Risk of diabetic ketoacidosis during Ramadan fasting: A critical reappraisal

Abstract

Objectives: To evaluate the validity of the perceived increased risk and the actual occurrence of DKA observed during fasting in Ramadan.

Methods: This is a non-systematic narrative review of the literature on the occurrence of DKA during Ramadan. Online databases (PubMed, Google Scholar, Cochrane Database, Medline OVID and CINAHL EBSCO) were searched. Three research questions are addressed 1. What is the basis of the expert opinion on the risk for DKA? 2. What is the likelihood that DKA is precipitated by Ramadan fast? and 3. What is the frequency of observed DKA during Ramadan?

Results: The expert opinion suggesting a risk of DKA during Ramadan fasting was proposed with no evidence in the early writing on Ramadan fasting and has been reiterated and propagated since then. However, from first principles, DKA is not readily precipitated by the usual stress-free metabolic environment induced by Ramadan fasting with the exception of cases involved in the usual risk factors for metabolic decompensation. Furthermore, recent studies could not document any increase in observed DKA during Ramadan fasting in retrospective, prospective and database studies.

Conclusions: The current state of knowledge and evidence suggests the risk of DKA is not increased during Ramadan fasting.

Keywords: DKA; Ethnicity, Muslims, Diabetic ketoacidosis; Fasting; Feasting, Hyperglycaemia; Hypoglycaemia; Infection; Ketosis; Ramadan.