Effects of Advanced Hybrid Closed Loop System on Glucose Control in People Fasting During Ramadan

For individuals with type 1 diabetes (T1D), fasting during Ramadan is feasible for those using an advanced hybrid closed loop (AHCL) automated insulin delivery (AID) system, a study published in Diabetes Research and Clinical Practice found.

During the month of Ramadan, practicing Muslims must refrain from eating and drinking between sunrise and sunset, and most people consume 2 meals a day during this period.

As a result of these dietary changes, individuals with T1D are at an increased risk of experiencing complications during Ramadan. In general, fasting for extended periods of time can increase the risk of the effects of poor glycemic control, such as hypoglycemia, hyperglycemia, diabetic ketoacidosis (DKA), dehydration, and higher glycemic variability.

Most expert guidelines advise this group to not partake in the fast.

“Islamic authorities agree with medical experts to provide explicit exemptions from fasting for people with T1DM,” the authors wrote. “Despite the clear exemptions from both medical and religious authorities being available, 43% of this population continues to fast during Ramadan even during COVID-19 pandemic which had minor impact on the decision to fast Ramadan in T1DM cohort.”

This prospective, single-center, randomized-controlled, intervention study focused on the use of the MiniMed 780G AHCL system, which provides customizable targets for users.

After withdrawals from the study or not meeting requirements, 42 patients stayed with the study until the end of follow-up, with 21 in the intervention group and 21 in the control group. The participants were aged between 12 and 25 years. The mean diabetes duration was approximately 4 years and the mean time on an AHCL system was almost 2 years.

Intervention consisted of participants adjusting AID pump settings during the full month of Ramadan differently than before joining the study. Meanwhile, participants in the control group had their AID pump settings adjusted by an algorithm based on data collection from the sensor on aggressive settings.

The authors noted all 42 participants had excellent glycemic levels prior to Ramadan, and there were no significant differences in baseline demographic and clinical data or AHCL system performance between groups.

Effects of the AHCL system on carbohydrate consumption, blood glucose control, times in range (TIR), and insulin doses delivered during Ramadan were measured.

The study demonstrated satisfactory glucose control without significant changes in TIR and without an effect on the proportion of time spent with low glucose values during Ramadan, compared with before Ramadan. However, the control cohort demonstrated the highest level in TIR and occurred without an increase in hypoglycemia at the lower set point. Meanwhile, the intervention group did not show any increase in levels of hypoglycemia at the higher set point.

Participants in the control group initiated the AHCL system with a glucose target of 100 mg/dL and an active insulin time (AIT) of 2 hours, while those in the intervention group had a target of 120 mg/dL and AIT of 3 hours.

Both groups saw a similar increase in carbohydrate intake at the end of Ramadan compared with before Ramadan, due to breaking the daily fast. The AHCL system maintained TIR between 70 and 180 mg/dL in both groups before and after Ramadan.

No significant changes were seen in sensor glucose levels.

Based on findings from this study, the authors introduced the following clinical recommendations for adolescents and young adults who have T1D, use an AHCL system, and fast during Ramadan:

• The goal is to set target to 100 mg/dL
• Use of AIT of 2 hours
• Make insulin to carbohydrate ratio more aggressive by increasing Iftar meal bolus by an average of 34.4%, especially if carbohydrate amount increases by more than 100 grams
• Temporary target feature in final hours before breaking the fast can be adjusted to 150 mg/dL
• Time spent in Auto Mode suggests that improvements in glycemia will be sustained

Reference

Elbarbary NS, Ismail EAR. Glycemic control during Ramadan fasting in adolescents and young adults with type 1 diabetes on MiniMed™ 780G advanced hybrid closed‑loop system: a randomized controlled trial. Diabetes Res Clin Pract. Published online August 17, 2022. doi:10.1016/j.diabres.2022.110045