Fasting Ramadan During COVID-19 Pandemic

Achmad Rudijanto

Endocrine and Metabolic Division of Internal Medicine Department

Faculty of Medicine Brawijaya University – Saiful Anwar Hospital
Malang
Topic of discussion

• Interrelation between DM and Covid-19.

• Potential pathogenic mechanisms in patients with T2DM and COVID-19
• Assessment of patients before and during Ramadan
• Risk score and risk categories
• Fasting Ramadan during sick days
• Blood glucose monitoring
• Pharmacotherapies for diabetes during COVID-19
• Time to be break the fasting
 Diabetes Mellitus and Covid-19
• People with diabetes (PWD) have been identified as being at increased
risk of serious illness from COVID-19.
• COVID-19 also presents substantial indirect risks to PWD through
disruptions in health care and lifestyle factors.
• A retrospective study of 451 people with COVID-19 with diabetes and/or
hyperglycaemia from the U.S. reported that people with uncontrolled
hyperglycaemia had longer length of stay and higher mortality
compared with people without diabetes or uncontrolled hyperglycaemia.
• Another retrospective study of people with type 2 diabetes from China
reported that well-controlled blood glucose correlated with improved
outcomes in infected patients.

Bode B, et al. J Diabetes Sci Technol.9 May 2020 [Epub ahead of print]. DOI: 10.1177/1932296820924469
Zhu L, et al. Cell Metab 2020;31:1068–1077
 Diabetes and COVID 19 Severity Meta‐analysis with forest plot
presenting the OR and 95% CI for
severity or mortality of COVID‐19
according to the presence of diabetes
mellitus

Favours Non- Favours Diabetes and COVID 19 Mortality

Severity Severity

de Almeida‐Pititto et al. Diabetol Metab Syndr (2020) 12:75 Favours Favours

https://doi.org/10.1186/s13098‐020‐00586‐4 Survival Mortality
 Survival of the Covid-19 patients with and
without diabetes.

28.8%
p <0.001

n=53

6.2%

n=24

Diabetes and/or uncontrolled No Diabetes or uncontrolled

hyperglycemia hyperglycemia

Bode B, et al. Journal of Shang J, et al. The American

Diabetes Science and Journal of Medicine (2021)
Technology (2020) 1:1–9 134:e6−e14
Potential Pathogenic Mechanism DM with Covid-19
Key risks associated with fasting for patients with diabetes (10\)

Hypoglycemia Hyperglycemia

Diabetic Dehydration
ketoacidosis and thrombosis

IDF – DAR Practice Guideline, 2016

Potential pathogenic mechanisms in patients with T2DM and COVID-19.

• Cardiovascular events
• Thromboembolism and DIC

Cardiovascular and Lim S, et al. NATURE REVIEWS | ENDOCRINOLOGY,

all-cause mortality 17:11-30, 2021
Patient Assessment
IDF-DAR Guideline, 2021
ASSESSMENT
FLOWCHART

To stratify risk and develop on individualized management

plan During Covid-19
Lung disease

Obesity
Hypertension
Smoking

IDF-DAR Guideline, 2021

ASSESSMENT
FLOWCHART

IDF-DAR Guideline, 2021

Risk Score and Categories
1. Type of DM
2. Duration of DM (years)
3. Presence of Hypoglycemia
4. Level of glycemic control
5. Type of treatment
6. SMBG
7. Acute complication
8. MVD complication
9. Renal complications/comorbidities
10. Pregnancy
11. Frailty and cognitive function
12. Physical labour
13. Previous Ramadan Experience
14. Fasting hours

IDF-DAR Guideline, 2021

Ramadan – Diabetes, Covid-19 ?

• First concern: SAFETY

• Risk of:
• Dehydration
• Hyperglycemic crisis
• Hypoglycemia
• Thrombosis
• Increased severity & mortality
• IDF-DAR 2016:
• Acute illness  very high risk
The IDF-DAR Practical Guidelines define three risk categories
for patients with diabetes (2016)
These risk categories take into account a more practical approach while recognising
the need to consider the everyday practice of many people with diabetes

Risk category Patient characteristics Comments

One or more of the following: If patients insist on fasting then they

•Severe hypoglycaemia within the 3 months prior to should:
Ramadan •Receive structured education
•DKA within the 3 months prior to Ramadan •Be followed by a qualified diabetes
•Hyperosmolar hypoglycaemic coma within the 3 months team
prior to Ramadan •Check their blood glucose regularly
•History of recurrent hypoglycaemia (SMBG)
Category 1: •Adjust medication dose as per
•History of hypoglycaemia unawareness
very high risk recommendations
•Poorly controlled T1DM
•Acute illness
Not to fast
•Pregnancy in pre-existing diabetes, or GDM treated with
insulin or SUs
•Be prepared to break the fast in
case of hypo- or hyperglycaemia
•Be prepared to stop the fast in case
•Chronic dialysis or CKD stage 4 & 5 of frequent hypo- or
•Advanced macrovascular complications hyperglycaemia or worsening of
•Old age with ill health other related medical conditions

*Level of glycaemic control to be agreed between physician and patient, according to multiple factors; CKD, chronic kidney disease; DAR, Diabetes and Ramadan
International Alliance; DKA, diabetic ketoacidosis; GDM, gestational diabetes mellitus; IDF, International Diabetes Federation; MDI, multiple dose insulin;
SMBG, self-monitoring of blood glucose; SU; sulphonylureas; T1DM, type 1 diabetes; T2DM, type 2 diabetes
 RISK LEVELS AND ASSOCIATED RECOMMENDATIONS

• Individuals who are in the high risk category should not fast.
• These individuals are of high-very high risk of developing complications when fasting
during Ramadan. We recommend that these individuals do not fast. If they do still insist
on fasting the utmost care and monitoring should be provided alongside the strategies
and recommendations mentioned above and in the other chapters of these guidelines.
• Those at the moderate risk level are advised not to fast.
• As previously mentioned, many of these patients will choose to fast anyway. This
important personal decision should be made after consideration of the associated risks in
consultation with HCPs. They also need to be aware of the techniques or strategies to
decrease this risk. If individuals choose to fast, then they would need to be cautious and
discontinue fasting if any problems arise.
• Those at the low risk level should be able to fast.
• These individuals are at a lower risk of in terms of complications arising when fasting
during Ramadan. However as mentioned, circumstances can change leading to a change
in the risk scoring. Therefore, risk stratification should be conducted annually to review
the level of risk in advance of Ramadan.
IDF-DAR Guideline, 2021
Key Components of
a Ramadan-focuses Educational Programs

IDF-DAR Guideline, 2021

Diabetes during sick days
What happens when people living with diabetes
are ill?
• When people living with diabetes are ill, their bodies react
by releasing hormones to fight the illness. These hormones
can be triggered by any number of conditions, such as
infections, cardiovascular ischaemic events, gastroenteritis,
dehydration etc.
• The hormones released during an illness raise blood sugar
levels and at the same time make it more difficult for
insulin to lower them. For people living with diabetes, even
a minor illness can lead to dangerously high blood sugar
levels. This may cause life-threatening complications, such
as diabetic ketoacidosis or a hyperosmolar hyperglycaemic
state.
General guidelines to manage diabetes during an illness
People with Type 2 Diabetes
People with Type 2 o People on oral diabetes treatment may have been provided
Diabetes should check with blood glucose testing equipment to ensure that their
whether they develop blood glucose levels do not fall too low (hypoglycaemia) and
the following symptoms to routinely monitor their diabetes.
which may be indicative o For those people, there is no need to test very often. During
of high blood sugar an illness, blood glucose levels usually rise.
levels: o People with T2D should use the test results as a guide and
aim to keep their blood glucose levels between 6 and 10
o Thirst/dry mouth mmol/l (110 and 180 mg/dl). They may need to test their
o Passing large amounts blood glucose levels at least twice a day.
or urine (this can lead o If the blood glucose levels get too high (over 15 mmol/l [270
to dehydration) mg/dl]), then they may need to perform a urine test for
o Tiredness ketones. If it is positive, they should contact their health-care
o Weight Loss provider for advice.
People with Type 1 Diabetes

Laffel LM, et al. Paediatric Diabetes October 2018; 19 (Suppl. 27): 193–204.
Blood Glucose Monitoring during Ramadan
Self-Monitoring of Blood Glucose (SMBG) – 7 point guide for Ramadan

Morning
Suhoor/Dawn

IDF-DAR Guideline, 2021

Mean continuous glucose monitoring (CGM) profiles
from people with diabetes before and during Ramadan.
Diabetes Pharmacotherapies during Covid-9
 Uninfected but living environment Ambulatory mild Hospitalized moderate Hospitalized severe
with prevalent COVID-19 disease disease disease (admitted to ICU

Insulin DPP4-inh Insulin Insulin Insulin

Recommended

Metformin GLP1-RA DPP4-inh DPP4-inh DPP4-inh

To use

TZD ⍺-GI Metformin Metformin

GLP1-RA GLP1-RA
Can be use with

SU SU SU Metformin
caution

SGLT2-i SGLT2-i ⍺-GI GLP1-RA

TZD ⍺-GI

⍺-GI
Recommended

TZD SU
Not

SGLT2-i TZD

SGLT2-i
Lim S, et al. NATURE REVIEWS | ENDOCRINOLOGY, 17:11-30, 2021
The use of
pharmacotherapies for
diabetes and related
comorbidities during
COVID-19

Katulanda P, et al.
Diabetologia (2020)
https://doi.org/10.1007/s
00125-020-05164-x
MEDICAL ADJUSMENT

IDF-DAR Guideline, 2021

MEDICAL
ADJUSMENT
One daily dosing Twice daily dosing Older drugs in SU class

IDF-DAR Guideline, 2021

MEDICAL
ADJUSMENT

IDF-DAR Guideline, 2021

MEDICAL
ADJUSMENT

IDF-DAR Guideline, 2021

MEDICAL
ADJUSMENT

IDF-DAR Guideline, 2021

When should break fast
Worsening of co-morbid ?
IDF-DAR Guideline, 2021
Summary
• People with diabetes have been identified as being at increased risk of serious
illness from COVID-19
• COVID-19 patients with uncontrolled hyperglycaemia reported longer length of
stay and higher mortality
• There are many risks associated with fasting for diabetic patients including
hypo/hyperglycaemia, KAD, dehydration and thrombosis, and may will
worsening co-morbid
• Due to very high risk for diabetic + COVID-19 patients  recommended not to
fast
• Take attention to do assessment before Ramadan, well monitoring during
fasting Ramadan, as well as patients education that are very important for
safety
Thank You
 Take home message
1. A big Muslim population in Indonesia will be going to fasting Ramadan
2. Ramadan increases event of hypo or hyperglycemia, dehydration,
thrombosis & may worsening of co-morbid
3. Assessment 6-8 weeks before Ramadan is needed to classify the risk
4. Patients are needed good information related fasting and DM 
education
5. SU still widely used by diabetic peoples to control their blood glucose,
even in Ramadan,  need adjusting dose and time of consume
6. Gliclazide is a SU with low risk of hypoglycemia and gliclazide MR was
proved save and effective to control blood glucose during Ramadan
7. Patients DM with Covid-19 have very high risk when fasting  not to fast