Ramadan Fasting,One Less Barrier Raised by Automated Insulin Delivery

Introduction

Ramadan is the holy month of fasting practiced by more than 50 million people with type 1 diabetes (PT1D). ¹ The International Diabetes Federation (IDF) and Diabetes and Ramadan expert group recommendations (DaR) issued practical guidelines for Ramadan fasting in 2021, with the production of a risk score based on 14 items ranging from the duration of diabetes, presence of hypoglycemia, and level of renal function to the existence of acute diabetes-related complications, pregnancy, and other co-morbidities, notably of a cardiovascular nature. ² Therefore, PT1D are considered high risk to practice Ramadan.

Automated insulin delivery through hybrid closed-loop (HCL) has been a revolution for the treatment of PT1D and is associated with significant improvement of metabolic outcomes, including the risk of severe hypoglycemia and glycemia variability. ³ Thus, the question of using HCL as a bulwark against the prejudice in considering PT1D in high risk for Ramadan fasting is legitimate.

With this objective in sight, large-scale studies are rare and very recently^4-6 have been achieved.

The most recent study ⁴ included a total of 294 PT1D who attempted fasting during Ramadan in 2022; participants were grouped according to the treatment received in 1 of 5 groups: (1) HCL (n = 62); (2) conventional pump + continuous glucose monitoring (CGM; n = 37); (3) pump + self-monitoring of blood glucose (SMBG; n = 8); (4) multiple daily injections (MDI) + CGM (n = 155); and (5) MDI + SMBG (n = 32). Users of HCL had a significantly greater time in range (TIR) and lower glycemia risk index, time below range, and time above range compared with users of conventional pumps and MDI (both P < .05); in this study, HCL users were twice as likely to complete fasting most days of Ramadan.

Another prospective study ⁵ had assessed the safety, effectiveness, and optimization of HCL system on glycemic metrics and the level of hypoglycemia in PT1D who wished to fast for Ramadan. A total of 24 PT1D (mean age, 15.2 ± 3.4 years) using HCL system were divided into 2 groups (each n = 21): intervention group who adjusted HCL settings and control group who kept the same settings as before Ramadan. Hybrid closed-loop settings accuracy maintained exceptional glycemia with TIR reaching 82.0% ± 10.2%, time above range >180 mg/dL of 12.1% ± 3.5% without an increase in hypoglycemia (time below range, 3.0% ± 0.3%). Note the very young age of the participants in this trial (mean age, 15.2 ± 3.4 years), which is extremely reassuring for a population sometimes doomed not to practice Ramadan compared with their friends and family members who are not affected by type 1 diabetes.

Using HCL during Ramadan fasting has also shown that the most cited fasting-related complication according to IDF-DAR expert group recommendations—hypoglycemia—is reduced or even absent. In another recent study, ⁶ data were extracted from HCL users from the Gulf region. Users were included if they had ≥10 days of sensor glucose data during the month of Ramadan 2022 as well as in the month before and after; glycemic control was well kept in the 449 included users. During Ramadan, there was no increased risk of hypoglycemia during daytime (time below 70 mg/dL = 2.3% ± 2.4%), and TIR was highest during daytime (80.0% ± 10.7%, night: 60.4% ± 15.3%). The algorithm adapted immediately upon lifestyle change.

In conclusion, these initial results are promising, confirming the superiority of HCL over other therapeutic options and the maintenance of metabolic control during Ramadan fasting, without safety concerns, for patients already using HCL before Ramadan. Current recommendations should move in this direction.