Fasting during the ramadan: a challenge for patients with adrenal insufficiency
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EDITORIAL
Fasting during the ramadan: a challenge for patients with adrenal insufficiency Miguel Debono1
Received: 10 April 2017 / Accepted: 12 May 2017 © Springer Science+Business Media New York 2017
During the Ramadan, Muslims fast every day, from dawn to sunset, for a whole month. The fast is a stressful period when individuals abstain from eating and drinking and are therefore at risk of dehydration, fainting, low glucose levels, intense thirst, and asthenia. In patients with adrenal insufficiency who are deficient in one of the major metabolic and stress hormones in the body, cortisol, this may be fatal. Daily treatment with glucocorticoids usually hydrocortisone is essential. In the paper by Chihaoui et al. [1], patients with adrenal insufficiency were mostly on twice daily hydrocortisone regimes with the higher dose during fasting administered at the sunset meal and the lower dose at the predawn meal. During Ramadan taking medicine orally is considered breaking the fast. For many fasting Muslims, strictly following their religious needs, changing the timing of their medications, in this case hydrocortisone, is inevitable. The physiological cortisol circadian rhythm is well defined with circulating levels rising at 02:00 to 04:00 h, reaching a peak an hour after waking, and after that gradually declining to lowest levels at midnight [2]. The cortisol rhythm regulates other bodily rhythms and acts as a secondary messenger between the central clock and peripheral clocks in different tissues and cells [3]. An example of this interaction is the relationship between the cortisol rhythm and the insulin resistance rhythm [4]. The
* Miguel Debono m.debono@sheffield.ac.uk 1
Consultant in Endocrinology and Honorary Senior Lecturer, Department of Endocrinology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals/University of Sheffield, Sheffield, UK
cortisol rhythm directly influences insulin resistance. If cortisol levels are abnormally high during the quiescent phase of the rhythm, that is between 19:00 and 02:00 h, this predisposes to abnormal glucose levels, increasing the risk of developing insulin resistance [5]. Similarly when subjects sleep out of phase to their normal sleep cycle, such as shift workers or during jet lag, the cortisol rhythm is misaligned hence resulting in glucose intolerance [6]. Therefore taking a higher dose of conventional hydrocortisone, which peaks within 30 to 60 min in the evening, is not advisable as this may cause metabolic disturbances and sleep problems. This may also result in fatigue and tiredness during the day. Superimposed on the stress of the fast this puts patients with adrenal insufficiency under a high risk for an adrenal crisis. In addition to this, low cortisol levels during the rest of the night have been associated with low concentrations of glucose, fatty acids, amino acids, and 3-hydroxybutyrate [7]. This could possibly explain why patients with adrenal insufficiency complain of fatigue early in the morning [8], and why patients on traditional regimes of conventional
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