Effect of Different Insulin Regimens on Individuals with Type 2 Diabetes during Ramadan Fasting in the DAR Global Surveys of 2020 and 2022

Abstract The DAR (Diabetes and Ramadan International Alliance) global surveys of 2020 and 2022 presented a unique opportunity to study the differences among various insulin treatment regimens during Ramadan fasting in individuals with diabetes to better understand the risks and complications associated with insulin therapy between the different regimens. Individuals with type 2 diabetes on an intensive insulin regimen were categorized into two cohorts: 1,527 receiving basal-bolus insulin (14.1%) and 1,355 on premixed insulin (12%). We examined the patterns of differences between the two cohorts concerning baseline characteristics, diabetes-related complications, dysglycemia occurrence, and hospitalization rates during fasting. The mean age was similar between cohorts (56.0 ± 12.1 years in basal-bolus vs. 55.1 ± 11.3 years in premixed insulin). However, the basal-bolus group had a significantly longer diabetes duration (14.1 ± 8.4 vs. 12.5 ± 7.5 years, p = 0.03). Other metabolic parameters, including HbA1c, body mass index, blood pressure, and low-density lipoprotein cholesterol levels were not different. Insulin use was slightly higher in women in both groups. Proportions of those who fasted, practiced self-monitoring of blood glucose, and had access to Ramadan-focused education were similar in the two cohorts. The basal-bolus cohort had tended to have increased occurrence of hypoglycemic episodes (23.9% vs. 17.7%, p = 0.08) but similar rates of hypoglycemia (6.5%). Frequent hyperglycemia (≥8 days) and the hyperglycemia-related emergency visits and hospitalizations were significantly higher in the basal-bolus group (9.0% vs. 3.7%, p < 0.001). Multiple-dose premixed insulin regimens in this study appear less prone to hyperglycemic episodes and hospitalizations. However, a causal relationship cannot be inferred as differences and variations in medical management, prescribing habits, and fasting practices across wider regions must be considered confounding factors. Carefully designed randomized-controlled studies are needed to establish a definitive link.