Management of Diabetes During Fasting and Feasting in India

70 Journal of The Association of Physicians of India ■ Vol. 67 ■ September 2019

Review Article

Management of Diabetes during Fasting and Feasting in India

Banshi Saboo1, Shashank Joshi2, Siddharth N Shah3, Mangesh Tiwaskar4, Vijay Vishwanathan5, Sudhir Bhandari6, Sujit Jha7, Tirthankar Chaudhary8, SR Arvind9, Rajeev Chawla10, Sanjay Kalra11, Dhruvi Hasnani12

fast during annual Karva Chauth and Abstract Guru Purnima to pray for long life for Fasting and feasting are integral part of many religions and cultures. As the their husbands, monthly fasts during Ekadashi, Purnima, and Pradosha, amount of food and fluid intake are markedly altered during these phases, patients and longer fasts during the Navratras with diabetes are prone to higher risk of complications. Even though several (9 days) twice a year etc.2 Moreover, guidelines for fasting and feasting are available; Indian specific recommendations fasting may be “nirahara” – without are the need of the hour, because of the distinct dietary habits and the diet food; “phalahara” – where fruit and content (high carbohydrate) of Indians. To fill this void, the current guidelines have milk are allowed and “alpahara” – been developed by experts from India who extensively reviewed the literature, when broken rice and the likes are shared their practical knowledge and ultimately arrived at a consensus. allowed.3Alike fasting, feasting is also marked by the Hindu religion where during various festivals including Introduction complications during fasting and Diwali, Pongal, Dussehra, Holi etc.; feasting in Indian population. people consume high amount of asting and feasting are the common carbohydrates from sweets prepared Fpractices observed by people as Methodology from sugar, jaggery, rice flour and 3 a regimen for traditional or cultural ghee. An extensive systematic review of reasons.1-3 People observe fasting or Islamic fasts and feasts literature has been initiated in several feasting depending on the religion and search engines including PubMed, Islamic fast, also known as Sawn, festival in context.2–7 Literature suggests Google Scholar, and Cochrane library is abstaining from eating and drinking that medically supervised fasting for databases in order to find out the best during daylight hours. During 7–21 days is efficacious in treatment possible evidence and quality studies Ramadan, all Muslims desist from of several diseases1, 8 however, erratic for management of diabetes during both eating and drinking from dawn to eating pattern and disrupted daily fasting and feasting. In the process sunset and refrain from smoking, taking fasting and feasting cycle may have an 14 of literature search, various MeSH oral medications, and sexual activities. impact on the progression of metabolic keywords including fasting, feasting, Followers consume a high calorie food diseases in India.9 hypoglycaemia, hyperglycaemia, at iftar (evening meal after breaking The International Diabetes Ramadan, diabetes, etc. have been used. the fast), and at suhur (meal consumed Federation (IDF) in their current Existing guidelines, meta‐analyses, early in the morning). Similarly, during report states that approximately 73 systematic reviews, randomized Eid-ul-Fitr, the festival of breaking the million people with diabetes are controlled trials (RCTs), non-RCTs, fast after Ramadan, Muslims celebrate 10 15 living in India. Data from multi- and key articles related to diabetes with eating and drinking. country studies, including India, management were reviewed. Jain fasts and feasts report that around 79–94% of Muslims Types of fasting Jain people do fast at special times with type 2 diabetes mellitus (T2DM) during festivals and on holy days.4In undergo fasting during Ramadan Hindu fasts and feasts Jainism, “Paryushan” is the most for at least 15 days. It is evident that There are several types of fasting observed festival during monsoon, many people with diabetes observe observed by the Hindu religion; for which lasts eight days in Svetambara fasting or feasting during various example women observe day-long Jains and ten days in Digambar Jains. festivals in India, hence management of diabetes during these phases becomes extremelyimportant.11-14 Importantly to 1Chairman, Consultant Diabetologist, Diacare Diabetes Care and Hormone Clinic, Ahmedabad, Gujarat; 2Consultant Endocrinologist, the best of our knowledge there is no Lilavati Hospital and Research Centre, Mumbai, Maharashtra; 3Consultant Diabetologist, Bhatia Hospital, Mumbai, Maharashtra; consensus statement available on the 4Consultant Diabetologist & Physician, Shilpa Medical Centre, Mumbai, Maharashtra; 5Consultant Diabetologist, MV Diabetes Centre, management of diabetes during fasting Chennai, Tamil Nadu; 6Dean & Prof of Medicine, SMS Medical College and Hospital, Jaipur, Rajasthan; 7Consultant Diabetologist 8 and feasting in Indian population. This & Physician, Max Super Speciality Hospital, Mumbai, Maharashtra; Consultant Endocrinologist, Apollo Hospital, Kolkata, West Bengal; 9Director & Consultant Diabetologist, Diacon Hospital, Banglore, Karnataka; 10Director and Consultant Diabetologist, Life consensus will highlight the evidence- Line Medical Centre, Delhi; 11Consultant Endocrinologist, Bharati Hospital, Karnal, Haryana; 12Consultant Diabetologist, Diacare- based management strategies for Diabetes Care & Hormone Clinic, Ahmedabad, Gujarat control of diabetes and its associated Received: 18.05.2018; Accepted: 22.05.2019 Journal of The Association of Physicians of India ■ Vol. 67 ■ September 2019 71

Table 1: Risk Stratification of patients with diabetes during fasting

Very high risk High risk Moderate risk Low risk o Severe hypoglycemia / ketoacidosis / hyperosmolar o Moderate hypoglycemia o Well controlled patients o Well controlled patients hyperglycaemic coma within last 3 months prior to Ramadan (Average blood glucose (HbA1c <7.5%) treated (HbA1c <7%) treated with o History of recurrent hypoglycemia 150-300mg/dL) with short-acting insulin diet alone, metformin, or a o Renal insufficiency secretagogues and modern thiazolidinedione who are o Hypoglycemia unawareness sulphonylureas otherwise healthy o Sustained poor glycemic control o People living alone that are treated with multiple insulin o Patients on dialysis injections o Patients who perform intense physical labor o Old age with ill health o Acute illness o Patients with macro and o Gestational diabetes mellitus treated with insulin microvascular complications o Pregnancy that present additional risk factors o Type 1 diabetes Patients with the following conditions should refrain from fasting:  Pregnant and lactating women;  Type 1 diabetes;  Acute peptic ulcer;  Cancer;  Severe bronchial asthma, pulmonary tuberculosis;  Overt cardiovascular diseases- recent MI, sustained angina;  Hepatic dysfunction Adapted from: South Asian Consensus Guideline, ADA 2005, IDF 2016, and IGDR 2015 various festivals and observe fasting and feasting. Literature advocates that Greek Orthodox Christians undergofast for a total of 180 to 200 days in each year. Nativity Fast (40 days before Christmas), Lent (48 days before Easter), and the Assumption (15 days in 6 Fig. 1: Factors responsible for the development of diabetes associated August) are the main fasting periods. complications during fasting. However, Parsis don’t have fasts on Fig. 1: Factors responsible for the development of diabetes associated complications their calendar but, have feasts and most during fasting of their diet is rich in non-vegetarian food.17 Diabetes, fasting and feasting Risk population It is important to stratify patients Adapted from: Kalra S 2015 into different risk categories according Figure 1: Factors responsible for the development of diabetes associated to their comorbid status, continued complications during fasting. medication, health status etc. (Table 1, Figure 1).2,13-14,18-24 Challenges • Hyperglycaemia, hypoglycaemia, dehydration, diabetic ketoacidosis (DKA), microvascular and macrovascular problems may create challenges, • Taking insulin and other OADs without any dose adjustment during fasting periodincreases the Adapted from: IDF 2016 risk of complications, Figure 2: List of complications associated withdiabetes along with their symptoms Fig. 2: List of complications associated with diabetes along with their symptoms • In spite of ill health, some people do fast Furthermore, Digambar Jains do not China and India.5,10 Vassa or Buddhist • During fasting, alteration of take food and/or water (boiled) more Lent is the fast and feast observed by physical and mental health, than once in a day, and Shwetambar Buddhists for three lunar months every especially in elder and comorbid Jains take onlyboiled water during year in the rainy season. During this patients with diabetes, places them their fast days.4 In addition, most Jains time they follow fast for 12 hour period at great risk of complications, observe “Ratri Bhojan Tyag,” where (from noon to midnight) and a feast they abstain from food and water after for 12 hours period (from midnight • Due toirregular food habit some sunset.4 During Diwali, New Year day, to noon). patients may miss their usual medication dose Mahavir Jayanti, and other festivals Fasts and feasts in other religions 26 they offer Prasad made from ghee, • Poor monitoring of diabetes Apart from discussed religions, sugar, jaggery, and mark their feasting. 26 complications, and blood sugar, India is the home for several other specifically in rural areas pose a Buddhist fasts and feasts religious people’ including Christians, significant risk.2-5,20,25-26 Many people follow Buddhism in Sikhs, Parsis etc.16 They also celebrate 72 Journal of The Association of Physicians of India ■ Vol. 67 ■ September 2019

Table 2: Management of diabetes complications (hypoglycaemia, hyperglycaemia, diabetic be sufficiently trained to deliver a ketoacidosis, and dehydration) during fasting and feasting period (Akbani F, 2005; structured patient education to patients Kalra S, 2015) and family members inclusive of Lifestyle Ο Attend pre-fast counselling and learn the warning symptoms of hyperglycaemia and blood glucose monitoring, nutritional modification hypoglycaemia advice, exercise advice, dosage, timing Ο Strict adherence to the diabetic diet of medications, their adjustments, Ο Take medication regularly as per instruction symptoms of complications and their Ο Do not overeat after the fast is broken and minimize eating sweet or fatty foods management, and knowing when to Ο Record weight daily and inform doctor of gains or loss of more than 2kg break the fast in order to reduce the Ο If a complication occurs, break the fast immediately and seek medical help complications.14, 21-22 Ο Patients/family should be aware of potential problems and alert their doctor immediately Management of T1DM Ο Serving of meal supplements may be added to pre-fast meals or intra fast liquids, to prevent hypoglycaemia Patients with T1DM have been Frequent Ο Test blood glucose regularly especially patients on insulin therapy during prolonged considered as a very high-risk group blood fasting like Ramadan, Navratri, and Vaasa etc. for fasting in various guidelines and glucose Ο Test blood glucose before and 2 hours after Iftar, before Suhur and at mid-day literature.14,20-22 This risk increases in monitoring Ο Frequent SMBGs testing should be introduced patients with uncontrolled/poorly- Exercise Ο Normal levels of physical activity may be maintained. However, excessive physical controlled diabetes and having activity may leadto higher risk of hypoglycaemia and should be avoided no access to medical care, unable/ Breaking the Ο If the blood glucose level is <70 mg/dL (3.9 mmol/L) or >300 mg/dL (16.7 mmol/L) and/or unwilling to monitor blood glucose fast development of diabetes complication, the fast should be broken level, uneducated and unaware of Ο After breaking the fast due to hypoglycaemia, patients should consume a little amount of a hypoglycaemic events that require fast-acting carbohydrate diet recurrent hospitalizations etc.14 The Medication Ο Patients taking insulin and sulfonylureas should be closely monitored for hypoglycaemia evidence suggests that fasting for 25 Ο SGLT-2 inhibitors should not be used in elderly and frail patients and those residing at hot & humid conditions hours is safe and can be observed by 31 Ο Dose modification should be done as per individual patients risk and the preference patients with T1DM. This group of patients should be made aware of Breaking of fast (defined as hospitalization due to the associated potential risks and be hypoglycaemia) by 4.7-fold in patients Literature and guidelines advocate monitored closely.21,32 that patients with diabetes should with T1DM (from 3 to 14 events/100 The South Asian Consensus break their fast if: people/month) and 7.5-fold in patients with T2DM (from 0.4 to 3 events/100 Guideline on insulin use during • Blood glucose level is <70 mg/dL 23 people/month).12,28,29 Ramadan advocates that once-or- (3.9 mmol/L) or >300 mg/dL (16.7 twice daily injections of intermediate or 21 There was a 5-fold increase in mmol/L) long-acting insulin along with pre-meal incidence of severe hyperglycaemia • Symptoms of hypoglycaemia, rapid-acting insulin can be safely used (requiring hospitalization) in T2DM hyperglycaemia, dehydration or in patients during fasting.23,33 (from 1 to 5 events/100 people/ acute illness develop (Figure 2)20 month) and an approximately 3-fold Management of T2DM • Patients taking insulin, or on any increase in patients T1DM (from 5 to Non-pharmacological management other OHA, if the blood glucose 17 events/100 people/month) during Fasting is considered as an element levels fall <70 mg/dL in the first Ramadan, as reported by the extensive of lifestyle modification (LSM), and few hours after the start of fast22 12,28 EPIDIAR study. Less fluid intake LSM itself is a management strategy • Patients suddenly feeling unwell21 for a prolonged time may attribute for T2DM patients.2 Physical activity to dehydration, and this may become • Dramatic changes in their blood and Yoga can be performed to lose body severe in hot and humid climates and glucose profile during fasting weight and to control the emotions; among individuals who perform hard period20 however, excessive and aggressive physical labour28 (Table 2). Patient monitoring physical activity should be avoided Management of diabetes during during prolonged fasting periods.14,30,34 Patients who are at higher risk of fasting and feasting Nutrition plan diabetes associated complications, Pre-fast medical assessment/counselling should be monitored regularly-20,22,25,27 A food-plate comprising all foods Pre-medical assessment decides the for diabetes individuals during fasting • Those on insulin therapy patient eligibility for fasting and aids in is depicted in Figure 4.14,35-36 • ill and comorbid patients eliminating further unavoidable risks The pre-fast meal should be • patients treated with OADs and complications. After assessing all composed of complex carbohydrates especially metformin, or the details, the physician should advise with low glycaemic index and proteins glibenclamide the patient on whether to fast or to seek such that it can provide enough “slow- • patients with T1DM exemption; the decision should take release” calories to take care of the into consideration person-centeredness fasting period; unprocessed cereals, Diabetes complications 2,21- and emotion and belief of the patient fruits, nuts, and lentils can be used in The population-based epidemiology 22 (Figure 3). the pre-fast meals.2In contrast, post-fast of Diabetes and Ramadan (EPIDAR) Structured diabetes education meal should be composed of simple study reports that fasting increases carbohydrates like bread, cereals, rice, the risk of severe hypoglycaemia The health care professionals should Journal of The Association of Physicians of India ■ Vol. 67 ■ September 2019 73

mango, pasta, and artificial syrups.14 Adequate water and fluids must be taken prior to the fast especially in cases where fluid intake will be restricted throughout the day. Pharmacological management The details of dose adjustment of medications are provided in Table 3.2-5,14,20 Metformin Metformin can be safely used during fasting periods due to minimal chances of hypoglycaemia.14However, patients who are taking metformin during lunch time should omit the dose during day fasting;37 morning dose can be taken as usual but, a larger dose should be taken after breaking the fast to avoid hyperglycaemia.2,14,37 Sulfonylureas Sulfonylureas (SUs), are widely used after metformin in patients with T2DM in India.14 The main concern with their use is hypoglycaemia and this might be due to their glucose- independent insulin secretory action. However, this is not the class effect and differs with agents due to variations in their individual pharmacokinetic and pharmacodynamic properties.38 Glibenclamide, gliclazide, glipizide, and glimepiride are the various SUs used in India for the management of T2DM. Evidence advocates that Adapted from: Hassenein M, 2017 gliclazide, among all the SUs,is Figure 3: Patient flow chart for assessment, risk stratification, education and associated with good glycaemic control Fig. 3: Patient flow chart for assessment, risk stratification, education and physician 39 physiciandecision decisionbefore prolonged before prolonged fasting fasting with lesser hypoglycaemia. This might be due to its lesser pancreatic overstimulation action and restoration of the early insulin peak in response 27 to glucose stimulation and higher reversibility of binding with receptors present in beta- cell.38 Moreover, a meta-analysis of RCTs did not find any significant difference in the incidence of symptomatic hypoglycaemic events between DPP-4 inhibitor and gliclazide (5.6% versus 7.2%, risk ratio 1.12, 95% CI 0.73-1.73, p=0.61) in patients during fasting.40 A systematic review and network meta-analysis of RCTs reports that gliclazide compared to other SUs is associated with lower risk of all-cause and cardiovascular- related mortality in patients with T2DM (Table 4).41-51 Thus, gliclazide Adapted from: Sadikot S, 2017 pertaining to its efficacy in glycaemic Fig. 4:Figure The nutrition 4:The nutrition plan (food plan plate) (food for plate)patients for with patients diabetes with during diabetes the fasting during the control, lower risk of hypoglycaemia, fastingperiod. period. The plate The demonstrates plate demonstrates the individual the individualdaily caloric daily intake, calori percentagec intake, less risk of CV complication and death, percentageof carbohydrate, of carbohydrate, fat and proteins fat and that proteins can meet that the can cultural meet thesetting cultural and food setting and food preference of each individual. along with lower cost might be an preference of each individual suitable alternative and can be used

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Table 3: Approach to adjustment or modification of continued antidiabetic medications in patients with diabetes during fasting period(IDF 2016, Sadikot S 2017, Kalra S 2015, Jhulka S 2017, and Latt TS & Kalra S 2012)

Anti-diabetic Muslim fast Hindu fast Jain fast Buddhist fast agents Prolonged Infrequent but Infrequent but Frequent High-risk Low-risk brief prolonged Ramadan Karva chauth Navratri Somvaar, Tiwihar upavas, Byasana, Ekasana, Vaasa Mangalvaar Upavas, Bela Ratri Bhojan Tyag (Chhath), Tela (Asththam) Metformin • Once daily: take at • Once daily: take • Once daily: take • Once daily: take Omit the therapy No change No change Iftar at night at night at night on the day of fast required required • Twice daily: take at • Twice daily: • Twice daily: • Twice daily: iftar & suhur take at morning take at morning take at morning • Thrice daily: take and night and night and night 2/3rdof the total daily • Thrice daily: • Thrice daily: • Thrice daily: dose at the iftar and omit the lunch take 2/3 of the omit the lunch 1/3rdat the suhur dose and follow total daily dose dose and follow above at night and 1/3 above at the morning Sulfonylureas* • Once daily: take at • Once daily: take • Once daily: take • Omit the Avoided, or taken Full dose at • Once daily: iftar at dinner at dinner therapy on the in half dose at morning and half take at morning • Twice daily: take ½ • Twice daily: • Twice daily: day of fast night dose at night Twice daily: take of usual evening dose omit the omit the 2/3rd at morning with the suhur and morning dose morning dose the usual morning in absence of dose with the Iftar breakfast DPP-4 inhibitors • No dose adjustments • No change, take • No change, take • No change Omit the therapy Taken at night • No change is required at dinner at dinner on the day of fast SGLT-2 inhibitors† • No dose adjustment • No change, take • No change, take • No change Omit the therapy Evening dose • No change is required and the at dinner at dinner on the day of fast avoided, or taken dose be taken with in half dose iftar Pioglitazone • No dose adjustments • No change • No change, or • No change No change No change • No change is required 2/3rd take at required dinner AGIs • No dose adjustments • No change • No change • No change Omit the therapy No change • No change is required on the day of fast required GLP-1 analogues • The dose should be • Reduce the • The dose • No change or Once weekly No change titrated 6 weeks prior dose to 1/2th and should be reduce the dose dose: No change required to Ramadan and no take at dinner titrated prior to to 1/2 (postpone due dose adjustment is Navratri dosestill the required completion of fasting) Long-acting • Once-daily:  dose by • Need no change • Need no change reduce the dose to 25% reduction in 10-20% reduction Once daily, before insulin 15–30% and take at or may reduce or may reduce 2/3rd dose in dose the main meal of iftar the dose to 2/3rd the dose to 2/3rd 24 hour period • Twice daily: Take usual morning dose at iftar &  evening dose by 50% and take at suhur Short-acting • Take normal dose at Reduce the dose Reduce the dose Reduce the dose 1 bolus 2 bolus Reduce the dose insulin iftar and lunch dose to 1/2th to 1/2th to 1/2th to 1/2th at dinner •  suhur dose by 50% Premixed insulin • Once daily: Take 30:70 or 25:75: 30:70 or 25:75: reduce the dose 30:70 at night or 50:50 once daily Can be given once normal dose at iftar reduce the dose reduce dose to to 2/3rd and prefer 50:50 at day daily, before the rd rd • Twice daily: Take 1/2 to 2/3 2/3 30:70 or 25:75 main meal of the of evening dose with 50:50:reduce the 50:50:reduce the 24 hour period suhur and the usual dose to 1/2th dose to 1/2th morning dose with the iftar • Thrice Daily; Omit afternoon dose and adjust iftar and suhur doses AGIs, alpha-glucosidase inhibitors; DPP-4, dipeptidyl peptidase-4; SGLT-2, sodium-glucose co-transporter-2; *Gliclazide and glimepiride should be preferred among all other sulphonylureas † Elderly patients, patients with renal impairment, hypotensive individuals, those at risk of dehydration or those taking diuretics should not be treated with SGLT2 inhibitors. safely during fasting periods in Indian period.14,38 fasting period due to the reduced patients.14,38-40 Moreover, glibenclamide DPP-4 inhibitors risk of hypoglycaemia, as they work should be avoided and other SUs can by increasing insulin secretion in a They can be safely used during be used with caution during the fasting glucose-dependent manner. However, Journal of The Association of Physicians of India ■ Vol. 67 ■ September 2019 75

Table 4: Studies investigating efficacy and safety of antidiabetic agents during fasting

Author et al. N Intervention Outcomes/conclusion Randomized clinical trials Azar S T et al. 201641 343 Liraglutide vs sulphonylureas • Similar  in fructosamine levels were observed for both groups during Ramadan: (liraglutide, (gliclazide, glimepiride, −12.8 μmol/L; sulphonylurea, −16.4 μmol/L; p = 0.43) glipizide, glibenclamide): • No severe hypoglycemic episodes were reported by either group outcomes • More subjects in the glibenclamide stratum (14.8%) experienced hypoglycemic episodes than in the glimepiride/gliclazide/glipizide stratum (9.8%) Hassanein M 201442 557 Vildagliptin (A) vs gliclazide • Confirmed hypoglycemia (A vs B): 3.0% vs 7.0%(p =0.039) (B) + metformin:Hypoglycemic • Adjusted mean change pre- to post-Ramadan in HbA1c (A vs B): 0.05%±0.04% vs −0.03%±0.04% events (p =0.165). • Adjusted mean  weight: −1.1±0.2 kg (p =0.987) for both group • No significant change in any parameter found in either group Malha LP 201443 69 Vildagliptin vs sulphonylureas • HbA1c from baseline to the last visit was similar for both groups (Glimepiride/ gliclazide): • Hypoglycemic events was not statistically significant (p = 0.334) between the groups hypoglycemia event • Vildagliptin may be a better agent than sulphonylureas Brady EM et al. 201444 99 Liraglutide (A) vs • There were no episodes of severe hypoglycemia in either group, however, self-recorded sulphonylureas (B) (gliclazide, episodes of blood glucose ≤3.9 mmol/L: AB;0.54% vs 0.27%(p=0.03) or glibenclamide): • Body weight 3 weeks post-Ramadan: A>B; 2.23 kg vs 0.42 kg (p=0.02) Aravind SR 201245 870 Sitagliptin (A) vs sulfonylureas • Hypoglycemic events in Indian patients (A vs B): 4.1% vs 7.7% (Gliclazide

which studied the outcomes of Special populations Executive summary alpha-glucosidase inhibitors (AGIs) Pregnant women, children, elderly, • A structured diabetes education should be during the fasting period. Acarbose, patients with comorbidities, and planned for patients with diabetes along with miglitol, and voglibose can be safely their family members in order to observe a safe poorly controlled T1DM are group of fasting. used without any dose adjustment patients requiring special attention • Patient with diabetes should break their fast during the fasting period. However, during the fasting and feasting period. if the blood glucose level is <70 mg/dL (3.9 ineffectiveness as monotherapy and Unless stable disease, these people are mmol/L) or >300 mg/dL (16.7 mmol/L) or when complications develop. concerns regarding the GI side effects categorized as high risk for fasting in • Patients with stable T2DM can undergo fasting reduces their applicability in T2DM various guidelines and need special 14 safely; however, their frequency and dose of patients during the fasting period. precautions with strict monitoring medications need to be adjusted or modified. Glucagon-like peptide-1 receptor agonists (Table 1).13,20-24 • Metformin can be safely used during fasting, Liraglutide, exenatide, albiglutide, however, some dose modification might be Pregnant women with diabetes required. lixisenatide, and dulaglutide constitute are generally managed with insulin • Hypoglycaemia is the major concern associated the family of glucagon-like peptide preparations during the fasting period. with SUs. However, gliclazide in this class (GLP)-1 receptor agonists. The Elderly patients, who wish to fast for has lowest risk of hypoglycaemia and CV important advantage associated with a prolonged period, are at increased complications with higher glycaemic efficacy. Moreover, owing to its low cost, gliclazide can these agents is weight loss and low risk of hypoglycaemia, hyperglycaemia be widely used in Indian population during the risk of hypoglycaemia; thus, they are and metabolic decompensation fasting period. chosen over other agents especially in including hyperosmolar coma, DKA, • DPP-4 inhibitors like vildagliptin and overweight and obese patients during dehydration and thrombosis.63-68 It is sitagliptin can be used during fasting; however 21 higher cost might restrict their use in Indian the fasting period. Several trials mandatory to examine the functional population. (Table 4) have been published including capacity, cognition, mental health, and • The SGLT-2 inhibitors should be cautiously the Treat 4 Ramadan trial and LIRA- comorbidities in elderly people with used in elderly and frail patients due to their Ramadan trial that investigated the diabetes during the pre-fast period volume contraction, infection and dehydration effects. efficacy and safety of liraglutide during in order to reduce the complications. fasting period,41,44 and did not found • Thiazolidinedione and alpha-glucosidase Moreover, SGLT-2 inhibitors should not inhibitors can be safely used; however any significant difference between be used in this group of patients due weight gain and GI upset are the respective liraglutide and SU concluded that to the risk of dehydration and volume complications that indicate treatment both agents can be safely used during contraction.14 individualization. fasting.41,44 GI upset was common with • GLP-1 receptor analogues can be used safely Conclusion during fasting because of their weight loss the usage of liraglutide.57 Furthermore, The panel concludes that appropriate effect and low risk of hypoglycaemia, however, some patients don’t prefer these high cost, GI side effects, and injectable nature lifestyle modifications including injectable agents due to their religious reduces their applicability, especially during physical activity, nutrition plan, fasting. views.14 pre-fast counselling and structured • Insulin requires dose modification during the Insulins diabetes education plan along with fasting period. Patients who are using insulin should be strictly monitored for hypoglycaemic Many T2DM patients use insulin proper treatment dose adjustment or complications. as a treatment option however the modification are important to ensure a 9. Gupta NJ, Kumar V, Panda S. A camera-phone based higher risk of hypoglycaemia and safe fasting or feasting period. study reveals erratic eating pattern and disrupted daily multiple injections reduces its usage eating-fasting cycle among adults in India. PloS one 2017; in T2DM patients especially during the References 12:e0172852. fasting period.14,21 Insulin analogues 10. International Diabetes Federation. The International 1. Nair PM, Khawale PG. Role of therapeutic fasting in women’s Federation (IDF) Diabetes Atlas, Eighth Edition. 2017. (basal, prandial and premix) are health: An overview. Journal of Mid-Life Health 2016; 7:61. Available from:.http://www.diabetesatlas.org/across-the- generally recommended over regular 2. 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