Category: General

It is better to avoid fasting following a severe infection within the last three months before fasting. Some people who had COVID 19 in the past may experience a prolonged and severe post-COVID syndrome. Some have a heightened risk of developing blood clots, blood pressure and heart rate variations, extreme exhaustion, and even lung fibrosis. People with prolonged illness secondary to COVID-19 can become severely dehydrated and risk sudden acute deterioration during fasting. Hence it is safe to abstain from fasting and let your body slowly recover. It is wise to undergo an assessment with your treating doctor to see if you can observe the fast. Please follow his advice closely on whether to fast or not.

According to scientific studies, there is a 3-fold increase in the risk of migraine during Ramadan fasting. Migraine can be triggered by stress, hunger, low glucose levels, dehydration, irregular sleeping habits, and acidity. When you observe fasting for more than 12 hours, these problems can arise, leading to another episode of migraine headache. However, if you plan to observe fasting, you must continue to take the prescribed medicine. Caffeine withdrawal can lead to increased migraines. If you regularly take caffeine, it is good to have a strong coffee at Suhoor. Increase the quantity of water during non-fasting hours to avoid dehydration. Make sure that you get enough sleep and reduce the use of smartphones. If the episodes of migraine worsen, consider abandoning the fast.

Yes. It is normal to find ketones in urine while fasting. During any typical day, the food that we intake contains carbohydrates that get digested into glucose, and this gets absorbed. This glucose provides the energy for our everyday activities. The additional glucose is stored in the liver and muscles. But during a fasting day, since there is no food intake, the glucose stored in the liver and muscles is used to maintain blood glucose levels. But with prolonged fasting, this alone is insufficient, and fat breakdown occurs to supply energy. Ketones are produced as a by-product during fat breakdown. In general, if your glucose levels are normal and you feel fine, these ketone levels are not dangerous. However, if your blood glucose is more than 200 mg/dl or you feel tired, have vomiting, or feel giddy, you should consult your doctor. If you have a fever, dehydration, or any infections, your doctor may give more importance to the ketones in the urine and ask you to abandon fasting.

It is now accepted that self-monitoring blood glucose with a glucometer does not invalidate the fast. People with diabetes should be educated about the frequency of monitoring during the pre-Ramadan education. The number of times blood glucose should be monitored differs according to the different risk categories of the patient. Regular glucose monitoring may not be required for people with well-controlled blood glucose levels and on medicines that do not cause low glucose (Metformin, SGLT2 inhibitors, DPP4 inhibitors). If you have well-controlled diabetes on oral drugs that cause hypoglycemia or insulin, you need to check at least two times daily. If glucose levels are not well controlled and you have diabetes complications, you need to check glucose more frequently.

An ideal 7-point glucose profile recommendation by IDF is as follows:

1. Pre-dawn meal (Suhoor)
2. Morning
3. Midday
4. Mid-afternoon
5. Pre-sunset meal (Iftar)
6. Two hours after Iftar
7. At any time when there are symptoms of hypoglycemia/ hyperglycemia or feelings of being unwell

Everyone with diabetes planning to observe fasting should undergo a pre-Ramadan check-up. This check-up assesses each person’s glucose control, diabetic complications, and safety in observing fast. The treating doctor will investigate the glucose control, risk and severity of diabetes complications, risk of possible hypoglycemia during fasting, and the potential for worsening complications. The check-ups include tests of glucose control, kidney functions, liver function, assessment of eye issues, and cardiovascular disease. Based on these reports and clinical evaluation, the doctor will help classify your risk for fasting. People with low risk can observe fasting without much risk of worsening the disease. Those with high risk should preferably avoid fasting.

People with type 2 diabetes at low risk of developing complications according to their current disease state are allowed to fast. This includes individuals with a shorter duration of type 2 diabetes (< 10 years), reasonably well-controlled glucose levels (HbA1c < 7.5 %), no major chronic diabetes complications, or no recent hospitalization for high or low glucose. However, if individuals choose to fast, they should be cautious and discontinue fasting if any problems arise. Likewise, those with uncontrolled type 2 diabetes, type 1 diabetes, and people with diabetes-related complications belonging to the high-risk category should refrain from fasting. People with diabetes planning to fast should meet their treating doctors and discuss the risks and safety of fasting. Your doctor is the best person to decide if it is safe for you to fast.

Type 1 diabetes (T1D) is an autoimmune condition in which the pancreas can no longer produce insulin to control your blood sugar naturally. So, you need to take insulin to manage your blood sugar to remain healthy and avoid serious complications. Most individuals with type 1 diabetes should be treated with multiple daily prandial and basal insulin injections or continuous subcutaneous insulin infusion (insulin pumps). Insulin replacement regimens typically consist of basal insulin and mealtime insulin. The newer faster-acting insulin Aspart(FiAsp) and insulin Lispro-Aabc may reduce prandial excursions better than conventional insulins. New longer-acting basal analogs (U-300 glargine or Degludec) may confer a lower hypoglycemia risk compared with existing basal insulins.

Injectable and oral glucose-lowering drugs have been studied as adjuncts to insulin treatment of type 1 diabetes. Pramlintide is based on the naturally occurring β-cell hormone and is approved for use in adults with type 1 diabetes. It is found to have a modest reduction in HbA1c. Similarly, results have been reported for several agents currently approved only for the treatment of type 2 diabetes. The addition of metformin, glucagon-like peptide 1 receptor agonists (GLP-1 Ra) and sodium-glucose cotransporter 2 (SGLT2) inhibitors have been studied in clinical trials in people with type 1 diabetes, showing mild improvements in HbA1C changes in body weight. However, SGLT2 inhibitor use in type 1 diabetes is associated with an increased rate of diabetic ketoacidosis. Regulators in Europe have approved using Dapagliflozin and Sotagliflozin in adults with type 1 diabetes as an oral therapy, and injection pramlintide has been approved in Europe and US.

For people with type 1 diabetes, there have been considerable strides in technologies for monitoring glucose and delivering insulin. Our blog will soon highlight this aspect. Watch out !

Injectable drugs are essential in the management of diabetes. This includes various forms of insulin and a relatively new class of molecules called GLP-1RA analogs.
For insulin, we now have short-acting (e.g., Aspart, Lispro, Glulisine) and ultrashort acting analogs (e.g., FiAsp), which act much faster than traditional human insulin and control the glucose levels after meals. We also have modern insulins like Degludec and U300 Glargine, which act beyond 24 hours). Although not available for clinical use, once-weekly insulin (ICODEC) is also available in research.

GLP-1RA is a class of injectable medicines in diabetes that are available as once-daily and once-weekly injections. They stimulate the pancreas to produce more insulin and suppress glucagon production. Once weekly injections called Dulaglutide (Trulicity) and once-daily injections called Liraglutide (Victoza) have heart and kidney protection in addition to lowering glucose levels. One of these molecules, called Semaglutide, is available as a once-weekly injection and for daily oral use. Tirzapatide is a new molecule in research that combines the actions of GLP-1 and GIP. It produces more glucose-lowering and weight loss than GLP-1RA.

Some injections combine both a GLP-1RA and long-acting insulin. They are called IDegLira (Xultophy) and IGlarLixi (Soliqua). IDegLira is available in India.

Author
Dr. Mathew John

Type 2 diabetes mellitus is a disease where multiple defects in insulin production and action or reduction in GLP-1RA result in high blood glucose levels and lead to significant complications. We have several drugs to treat Type 2 DM, which addresses many of the above defects and gives the patient reasonable overall metabolic control. Most people with diabetes are first started on oral medicines before injectable medications. The older oral medicines include Metformin, Sulphonylureas(e.g Glimepiride), Pioglitazone and DPP4 inhibitors.

The new drugs are mainly of two groups:

1.Semaglutide (RYBELSUS) is a new oral diabetes medicine that acts similar to GLP-1. The levels of GLP-1 are reduced in diabetes. GLP-1 increases insulin production from the pancreas and reduces the production of glucagon. Glucagon is a hormone that raises blood glucose.

2.GLIFLOZINS or Sodium-Glucose cotransporter 2 (SGLT2) Inhibitor are a group of medicines that act by flushing out glucose through the urine and reducing blood glucose. As a result, they have kidney and heart protection benefits, especially in people with previous kidney and heart disease. The drugs in this group are Empagliflozin, Canagliflozin, and Dapagliflozin.

Author
Dr. Deepa G

It is well known that diabetes is one of the most common causes of developing kidney disease. But most often, it is thought that it is the diabetes medicines that are responsible for the development of kidney diseases. This is not true. Not only are diabetes medicines safe, but some medications even protect your kidneys. High blood glucose, uncontrolled hypertension, and smoking are responsible for increasing the risk of kidney disease. But once a person develops kidney disease, doctors may adjust the dose of many medications used. This is because many drugs are excreted out of the body by the kidney, and the blood levels of these drugs may increase in kidney disease. Therefore, some medications may need to be stopped or dosages adjusted according to the kidney functions of that person. (E.g., Pain killers (NSAID), Antibiotics).

Some of the newer classes of diabetes medications also prevent the progression of diabetic kidney disease. The most prominent among these are SGLT2 inhibitors, whose latest studies show they help treat diabetic kidney disease. The common drugs in this group are empagliflozin, dapagliflozin and canagliflozin. In addition, GLP-1 receptor agonists, another newer group of medicines too, can prevent the progression of diabetic kidney disease. The common drugs in this group are Liraglutide and Dulaglutide. Finally, a new drug class named Finerenone was recently approved for treating kidney disease in people with diabetes.

Author
Dr. Tittu Oommen