Focus on diabetes and Ramadan
Ramadan is just two months away – the perfect time to assess and advise your patients with diabetes who wish to observe the Ramadan fast. In the latest EASD e-Learning module, Dr Ehtasham Ahmad focuses on applying the principles set out in ADA/EASD consensus recommendations for type 2 diabetes to the management of people with type 2 diabetes during Ramadan.
The Qur’an requires Muslims to fast during the month of Ramadan from sunrise to sunset and although people with a chronic medical condition such as diabetes are exempt from fasting, many wish to do so. It is important, therefore, that their healthcare team supports them to do so safely. EASD e-Learning now has an extensive course, with several modules covering various aspects of this challenge. The starting point for the latest of these, which launches today, is the 2018 ADA/EASD consensus report on the management of type 2 diabetes (including the 2019 update). It is written and presented by Dr Ehtasham Ahmad, Clinical Research Fellow in Diabetes at the University of Leicester.
As Ehtasham explains at the start of his module: “A key focus of the ADA/EASD consensus report was on lifestyle management and diabetes education and support. According to the report, the goals of care of diabetes revolve around the prevention of complications and maintaining a good quality of life. In order to facilitate that, it is important to assess key patient characteristics and consider specific factors that might impact your choice of therapy. It is important and crucial to take patients and their family on board with all decision making and implement a safe and effective management plan. Set realistic targets for your patient, provide ongoing support and agree on any management decisions. We believe that these principles set out in the decision cycle are pertinent to all aspects of diabetes care, and Ramadan does not need to be an exception here. It is crucial to remember that the goals of management of type 2 diabetes during the month of Ramadan are the same as during non-fasting days. That is: to prevent any decline in glycaemic control, prevent the development of complications and maintain a good quality of life.”
From this first principle flows a powerful and detailed adaptation of the much-cited ADA/EASD decision cycle, applying the same principles to people with diabetes who wish to fast during Ramadan. This decision cycle forms the first half of the module. As Ehtasham explains: “We should support our patients with diabetes who decide to fast during Ramadan, even though diabetes is considered an exemption from fasting. Healthcare professionals working in diabetes should use the principles set out in the decision cycle adapted from the ADA/EASD consensus recommendations to help your patients fast safely during Ramadan.”
The second part of the module is taken up with another key focus of the ADA/EASD consensus report: the role of novel antihyperglycaemic drugs, namely SGLT-2 inhibitors and GLP-1 receptor agonists. Says Ehtasham: “The ADA and EASD recommend early addition of these agents after lifestyle and metformin, particularly for individuals who have high risk or established cardiovascular disease, heart failure or chronic kidney disease. So we also recommend continuing with these agents during Ramadan for people planning to fast who are already established on these agents. But we advise against introducing these agents as a new therapy immediately before the start of Ramadan or during the month of Ramadan, to avoid any complications from developing. We know that the SGLT-2 inhibitors can increase the risk of dehydration and postural hypotension. And similarly, GLP-1 receptor agonists can increase the risk of GI side effects, mainly nausea and vomiting. So, you don’t want your patient to start experiencing nausea and vomiting with the potential risk of dehydration if they start a GLP-1 receptor agonist during the month of Ramadan.”
Which brings us back to the central importance of risk stratifying patients and making management decisions during pre-Ramadan counseling. “Pre-Ramadan counselling is an essential component for successful implementation of this decision cycle,” says Ehtasham. “This should focus around Ramadan-specific factors like self-monitoring of blood glucose, risk of hypoglycaemia, the complexity of your regimen, while bearing in mind the duration of fasting and the cost of medications. Patients and their families should be involved when making those decisions, bearing in mind their cultural and religious beliefs, with agreement on mutual goals and a strategy for implementation. This pre-Ramadan assessment should happen at least one to two months prior to the start of Ramadan – which gives you ample opportunity to start a new medication, if needed.”
Enrol on the latest module in our ‘Diabetes and Ramadan’ course, ‘Module 7: Applying ADA/EASD recommendations to the management of type 2 diabetes during Ramadan’
Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.