Most Muslims with diabetes will take part in Ramadan even though they may be exempt from doing so. In some countries a religious fast can last between 10 and 21 hours. The main risk of fasting to people with diabetes is hypoglycemia. People with diabetes who fast may have to alter the dose of their medications or modify their therapeutic regimen to avoid hypoglycemia, which can have adverse effects on glycemic control. Therapies which pose a high risk of hypoglycemia when used during fasting are sulfonylureas and insulin therapy. Metformin, incretin therapies and the newer sodium glucose co-transporter 2 inhibitor class have a low risk of hypoglycemia. The practice of fasting during Ramadan is advocated for all healthy individuals. If deemed detrimental to health then a person can be considered exempt from fasting; this includes frail and elderly people, pregnant and breast feeding women, children and people with multi-morbidities.
Diabetic nephropathy is the principal cause of end-stage renal disease (ESRD) in patients requiring renal replacement therapy. Insulin-treated patients with diabetes on hemodialysis (HD) have a higher rate of severe hypoglycemia compared with non-insulin treated patients. This results from multiple factors, such as increased sensitivity to insulin. In addition, most patients with long-term type 1 diabetes have diminished counter-regulatory responses to hypoglycemia; HD therefore poses a major challenge to their management. Different therapeutic strategies (eg use of glucose-containing solutions for dialysis and strict monitoring of blood glucose during and after dialysis sessions) are recommended to reduce the risk of developing hypoglycemia. However, little evidence is available to help clinicians optimize the dose of insulin before, during and after dialysis sessions. The pharmacokinetics of insulin preparations are complicated and not well described in the setting of glomerular filtration rate <15 ml/min/1.73 m2. The difficulties encountered in managing patients with type 1 diabetes and ESRD who are receiving HD are illustrated in this case report.
This case study describes a 40-year-old lady with long-standing type 1 diabetes for 37 years. Despite a history of recurrent hypoglycemia, impaired hypoglycemia awareness and an eating disorder, by changing to continuous subcutaneous insulin infusion therapy with an insulin pump, in combination with carbohydrate counting, she restored her hypoglycemia awareness and reduced blood glucose variability. This gave her the confidence to register to run in a marathon but during training experienced wide fluctuations in blood glucose with frequent hypoglycemia. With continuous glucose monitoring using a glucose sensor, she was able to undertake a strenuous training programme and subsequently manage her glucose to avoid hypoglycemia and maintain good control for the duration of the marathon. For some people with type 1 diabetes, technological advances have provided the capacity to reduce hypoglycemia risk, improve their quality of life, and enable them to participate in demanding physical activities.
