A clinical algorithm developed in Singapore improved glycemic control fourfold among Muslims with diabetes who fast during Ramadan, according to results from a randomized trial.

Ramadan is a challenge for Muslims with diabetes worldwide. Observing the month-long fast requires a dramatic break from normal eating patterns, which includes abstaining from food and liquids, including medications, from dawn to dusk. Not adjusting medications during fasting may harm glycemic control, and though international guidelines have become available in recent years, a large multinational study showed that fewer than 40% of people with diabetes got help from clinicians on medication management during Ramadan (Diabet Med. 2015;32[6]:819-828).

The Fasting Algorithm for Singaporeans With Type 2 Diabetes (FAST), developed and validated in 2018 by Joyce Lee, PharmD, and her colleagues at the National University of Singapore, is a clinical decision-making tool for both clinicians and patients. It involves clinicians engaging in risk-assessment screening of patients and educating patients on self-monitoring of blood glucose timing and technique, hypoglycemia management, nutrition, and Ramadan-related misconceptions. FAST also provides glucose-lowering medication modification guidance for clinicians along with patient self-dose adjustment guidance based on self-monitoring of blood glucose four times a day. The algorithm specifically requires patients to check their blood glucose levels before their sunset meal, two hours after their sunset meal, before their predawn meal, and a fourth time each day of their choice.

For their new study, published March 9 in Annals of Family Medicine, Dr. Lee and colleagues tested the algorithm in a clinical trial in which patients and clinicians were randomized to follow FAST protocols or receive and provide standard care. All patients (n = 97; mean age 59.5 years; 60% female) had glycated hemoglobin of 9.5% or higher, no history of recurrent hypoglycemia, and an estimated glomerular filtration rate of less than 30 mL/min at baseline (before Ramadan). These patients partook in Ramadan fasting and were willing to self-monitor blood glucose during the study. Pregnant women and people taking corticosteroids were excluded.

The trial took place during two different Ramadan cycles during 2017-2018, and the main endpoint was glycemic control pre- and post-Ramadan. Dr. Lee and her colleagues reported that patients in the algorithm arm (n = 46), showed four times the amount of improvement in HbA1c (–0.4%; –4.4 mmol/mol), compared with subjects receiving standard care (–0.1%; P = .049).

Mean fasting blood glucose decreased in the intervention group (–3.6 mg/dL) and increased in the control group (+20.9 mg/dL) over the study period (P = .034). The control group saw more confirmed incidents of minor hypoglycemia than did the intervention group, but these did not reach statistical significance.

“Before this study, the effect of Ramadan fasting on glycemic control was found to be affected by support from health care clinicians,” Dr. Lee and colleagues wrote in their analysis. “By standardizing diabetes care with the FAST tool, intervention participants showed four times the amount of improvement in glycemic control,” compared with controls. The investigators described the open-label design and the potential for different management practices among the participating clinicians having been used as weaknesses of the study.

In an editorial comment accompanying the article by Dr. Lee and colleagues, Jonathan G. Gabison, MD, of the University of Michigan in Ann Arbor, praised the study as demonstrating “that persons with type 2 diabetes can, with the help of their physicians, engage in safe fasting practices, and they can attain positive health benefits” (Ann Fam Med. 2020;18:98-99). Patients observing the FAST protocol “are less likely to avoid their doctors and have an improved therapeutic relationship with the medical community in their time of spiritual work.” But the study has implications beyond the observant Muslim community, Dr. Gabison argued, as “people with or without diabetes are more frequently engaging in the practice of fasting ... Although a controversial topic in the medical and nutritional community, patients, including those with type 2 diabetes, are increasingly using it as a strategy for weight loss or health benefits.”

While more research is needed, Dr. Gabison wrote, “a protocol to manage diabetes medications safely with intermittent fasting may help keep patients safe while we learn more about the use of these strategies to help combat obesity and diabetes.”

The Singapore Ministry of Education funded Dr. Lee and colleagues’ study. The investigators disclosed no conflicts of interest, and Dr. Gabison also reported no conflicts related to his editorial.

SOURCE: Lee et al. Ann Family Med. 2020;18:139-47.