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

Abstract

Background: Ramadan, the ninth month of the Islamic lunar calendar, is the holy month of fasting for adolescent and adult Muslims. Observance of Ramadan is considered obligatory for every healthy adult Muslim. During this time, Muslims refrain from eating, drinking, smoking, and administering oral or parenteral medications from sunrise to sunset daily for 28 to 30 days. Case summary: We evaluated the need for changes in basal insulin regimen in 5 patients (4 males and 1 female; age range, 15-19 years) with type 1 diabetes mellitus (T1DM) who fasted during Ramadan. The patients were receiving insulin pump therapy with regular human insulin and maintained weekly visits with their endocrinologist at The Chronic Care Center (Beirut, Lebanon). They were instructed to break the fast after any episode of hypoglycemia (finger stick glucose <70 mg/dL) or severe hyperglycemia (finger stick glucose ≥300 mg/dL or any hyperglycemia associated with presence of urine ketone bodies on urinary dipstick). Blood glucose concentrations did not change significantly with fasting. Finger stick blood glucose taken at 4-hour intervals decreased in the afternoon (at 4 pm) and increased in the evening and morning (10 pm and 8 am, respectively) during this month in 4 of 5 patients, while no significant change in circadian rhythm of finger stick blood glucose was observed in 1 patient. Based on the investigators' findings, the basal insulin requirement decreased by 5.5% to 25.0% (4 patients) or did not change (1 patient) during the fast. Changes in regimens, based on collaboration between the endocrinologist and diabetes educational nurse, were determined by blood glucose self-monitoring done at 4-hour intervals during the fasting period, pre-Suhur (predawn breakfast), and ≥2 hours after Iftar (evening fast-breaking meal). No cases of keto-acidosis or severe hypoglycemia were reported. Conclusion: These 5 adolescent and adult patients with T1DM who were using an insulin pump were able to fast during Ramadan without incidences of severe hypoglycemia or ketoacidosis by using close blood glucose self-monitoring and weekly follow-up with their endocrine team, which consisted of an endocrinologist, a registered nutritionist, and a diabetes educational nurse.