Case Report:

Diabetic Ketoacidosis Complication in

Type 1 Diabetes Mellitus Patient Who
Performed Ramadhan Fasting
Surya Abadi Kristyoadi1, Nur Handy Megawanto1, Laksmi Sasiarini2

1.Internal Medicine Resident, Faculty of Medicine, Brawijaya University, Malang

2.Endocrinology, Metabolism & Diabetes Consultant, Faculty of Medicine, Brawijaya University –
dr. Saiful Anwar General Hospital Malang

Fasting during Ramadhan is obligatory for all healthy Muslims.1 Fasting will result in hypoinsulinemia and hyperglucagonemia.
Fasting can lead to excessive glycogenolysis, increased lipolysis and This can lead to excessive glycogenolysis, lipolysis and ketone
ketogenesis especially in patients with Type 1 Diabetes Mellitus body formation and eventually development of DKA.4
(T1DM).1 Gluconeogenesis &
The risk of Diabetic Ketoacidosis (DKA) in T1DM patient are increased ketogenesis Peripheral tissues
during fasting.1 Increased glucose uptake
Liver
The International Diabetes Federation – Diabetes and Ramadan (IDF-
Glucose
DAR) Practical Guidelines categorised T1DM patient in very high risk
group, so they must be advised not to fast.2
Glycogen stores depleted
Excessive breakdown Pancreas
 A 24-year-old male was brought to emergency department with a Insulin secretion
gradual decreased of consciousness, vomit, and shortness of breath. decreased or absent
 He had T1DM since 15 years ago and routinely used Detemir 12 iu at
night and Aspart 6 iu three times daily before meal. IDF-DAR Practical Guidelines categorised people with diabetes into
 He performed Ramadhan fasting for 10 days and decreased the three risk groups (very high, high, and moderate/low risk).2
dosage of the insulin by himself.
 He had experienced a similar incident (DKA) 3 months before • Severe hypoglycemia within 3 months prior to
Ramadan
Ramadan with poor glycemic control (HbA1C 12.7%).
• Unexplained DKA within 3 months prior to
Ramadan
• Hyperosmolar hyperglycemic coma within 3
Very months prior to Ramadan
High • History of recurrent hypoglycemia
Weight : 57 kg Risk • Poorly controlled T1DM
Height : 162 cm Groups • Acute Illness
BMI : 21,72 kg/m2 • Pregnancy in pre-existing diabetes or Gestational
Diabetes
Somnolence, GCS 345 • Chronic dialysis or CKG stage 4 & 5
Blood pressure 120/70 mmHg
• Advanced macrovascular complications
• Old age with ill health
Tachycardia 112 bpm
People with poorly controlled T1DM must be advised not to fast.
Tachypneu 26 tpm (kussmaul) If they insist on Ramadhan fasting, then they should :
 Receive structured education
 Be followed by a qualified diabetes team
Laboratory Result Laboratory Result  Check their blood glucose regularly (Self Monitored Blood
Glucose)
Hb 13.7 g/dL Natrium 126 mmol/L
 Adjust medication dose as per recommendation
Leucocyte 19,720 /µL Kalium 5,13 mmol/L  Be prepared to break the fast in case of hypo- or
Random blood 1,130 Chloride 75 mmol/L hyperglycemia
glucose mg/dL  Be prepared to stop the fast in case of frequent hypo- or
HbA1c 13.6% Osmolality 328 mOsm/L hyperglycemia or worsening of other related medical
6.3 conditions.2
Keton Serum
BGA : Ph 7.18 ; HCO3 7.4 mmol/L ; PCO2 19.4 mmHg Recommended Timings to Check Blood Glucose Levels during
Anion Gap 43.6 Ramadan Fasting3
3
Conclusion : High anion gap metabolic acidosis 1. Pre-dawn meal (suhoor) DAY 4
2. Morning 2
Diagnosis : Type 1 diabetes with severe DKA 3. Midday Suhoor 5 Iftar
7
precipitating factor : Ramadhan Fasting 4. Mid-afternoon 1
6
5. Pre-sunset meal (iftar)
Rehydration NIGHT
6. 2-hour after iftar
Continuous IV insulin 7. At any time when there are
Kalium Correction symptoms of hypoglycemia/
Subcutaneous insulin basal bolus hyperglycemia or feeling
unwell
DKA was resolved All patients should break their fast if :
25 1,130 1,250
20.5 •Blood glucose <70mg/dl (re-check within 1 hour)
20 1,000 •Blood glucose >300mg/dl
15
15 750 •Symptoms of hypoglycemia or acute illness occur.2
13
10 500
7.4
5 3.47 250
5.13 137
0 •A pre-Ramadhan assessment is vital for patient with poorly-
Day 1 Day 2 Day 3 Day 4 Discharged controlled T1DM, who are classified as very high risk group.
•They must be advised not to fast. Close medical supervision is
GCS Blood glucose (mg/dL) HCO3 (mmol/L) Potassium (mmol/L)
needed if they insist on Ramadan fasting.

1. Hassanein M, Al-Arouj M, Hamdy O, Bebakar W, Jabbar A, Al-Madani A, et al Diabetes and Ramadan: Practical guidelines. International Diabetes Federation (IDF), in
collaboration with the Diabetes and Ramadan (DAR) International Alliance. 2016:1-141
2. Hui E, Bravis V, Hassanein M, Hanif W, Malik R, Chowdury T, et al. Management of people with Diabetes wanting to fast during Ramadan. BMJ 2010;340:c3053. doi:
10.1136/bmj.c3053
3. Ibrahim M, Abu Al, Magd M, Annabi FA, Asaad-Khalil S, Ba-Essa E, et al. Recommendations for management of diabetes during Ramadan: update 2015. BMJ Open Diabetes
Research and Care 2015;3: e000108. doi:10.1136/bmjdrc-2015-000108
4. Karamat M, Syed A, Hanif W. Review of Diabetes management and guidelines during Ramadan. J R Soc Med 2010: 103: 139-147.