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Current Pediatric Research

Insulin pump therapy during Ramadan fasting

Author(s): Bassam Saleh Bin-Abbas

Vol. 11, No. 1 (2007-10 - 2007-12)

Curr Pediatr Res 2007; 11 (1 & 2): 33-34

Bassam Saleh Bin-Abbas

Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia

Keywords: Type 1 diabetes, insulin pump therapy, Ramadan Fasting

Accepted July 07 2007

Abstract

The present study was undertaken to assess the efficacy, effectiveness and safety of insulin pump therapy in type 1 diabetic Saudi adolescents during Ramadan fasting and to compare it with conventional insulin (CI) therapy. nsulin pump therapy improved the glycemic control in type 1 diabetic adolescents and decreased frequency of hypoglycemic episodes requiring breaking the fast during the holy month of Ramadan.

Introduction

Since the introduction of continuous subcutaneous insulin infusion (CSII) in the late 1970s, it has become apparent that the use of insulin pump therapy has many potential benefits for children and adolescents with type 1 diabetes. It improves the glycemic control, reduces hypoglycemia and decreases the episodes of recurrent diabetic ketoacidosis (DKAs) [1-3]. Fasting during Ramadan has been uniformly discouraged by the medical profession for children and adolescents with type 1 diabetes especially those with brittle poorly controlled diabetes [4]. Insulin pump therapy may help in controlling blood glucose during fasting and its continuous insulin infusion can be modified and adjusted instantaneously to avoid hypoglycemia and breaking the fast. To our knowledge, this is the first study that describes the use of insulin pump therapy in adolescents with type 1 diabetes and shows its efficacy and safety during Ramadan fasting. The present study was undertaken to assess the efficacy, effectiveness and safety of CSII through insulin pump therapy in type 1 diabetic Saudi adolescents during Ramadan fasting and to compare it with conventional insulin (CI) therapy.

Methods

CSII was initiated in 5 Saudi adolescents with type 1 diabetes mellitus through insulin pump therapy between October 2003 and June 2005. All patients were followed at The Pediatric Endocrinology Clinic at The Specialized Medical Center Hospital, Riyadh, Saudi Arabia. These adolescents showed interest in fasting the Holy month of Ramadan in the Higri year of 1427 (between 23 September and 23 October 2006). The patients were trained on insulin pump programming and carbohydrates counting and started on continuous basal insulin infusion in addition to meal and high blood glucose correction insulin boluses. The results of blood glucose levels and the rate of hypoglycemic episodes were compared with those in 4 adolescents with type 1 diabetes who were on CI therapy. CI therapy is defined as 2 insulin injections per day; before breakfast and before dinner combining the intermediate acting insulin (NPH) and the short-acting insulin (regular). The patients on CI therapy were trained on the exchange program for diet therapy and showed also interest in fasting Ramadan. All patients visited the clinic prior to the month of Ramadan to adjust insulin doses and they were instructed to check blood glucose more frequently especially during the fasting hours. The recommended times for blood glucose checkup were presunset meal, 2 hours after, pre-dawn meal, 2 hours after, pre-school, after school and as needed.

Results

The patients included in the study had type 1 diabetes mellitus for a mean duration of 7 years (range from 5 to 9 years). The age of the adolescents ranged from 15 to 19 years. They were followed on insulin pump therapy for a mean duration of 18 months. There was a significant reduction in HbA1c, mean blood glucose level and the frequency of hypoglycemic episodes in adolescents on insulin pump therapy in comparison to CI therapy during Ramadan fasting. The mean HbA1c was 7.8% (7.1-8.9%) in insulin pump group of adolescents in comparison to CI group which was 9.1% (8.3-10.6%) (p <0.001).

The mean blood glucose was 123 mg/dl (72-201) in insulin pump group in comparison to CI group which was 192 (122-394) (p <0.001). The mean frequency of simple hypoglycemia (defined as blood glucose less than 60mg/dl) was 16 episodes (12-29) per patient per month in comparison to CI group which was 29 episodes (19-36) per patient per month (p <0.002). None of the patients developed severe hypoglycemia (defined as hypoglycemia associated with coma or convulsion) or DKA during Ramadan fasting. One month prior to Ramadan, the mean frequency of simple hypoglycemia in insulin pump group was 11 episodes per patient per month and the mean frequency of simple hypoglycemia in CI group was 18 episodes (p<0.001).

Three of adolescents on CI therapy had to break their fast during Ramadan once or twice because of hypoglycemia. However, none of the insulin pump group broke their fast. All adolescents on insulin pump therapy had to adjust their basal rate insulin infusion to avoid hypoglycemia prior to Ramadan fasting. Ten to 15% of the basal insulin infusion rate was reduced during the hours of fasting. One patient on insulin pump therapy suspended the pump for 2 hours to avoid hypoglycemia. The predawn insulin doae was reduced 10 to 20% in CI group of patients. Total insulin dose requirement was 0.9 units/kg/day (0.8-1.2) in insulin pump group in comparison to 1.1units/kg/day (1.0-1.3) in CI group. One unit of the ultra-short acting insulin lispro (Humalog) was required to cover for 10 grams of carbohydrates and one unit of lispro insulin was required to cover for 50 to 100mg/dl of blood glucose above 100mg/dl as a correction bolus for high blood levels.

Discussion

Several reports [4] indicated that fasting in Ramadan is safe for the majority of diabetic patients with proper education and diabetes management. Most type 2 diabetics can fast safely during Ramadan. Ooccasionally patients with type 1 diabetes who insist on fasting during Ramadan can also fast if they are carefully managed. In this study, we compared the frequency of hypoglycemia and the blood glucose level in type 1 diabetic adolescents using insulin pump therapy with conventional insulin regimen. The frequency of hypoglycemia was significantly lower in CSII group. The ability to lower the basal insulin infusion rate in insulin pump or even suspend it helped diabetics to avoid major hypoglycemic attacks during fasting. Patients were able to continue fasting till the dawn time by controlling and adjusting the basal rate. None of insulin pumpers broke their fast during Ramadan in comparison to the adolescents on CI therapy who had once or twice fasting breakthrough. Eating during the period of fasting in Ramadan may have a negative psychological effect on patients especially during the adolescence period. Adolescents may feel embarrassed to eat or drink and break their fast although they feel hypoglycemic. Insulin pump therapy helped these adolescents to feel more satisfied and confident.

Conclusion

Insulin pump therapy improved the glycemic control in type 1 diabetic adolescents and decreased frequency of hypoglycemic episodes requiring breaking the fast during the holy month of Ramadan.

References

  1. Bin-Abbas BS, Sakati N, Raef H, Al-Ashwal AA. Continuous subcutaneous insulin infusion in type 1 diabetic Saudi children: A comparison with conventional insulin therapy. Saudi Med J 2005; 26: 918-922
  2. Bin-Abbas BS, Sakati N, Al-Ashwal AA. Continuous subcutaneous insulin infusion in type 1 diabetic Saudi children. A comparison with multiple daily insulin injection therapy. Ann of Saudi Med 2006; 26:327-328
  3. Bin-Abbas BS, Sakati N, Al-Ashwal AA. Glycemic control and treatment satisfaction in diabetic Saudi children on insulin pump therapy. Ann Saudi Med 2006;26:405
  4. Al-Arouj M, Bouguerra R, Buse J, Hafez S, Hassanein M, Ibrahim MA et al. Recommendations for management of diabetes during Ramadan. Diabetes Care 2005; 28: 2305-2311

Correspondence:
Bassam S. Bin-Abbas
Section of Pediatric Endocrinology
Department of Pediatrics, MBC 58
King Faisal Specialist Hospital and Research Center
PO Box 3354, Riyadh 11211,
Saudi Arabia
Phone: 009661-4427763
Fax: 009661-4427784
Cellphone: 009661-505-66255
e-mail: benabbas(at)kfshrc.edu.sa

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