Abstract 178: Importance of risk stratification and utility of Acarbose as a treatment option in patients with diabetes mellitus during Ramadan fasting

Background: Ramadan is a holy month in the Islamic calendar during which Muslims all over the world observe a fast between dawn and sunset. The management of people with diabetes who fast during Ramadan had previously been based on expert opinion rather than medical evidence gained from scientific data. Risk stratification is an essential aspect of all diabetes and Ramadan recommendations. The International Diabetes Federation has recently in 2021 formulated an excellent tool based on recent evidences that will help people with diabetes and their health care professionals to make better decisions regarding fasting during Ramadan. Through this study we aimed to apply this risk stratification tool in our patients with diabetes who opted to fast during Ramadan as well as compare their glycemic control and change in clinical and biochemical parameters pre and post Ramadan. Aims: To study the effect of Ramadan fasting on the glycemic control, occurrence of hypoglycemia as well as clinical and biochemical parameters of patients with diabetes and to categorize them based on risk stratification. We also aimed to assess the impact of adjustment of antidiabetic medications and their dosages with specific emphasis on hypoglycemia. Methods: We conducted an observational, single centre, prospective study in the outpatient clinic of department of Endocrinology at Osmania Medical College, Hyderabad. 150 patients who satisfied inclusion criteria were recruited at least 1 week prior to the month of Ramadan after taking informed written consent. A structured questionnaire was undertaken which included demographic details, type of diabetes, antidiabetic medications used (oral antidiabetic agents/insulin), any other chronic drug intake and comorbidities. Risk stratification tool as proposed by IDF in 2021 was used to categorise patients into low risk, moderate risk and high risk and appropriate health education and counselling were given. The patients were divided into 5 drug groups based on the drug modifications done for Ramadan. Modifications to treatment regimens were done as per standard protocols in order to achieve glycemic control and avoid the risk for hypoglycemia. The patients were followed up 1 week after Ramadan to assess the number of individuals who developed hypoglycemia during fasting and parameters like BMI, lipid profile, FBS, PPBS, HbA1c were measured. Results: The mean age of the study population was 47.63+/- 10.5 years.140 patients had type 2 diabetes and 10 patients had type 1 diabetes. 44% of study population belonged to low risk, 33% into moderate risk and 23% into high-risk category as per IDF 2021 risk stratification tool. Out of the total 150 study participants, 137 of them had fasted in the previous year's Ramadan (2020).46 of 137 (33.57%) patients gave history of experiencing hypoglycemia during the previous year's fasting (2020) as compared to only 27/148 (18.24%) in 2021. Among these, 62.9% were from the high-risk group. Comparison of the patient characteristics between Ramadan 2020 and Ramadan 2021 revealed that pre-Ramadan education resulted in lower number of patients with hypoglycemic episodes (16.05% vs 33.57%), motivated more number of patients to do SMBG during fasting (12.4% to 21.8%) and lower number of patients with hyperglycemia (10.94% to 5.83%). The percentage of individuals who fasted for at least 15 days increased from 90.5% to 97.08%. BMI showed an improving trend post Ramadan (25.97 ± 2.63 kg/m2 vs 25 kg/m2 ± 1.98) which was also statistically significant (P < .0001). Other parameters like Blood pressure, HbA1c, FBS, PPBS and LDL cholesterol showed improving trends post Ramadan although statistical significance could not be achieved. It was also noted that those who were prescribed Acarbose did not experience any hypoglycemic episodes as compared to other drug regimens like gliptins, metformin glimepiride combination, repaglinide and insulin and this difference was also statistically significant (P < .001). Maximum number of hypoglycemic episodes were reported in the insulin group (63.1%; 12/19), majority of them being type 1 diabetics (42.1%; 8/19), which highlights the importance of focusing on this group with regard to counselling and advice as well as risk stratification. Conclusion: The development and utilization of Ramadan-focused diabetes education programs is essential to provide better care and ensure the safety of people with diabetes who fast during Ramadan. The findings of this study clearly emphasize the continuous need to prioritize risk stratification and to institute pre-Ramadan assessment and interventions in advance. It is essential to promote and strengthen a structured approach to Ramadan focused diabetes education and self-monitoring to ensure safe fasting, thereby preventing and reducing complications. It also highlights potential role of Acarbose for use among diabetics during Ramadan.