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Assessing care plans for patients with type 2 diabetes practicing religious and cultural fasting

17 Jan 2020 1:28 PM | Anonymous

Author: Lourdes M. Vega, PharmD; St. Louis College of Pharmacy/Department of Public Health PGY1 Pharmacy Resident

Mentor: Justinne Guyton, PharmD, BCACP; St. Louis College of Pharmacy Associate Professor of Pharmacy Practice, PGY1 Pharmacy Residency Program Director

Introduction

Fasting practices vary significantly between religious and cultural backgrounds, regions, families, and persons, ranging from giving up a specific food or ingredient to abstaining from food and water entirely. A prolonged fast is defined as abstinence from all food for greater than eight hours while awake. This prolonged fast comes with risk when practiced by patients with type 2 diabetes and is an opportunity for a pharmacist to reevaluate pharmacotherapy selection.1

Risks and Complications Associated with Prolonged Fasting

Continuous glucose monitoring of patients with diabetes practicing prolonged daytime fasting over four weeks revealed dangerously low drops in blood glucose between meals followed by dangerously high spikes after consumption of the meal that breaks the fast.2 During prolonged periods without food, glycogen stores are depleted, increasing the risk for hypoglycemia. Additionally, this risk is furthered with strenuous activity performed throughout the fast. On the other hand, hyperglycemia, due to eating large, frequently carbohydrate-heavy meals to break the daily fast can also be problematic for the patient. In some extreme cases, diabetic ketoacidosis (DKA) can occur. Because of the often drastic changes in caloric consumption, a previously therapeutic medication plan can become dangerous or ineffective during a prolonged fast. Along with complications from changes in eating patterns, some fasting practices refrain from intake of water increasing the risk for dehydration and associated complications.

Assessing and Adjusting Care Plans

Pre-Fast Assessment:

Patients who fast without a fasting-focused education program have a fourfold increase in hypoglycemia than those who do not, and unfortunately the majority of primary care providers do not routinely inquire about fasting practices.3, 4 The American Diabetes Association (ADA) and International Diabetes Federation (IDF)/ Diabetes and Ramadan (DAR) International Alliance provide recommendations for patients who fast during Ramadan. The data from this population can be applied to others who also fast for a prolonged period. Recommendations include performing a pre-fast assessment in any patient intending to participate in a prolonged fast six to eight weeks prior to the fast. This should include performing a risk stratification based on the following: medical history, diabetes medications, fasting duration and type, experience during previous fast, and ability to detect and treat hypoglycemia.5, 6

Education:

Fasting-focused education should include discussion about monitoring blood glucose, diet, exercise, and breaking the fast when needed. Significant times to check blood glucose include mid-fast, pre-prandial, post-prandial, and any time the patient identifies symptoms of hypo- or hyperglycemia. All meals should begin with intake of water or non-sugary drinks and contain a balance of carbohydrates, protein and fat. Exercise should not be increased during fasting periods and if participating in strenuous activity, hydration and consumption of carbohydrates should be stressed. All patients should be educated on recognizing signs and symptoms of hypoglycemia and the importance of breaking the fast if needed to treat hypoglycemia.

Non-Insulin Medication Adjustment:

Hypoglycemia risk as well as effect on glycemic control during fasting periods must be considered to ensure safe and effective therapy. Most non-insulin diabetes therapies, with the exception of sulfonylureas, carry a low hypoglycemic risk and do not require adjustment in patients participating in 8-12 hour daily fasts. Sulfonylureas, however, carry a moderate to high hypoglycemia risk. When possible, a second generation agent should be used. In patients who receive a sulfonylurea once daily, the full dose should be taken with the post-fast meal. If the diabetes is well controlled, it is appropriate to decrease the dose during the fasting period. In patients who receive twice daily dosing, the total daily dose should be continued and split equally between the two meals. If the patient’s diabetes is well controlled, the dose taken with the pre-fast meal in the morning should be decreased.5,6

Another strategy to avoid hypoglycemia that has been evaluated is to switch from a sulfonylurea to an agent with a lower hypoglycemia risk. In a study by Wan Seman et al., 110 patients receiving metformin and a sulfonylurea who fasted during Ramadan were randomized to continue their current therapy or switch to a combination of dapagliflozin and metformin therapy. Six weeks after the switch and at the end of the fast, the rate of hypoglycemia was 19.2% in the sulfonylurea group compared to 3.4% in the dapagliflozin group (p=0.008). There was no significant difference in change in A1c between the two groups from baseline to 10 to 12 weeks of therapy (p= 0.174). The authors concluded that switching from a sulfonylurea to dapagliflozin decreased hypoglycemic events through Ramadan without compensating glycemic control. Although effective in reducing hypoglycemia, cost and the general impracticality of switching solely during fasting periods should be considered. 7

Insulin Adjustments

Adjustments to insulin regimens vary based on the pre-fasting insulin regimen. In general, both basal and bolus regimens should be reviewed. The recommendations for these adjustments are largely based on data from those participating in a fast for Ramadan. Therefore, the adjustments recommended in Table 2 are based on those who eat a meal before sunrise, fast during the day, and have a meal after sunset. Ideally, those with diabetes will still be in contact with their providers to report their blood glucose log. Hypoglycemia, should still be managed with a 10-20% reduction in the insulin dose.


Conclusion

It is important that healthcare practitioners inquire about fasting practices while taking into consideration that various definitions and interpretations of a fast exist among different people. Characteristics of the fast, patient’s history, and the hypoglycemic profiles of the medications should be considered when assessing therapy. In patients participating in frequent, prolonged fasts, attention should be paid to medications that already have a higher risk of hypoglycemia such as sulfonylureas and insulin. There is data to suggest that short-term switches to oral agents with a low hypoglycemic profile, such as an SGLT-2 inhibitor might be an appropriate consideration. It may also be more practical to consider such a switch for the long-term, rather than the short-term. The practitioner should adjust insulin regimens to take into account the prolonged fast in the day based on the patients plans for a fast and agreement to continue to routinely check the blood glucose. Finally, this dialogue with the patient is crucial to avoid potentially life-threatening complications from unsafe fasting practices and should not be dependent on the patient initiating the conversation.

References

  1. Cryer PE, Davis SN. Hypoglycemia. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 20e New York, NY: McGraw-Hill; http://accesspharmacy.mhmedical.com/content.aspx?bookid=2129& sectionid=192288656.
  2. Lessan N, Hannoun Z, Hasan H, et al. Glucose excursions and glycaemic control during Ramadan fasting in diabetic patients: Insights from continuous glucose monitoring (CGM). Diabetes Metab. 2015;41:28–36.
  3. Bravis V, Hui E, Salih S et al. European implications of the READ (Ramadan focused Education and Awareness in Diabetes) programme [Abstract]. Diabetologia 2008; 51(Suppl.): S454.
  4. Ali M, Adams A, Hossain MA, et al. Primary care providers’ knowledge and practices of diabetes management during Ramadan. J Prim Care Community Health. 2016;7:33-7.
  5. International Diabetes Federation and the DAR International Alliance. Diabetes and Ramadan: Practical Guidelines. Brussels, Belgium: International Diabetes Federation, 2016. www.idf.org/guidelines/diabetes-in-ramadan and www.daralliance.org
  6. Al-Arouj M, Assad-Khalil S, Buse J, et al. Recommendations for Management of Diabetes During Ramadan Update 2010. Diabetes Care. 2010; 33(8): 1895-1902.
  7. Wan Seman WJ, Kori N, Rajoo S, et al. Switching from sulfonylurea to a sodium-glucose cotransporter2 inhibitor in the fasting month of Ramadan is associated with a reduction in hypoglycaemia. Diabetes Obes Metab. 2016;18(6):628-32.


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