftar) and 50% at a predawn meal would produce good results. Furthermore, the use of 70% of intermediate-acting insulin and 30% of short-acting insulin with two meals is also shown to be safe and episodes of serious hypoglycemia or ketoacidosis were observed., Further research is needed to evaluate the safety of insulin pump during fasting.
Several studies have shown the potential benefit of insulin pump during the fasting month. In adolescents with Type 1 diabetes, the use of subcutaneous insulin infusion (continuous subcutaneous insulin infusion) was associated with less hypoglycemia and improvement in diabetes control. Interestingly, case series studies in adolescents and adults with Type 1 diabetes mellitus receiving insulin pump therapy during fasting showed fewer hypoglycemia episodes and adequate glycemic control. The use of highly advanced insulin pumps or artificial pancreas may provide an excellent opportunity for individuals with diabetes to fast without the risk of hypoglycemia. For instance, the new MiniMed 640G insulin pump is designed to sense hypoglycemia before it occurs and suspends insulin infusion delivery immediately. Less advanced pump such as Medtronic insulin pump, which stops insulin infusion when prespecified sensor glucose threshold is reached, has shown potential benefit. For instance, in a study of 49 patients fasted, the use of insulin pump was associated with less severe hypoglycemia and average diabetes control, no deterioration in diabetes control. In a prospective observational, single-center study, the use of insulin pump was not associated with a change in insulin administrated, no major hypoglycemia event, and stable glycemic control. Due to high cost, an insulin pump is not widely used.
| New Pharmacological Agents for Diabetes and Their Potential Role during Ramadan Fasting|| |
Within the last 5 years, several pharmacological agents for the treatment of diabetes were discovered. Importantly, the main potential benefits of all these medications are a lower risk of hypoglycemia (insulin glargine 300, inhaled insulin - Afrezza, SGLT2 inhibitors, insulin degludec, and IDegLira [insulin degludec + liraglutide]). Therefore, we recommend that clinical studies in the future may reveal which of these medications can be safely used during Ramadan fasting.
| Pregnancy, Diabetes, and Fasting|| |
Currently, there is no scientific evidence to recommend fasting for pregnant women with diabetes. The Islamic Holy texts also exempt pregnant and lactating women from fasting.
| Conclusion|| |
In recent years, numerous studies about diabetes and Ramadan fasting were published. The dipeptidyl peptidase-4 inhibitors such as sitagliptin and vildagliptin are associated with less risk of hypoglycemia without significant hyperglycemia during Ramadan. In addition, these agents can also be safely used alongside metformin. The use of sulfonylureas is not widely endorsed in the recent guidelines due to the risk of hypoglycemia. The use of liraglutide is so far appeared to be potentially safe therapy during Ramadan, but as yet there is one study about using liraglutide during Ramadan. Administration of the long-acting insulin such as glargine has shown potential benefit in selected patients with diabetes. An insulin pump can potentially enhance patients' chances to fast Ramadan without significant risks. There are still a lot of unanswered questions about the new therapeutic treatments for diabetes and Ramadan; therefore, further research is needed to evaluate the therapeutic benefit of these agents.
We are thankful to our families and children during the time of preparation of this review. We are also indebted to authors of articles that we cited in this study.
Financial support and sponsorship
Patients Helping Fund-Khartoum, Sudan.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Salti I, Bénard E, Detournay B, Bianchi-Biscay M, Le Brigand C, Voinet C, et al.
A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: Results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care 2004;27:2306-11.
The Holy Quran. Surat 2 (Sūrat al-Baqarah) verses 183-185.
Ahmad J, Pathan MF, Jaleel MA, Fathima FN, Raza SA, Khan AK, et al.
Diabetic emergencies including hypoglycemia during Ramadan. Indian J Endocrinol Metab 2012;16:512-5.
Bener A, Yousafzai MT. Effect of Ramadan fasting on diabetes mellitus: A population-based study in Qatar. J Egypt Public Health Assoc 2014;89:47-52.
Lessan N, Hannoun Z, Hasan H, Barakat MT. Glucose excursions and glycaemic control during Ramadan fasting in diabetic patients: Insights from continuous glucose monitoring (CGM). Diabetes Metab 2015;41:28-36.
Shariatpanahi ZV, Shariatpanahi MV, Shahbazi S, Hossaini A, Abadi A. Effect of Ramadan fasting on some indices of insulin resistance and components of the metabolic syndrome in healthy male adults. Br J Nutr 2008;100:147-51.
Bouhlel E, Denguezli M, Zaouali M, Tabka Z, Shephard RJ. Ramadan fastings effect on plasma leptin, adiponectin concentrations, and body composition in trained young men. Int J Sport Nutr Exerc Metab 2008;18:617-27.
Haghdoost AA, Poorranjbar M. The interaction between physical activity and fasting on the serum lipid profile during Ramadan. Singapore Med J 2009;50:897-901.
Lamri-Senhadji MY, El Kebir B, Belleville J, Bouchenak M. Assessment of dietary consumption and time-course of changes in serum lipids and lipoproteins before, during and after Ramadan in young Algerian adults. Singapore Med J 2009;50:288-94.
Aksungar FB, Eren A, Ure S, Teskin O, Ates G. Effects of intermittent fasting on serum lipid levels, coagulation status and plasma homocysteine levels. Ann Nutr Metab 2005;49:77-82.
Aksungar FB, Topkaya AE, Akyildiz M. Interleukin-6, C-reactive protein and biochemical parameters during prolonged intermittent fasting. Ann Nutr Metab 2007;51:88-95.
Khaled BM, Belbraouet S. Effect of Ramadan fasting on anthropometric parameters and food consumption in 276 type 2 diabetic obese women. Int J Diabetes Dev Ctries 2009;29:62-8.
Khaled MB, Belbraouet S. Ramadan fasting diet entailed a lipid metabolic disorder among type 2 diabetic obese women. Am J Appl Sci 2009;6:471-7.
Bonakdaran SH, Khajeh-Dalouie M. The effects of fasting during Ramadan on glycemic excursions detected by continuous glucose monitoring system (CGMS) in patients with type 2 diabetes. Med J Malaysia 2011;66:447-50.
Vasan SK, Karol R, Mahendri NV, Arulappan N, Jacob JJ, Thomas N. A prospective assessment of dietary patterns in Muslim subjects with type 2 diabetes who undertake fasting during Ramadan. Indian J Endocrinol Metab 2012;16:552-7.
Bakhotmah BA. The puzzle of self-reported weight gain in a month of fasting (Ramadan) among a cohort of Saudi families in Jeddah, Western Saudi Arabia. Nutr J 2011;10:84.
Kul S, Savas E, Öztürk ZA, Karadag G. Does Ramadan fasting alter body weight and blood lipids and fasting blood glucose in a healthy population? A meta-analysis. J Relig Health 2014;53:929-42.
Al-Hader AF, Abu-Farsakh NA, Khatib SY, Hasan ZA. The effects of Ramadan fasting on certain biochemical parameters in normal subjects and in type II diabetic patients. Ann Saudi Med 1994;14:139-41.
Wilcox G. Insulin and insulin resistance. Clin Biochem Rev 2005;26:19-39.
Gnanou JV, Caszo BA, Khalil KM, Abdullah SL, Knight VF, Bidin MZ. Effects of Ramadan fasting on glucose homeostasis and adiponectin levels in healthy adult males. J Diabetes Metab Disord 2015;14:55.
Adlouni A, Ghalim N, Benslimane A, Lecerf JM, Saile R. Fasting during Ramadan induces a marked increase in high-density lipoprotein cholesterol and decrease in low-density lipoprotein cholesterol. Ann Nutr Metab 1997;41:242-9.
Maislos M, Khamaysi N, Assali A, Abou-Rabiah Y, Zvili I, Shany S. Marked increase in plasma high-density-lipoprotein cholesterol after prolonged fasting during Ramadan. Am J Clin Nutr 1993;57:640-2.
Qujeq D, Bijani K, Kalavi K, Mohiti J, Aliakbarpour H. Effects of Ramadan fasting on serum low-density and high-density lipoprotein-cholesterol concentrations. Ann Saudi Med 2002;22:297-9.
Faris MA, Kacimi S, Al-Kurd RA, Fararjeh MA, Bustanji YK, Mohammad MK, et al.
Intermittent fasting during Ramadan attenuates proinflammatory cytokines and immune cells in healthy subjects. Nutr Res 2012;32:947-55.
Salim I, Al Suwaidi J, Ghadban W, Alkilani H, Salam AM. Impact of religious Ramadan fasting on cardiovascular disease: A systematic review of the literature. Curr Med Res Opin 2013;29:343-54.
Sweileh N, Schnitzler A, Hunter GR, Davis B. Body composition and energy metabolism in resting and exercising muslims during Ramadan fast. J Sports Med Phys Fitness 1992;32:156-63.
Caglayan EK, Göçmen AY, Delibas N. Effects of long-term fasting on female hormone levels: Ramadan model. Clin Exp Obstet Gynecol 2014;41:17-9.
Temizhan A, Dönderici O, Ouz D, Demirbas B. Is there any effect of Ramadan fasting on acute coronary heart disease events? Int J Cardiol 1999;70:149-53.
Siddiqui QA, Sabir S, Subhan MM. The effect of Ramadan fasting on spirometry in healthy subjects. Respirology 2005;10:525-8.
Subhan MM, Siddiqui QA, Khan MN, Sabir S. Does Ramadan fasting affect expiratory flow rates in healthy subjects? Saudi Med J 2006;27:1656-60.
Fariduddin M, Mahtab H, Latif ZA, Siddiqui NI. Practical management of diabetes during Ramadan fasting. Mymensingh Med J 2011;20:541-6.
Jaleel MA, Raza SA, Fathima FN, Jaleel BN. Ramadan and diabetes: As-Saum (The fasting). Indian J Endocrinol Metab 2011;15:268-73.
Fatim J, Karoli R, Chandra A, Naqvi N. Attitudinal determinants of fasting in type 2 diabetes mellitus patients during Ramadan. J Assoc Physicians India 2011;59:630-4.
Ahmedani MY, Haque MS, Basit A, Fawwad A, Alvi SF. Ramadan Prospective Diabetes Study: The role of drug dosage and timing alteration, active glucose monitoring and patient education. Diabet Med 2012;29:709-15.
McEwen LN, Ibrahim M, Ali NM, Assaad-Khalil SH, Tantawi HR, Nasr G, et al.
Impact of an individualized type 2 diabetes education program on clinical outcomes during Ramadan. BMJ Open Diabetes Res Care 2015;3:e000111.
Lee JY, Lee SW, Nasir NH, How S, Tan CS, Wong CP. Diabetes telemonitoring reduces the risk of hypoglycaemia during Ramadan: A pilot randomized controlled study. Diabet Med 2015;32:1658-61.
Suliman M, Abdu T, Elhadd T, Ibrahim S, Hassanein M, Ahmed MH, et al
. Diabetes and fasting in Ramadan: Can we provide evidence-based advice to patients? Sudan Med J 2010;46:4-14.
Hassan A, Meo SA, Usmani AM, Shaikh TJ. Diabetes during Ramadan – PRE-approach model: Presentation, risk stratification, education. Eur Rev Med Pharmacol Sci 2014;18:1798-805.
Chamsi-Pasha H, Aljabri KS. The diabetic patient in Ramadan. Avicenna J Med 2014;4:29-33.
] [Full text]
Wilbur K, Al Tawengi K, Remoden E. Diabetes patient management by pharmacists during Ramadan. BMC Health Serv Res 2014;14:117.
Ibrahim M, Abu Al Magd M, Annabi FA, Assaad-Khalil S, Ba-Essa EM, Fahdil I, et al.
Recommendations for management of diabetes during Ramadan: Update 2015. BMJ Open Diabetes Res Care 2015;3:e000108.
Alkaabi JM, Al-Dabbagh B, Ahmad S, Saadi HF, Gariballa S, Ghazali MA. Glycemic indices of five varieties of dates in healthy and diabetic subjects. Nutr J 2011;10:59.
Miller CJ, Dunn EV, Hashim IB. Glycemic index of 3 varieties of dates. Saudi Med J 2002;23:536-8.
Al-Farsi MA, Lee CY. Nutritional and functional properties of dates: A review. Crit Rev Food Sci Nutr 2008;48:877-87.
Atkinson FS, Foster-Powell K, Brand-Miller JC. International tables of glycemic index and glycemic load values: 2008. Diabetes Care 2008;31:2281-3.
Zargar AH, Siraj M, Jawa AA, Hasan M, Mahtab H. Maintenance of glycaemic control with the evening administration of a long acting sulphonylurea in male type 2 diabetic patients undertaking the Ramadan fast. Int J Clin Pract 2010;64:1090-4.
Schernthaner G, Grimaldi A, Di Mario U, Drzewoski J, Kempler P, Kvapil M, et al.
GUIDE study: Double-blind comparison of once-daily gliclazide MR and glimepiride in type 2 diabetic patients. Eur J Clin Invest 2004;34:535-42.
Glimepiride in Ramadan (GLIRA) Study Group. The efficacy and safety of glimepiride in the management of type 2 diabetes in Muslim patients during Ramadan. Diabetes Care 2005;28:421-2.
Anwar A, Azmi KN, Hamidon BB, Khalid BA. An open label comparative study of glimepiride versus repaglinide in type 2 diabetes mellitus Muslim subjects during the month of Ramadan. Med J Malaysia 2006;61:28-35.
Al-Arouj M, Bouguerra R, Buse J, Hafez S, Hassanein M, Ibrahim MA, et al.
Recommendations for management of diabetes during Ramadan. Diabetes Care 2005;28:2305-11.
Belkhadir J, el Ghomari H, Klöcker N, Mikou A, Nasciri M, Sabri M. Muslims with non-insulin dependent diabetes fasting during Ramadan: Treatment with glibenclamide. BMJ 1993;307:292-5.
Bakiner O, Ertorer ME, Bozkirli E, Tutuncu NB, Demirag NG. Repaglinide plus single-dose insulin glargine: A safe regimen for low-risk type 2 diabetic patients who insist on fasting in Ramadan. Acta Diabetol 2009;46:63-5.
Mafauzy M. Repaglinide versus glibenclamide treatment of Type 2 diabetes during Ramadan fasting. Diabetes Res Clin Pract 2002;58:45-53.
Cesur M, Corapcioglu D, Gursoy A, Gonen S, Ozduman M, Emral R, et al.
A comparison of glycemic effects of glimepiride, repaglinide, and insulin glargine in type 2 diabetes mellitus during Ramadan fasting. Diabetes Res Clin Pract 2007;75:141-7.
Mbanya JC, Al-Sifri S, Abdel-Rahim A, Satman I. Incidence of hypoglycemia in patients with type 2 diabetes treated with gliclazide versus DPP-4 inhibitors during Ramadan: A meta-analytical approach. Diabetes Res Clin Pract 2015;109:226-32.
Mahar SA, Hasan MI, Khan MI, Fawwad A, Hussain S, Maheshwary N, et al.
Comparison of hypoglycaemia episodes in people with type-2 diabetes fasting in Ramazan, treated with vildaglipton or sulphonylurea: Results of the Pakistani cohort of the VIRTUE study. J Pak Med Assoc 2014;64:1297-302.
Al-Arouj M, Hassoun AA, Medlej R, Pathan MF, Shaltout I, Chawla MS, et al.
The effect of vildagliptin relative to sulphonylureas in Muslim patients with type 2 diabetes fasting during Ramadan: The VIRTUE study. Int J Clin Pract 2013;67:957-63.
Hassanein M, Abdallah K, Schweizer A. A double-blind, randomized trial, including frequent patient-physician contacts and Ramadan-focused advice, assessing vildagliptin and gliclazide in patients with type 2 diabetes fasting during Ramadan: The STEADFAST study. Vasc Health Risk Manag 2014;10:319-26.
Shete A, Shaikh A, Nayeem KJ, Rodrigues L, Ali MS, Shah P, et al.
Vildagliptin vs sulfonylurea in Indian Muslim diabetes patients fasting during Ramadan. World J Diabetes 2013;4:358-64.
Devendra D, Gohel B, Bravis V, Hui E, Salih S, Mehar S, et al.
Vildagliptin therapy and hypoglycaemia in Muslim type 2 diabetes patients during Ramadan. Int J Clin Pract 2009;63:1446-50.
Aravind SR, Ismail SB, Balamurugan R, Gupta JB, Wadhwa T, Loh SM, et al.
Hypoglycemia in patients with type 2 diabetes from India and Malaysia treated with sitagliptin or a sulfonylurea during Ramadan: A randomized, pragmatic study. Curr Med Res Opin 2012;28:1289-96.
Al Sifri S, Basiounny A, Echtay A, Al Omari M, Harman-Boehm I, Kaddaha G, et al.
The incidence of hypoglycaemia in Muslim patients with type 2 diabetes treated with sitagliptin or a sulphonylurea during Ramadan: A randomised trial. Int J Clin Pract 2011;65:1132-40.
Hanif W, Malik W, Hassanein M, Kamal A, Geransar P, Andrews C, et al.
Treatment adherence with vildagliptin compared to sulphonylurea as add-on to metformin in Muslim patients with type 2 diabetes mellitus fasting during Ramadan. Curr Med Res Opin 2013;29:807-11.
Halimi S, Levy M, Huet D, Quéré S, Dejager S. Experience with vildagliptin in type 2 diabetic patients fasting during Ramadan in France: Insights from the VERDI study. Diabetes Ther 2013;4:385-98.
Brady EM, Davies MJ, Gray LJ, Saeed MA, Smith D, Hanif W, et al.
A randomized controlled trial comparing the GLP-1 receptor agonist liraglutide to a sulphonylurea as add on to metformin in patients with established type 2 diabetes during Ramadan: The Treat 4 Ramadan Trial. Diabetes Obes Metab 2014;16:527-36.
Pathan MF, Sahay RK, Zargar AH, Raza SA, Khan AK, Siddiqui NI, et al.
South Asian Consensus Guideline: Use of GLP-1 analogue therapy in diabetes during Ramadan. Indian J Endocrinol Metab 2012;16:525-7.
Mattoo V, Milicevic Z, Malone JK, Schwarzenhofer M, Ekangaki A, Levitt LK, et al.
A comparison of insulin lispro Mix 25 and human insulin 30/70 in the treatment of type 2 diabetes during Ramadan. Diabetes Res Clin Pract 2003;59:137-43.
Mucha GT, Merkel S, Thomas W, Bantle JP. Fasting and insulin glargine in individuals with type 1 diabetes. Diabetes Care 2004;27:1209-10.
Kobeissy A, Zantout MS, Azar ST. Suggested insulin regimens for patients with type 1 diabetes mellitus who wish to fast during the month of Ramadan. Clin Ther 2008;30:1408-15.
Azar ST, Khairallah WG, Merheb MT, Zantout MS, Fliti F. Insulin therapy during Ramadan fast for patients with type 1 diabetes mellitus. J Med Liban 2008;56:46.
Kassem HS, Zantout MS, Azar ST. Insulin therapy during Ramadan fast for Type 1 diabetes patients. J Endocrinol Invest 2005;28:802-5.
Kadiri A, Al-Nakhi A, El-Ghazali S, Jabbar A, Al Arouj M, Akram J, et al.
Treatment of type 1 diabetes with insulin lispro during Ramadan. Diabetes Metab 2001;27(4 Pt 1):482-6.
Reiter J, Wexler ID, Shehadeh N, Tzur A, Zangen D. Type 1 diabetes and prolonged fasting. Diabet Med 2007;24:436-9.
Bin-Abbas BS. Insulin pump therapy during Ramadan fasting in type 1 diabetic adolescents. Ann Saudi Med 2008;28:305-6.
] [Full text]
Hawli YM, Zantout MS, Azar ST. Adjusting the basal insulin regimen of patients with type 1 diabetes mellitus receiving insulin pump therapy during the Ramadan fast: A case series in adolescents and adults. Curr Ther Res Clin Exp 2009;70:29-34.
Benbarka MM, Khalil AB, Beshyah SA, Marjei S, Awad SA. Insulin pump therapy in Moslem patients with type 1 diabetes during Ramadan fasting: An observational report. Diabetes Technol Ther 2010;12:287-90.
Khalil AB, Beshyah SA, Abu Awad SM, Benbarka MM, Haddad M, Al-Hassan D, et al.
Ramadan fasting in diabetes patients on insulin pump therapy augmented by continuous glucose monitoring: An observational real-life study. Diabetes Technol Ther 2012;14:813-8.
[Table 1], [Table 2], [Table 3], [Table 4]