Diabetics must take care when fasting

The type of treatment a diabetic receives plays an important role in the way the body reacts during fasting, doctors have warned. Estimates suggest that more than 90 per cent of Muslim Type 2 diabetics in the UAE and Saudi Arabia still choose to fast during Ramadan, despite physicians' concerns. Globally, that number is nearly 80 per cent. This change in eating patterns coupled with certain diabetes medication that stimulates insulin production can put diabetics at risk, said Dr Alaa Eldin Bashier, an endocrinologist at Dubai Hospital. There are three main forms of Type 2 diabetes treatment: metformin, which increases the body's sensitivity to the insulin it produces; sulfonylurea, which stimulates the pancreas to produce more insulin; and sitagliptin, which also stimulates the pancreas to produce more insulin, but only when blood-sugar levels are high. Metformin is usually prescribed to patients who show insulin resistance, in which case a combination of medication is sometimes used, Dr Bashier said. "There is no point in stimulating insulin if the body does not react to it, so sometimes we use metformin with another drug," he said on the sidelines of a conference on treatment options for diabetics last week. However, he warned that medications such as sulfonylureas, which induce insulin production regardless of blood-sugar levels, put patients at risk when they go without food for longs hours. He added that the drugs were still prescribed when the pancreas was exhausted and producing very little insulin. Results from a clinical study last year by MSD, a UK-based pharmaceutical company that manufacturers sitagliptin, the generic for Januvia, showed that Muslims fasting during Ramadan who are taking the medication run a lower risk of low blood pressure. More than 11,000 Muslim Type 2 diabetics were asked to report incidents of symptomatic and asymptomatic low blood sugar during the study. Among all the patients, incidents of symptomatic low blood sugar fell from 13 per cent to 7 per cent, and incidents of asymptomatic hypoglycaemia fell from 18 per cent to 9 per cent. Dr Harvey Katzeff, global director for scientific affairs at MSD, said dehydration during Ramadan could also lower blood sugar, leaving patients with an "intoxicated" feeling. "They may feel confused, weak and disorientated," he said. "This is particularly concerning for patients when they are driving or operating heavy equipment." The American Diabetes Association recommends that people with Type 2 diabetes wishing to fast during Ramadan undergo a medical assessment one to two months in advance. Despite the availability of new medications, many patients still choose traditional forms because of cost. Sulfonylureas, which have been around for decades, cost between Dh50 and Dh90 for a one-month supply, while sitagliptin, which has only been available for about three years, costs more than four times that, between Dh280 and Dh300. Insurance coverage varies. Meanwhile, those with Type 1 diabetes have limited options, Dr Bashier said. "These are people who do not produce insulin at all, and their only choice is direct injection of insulin into the body," he said. "This makes it difficult to control the way a patient reacts during Ramadan."