This ‘ten minute consultation,’ part of a series of occasional articles in the BMJ on common problems in primary care, looks at issues to cover and subsequent management, when a patient with type 2 diabetes mellitus turns up for advice on how he might fast safely during Ramadan. The main advisory points are as follows:
- If blood glucose is well controlled by diet alone, advise him that fasting is safe
- Encourage him to eat foods high in dietary fibre and have a low glycaemic index at the pre-dawn (Suhur) and sunset (Iftar) meals to promote glycaemic control and discourage foods with a high glycaemic index until about half an hour after taking drugs to minimise sharp rises in blood sugar at sunset.
- Self monitoring of blood glucose is essential for safe fasting in patients taking antidiabetic drugs, particularly before and after the pre-dawn and sunset meals.
- To minimise the risk of hypoglycaemia in patients on oral therapy, those on a long acting sulphonylurea should be switched to a short acting preparation or metformin, or both. If a single daily dose is used, take this with the sunset meal, if two or three doses are taken daily, take half the normal evening dose before dawn and the normal morning (and any midday) dose after sunset.
- To minimise the risk of hypoglycaemia in patients on insulin, those on a once daily regimen should be switched to a twice daily regimen whilst those on a twice daily regimen should use half of the evening dose before dawn and the normal morning dose after sunset. If basal bolus insulin is used, reduce the long acting component to two thirds of normal, split into two equal doses taken during the sunset and pre-dawn meals; take the rapid acting component as before, but omit the middle dose.
- Emphasise the need to carry glucose tablets at all times to treat hypoglycaemia and explain the importance and legitimacy of breaking the fast in emergency situations.
- Arrange for a review one week into Ramadan or earlier if concerns arise.