Muslims are required to fast during the month of Ramadan from sunrise to sunset.
However, there are exceptions to this. One of them is that people who are ill or have medical conditions do not have to fast. This includes some people with diabetes.
Patients should be stratified into their risk of hypoglycemia and/or the presence of complications prior to the beginning of fasting. Patients at high risk of hypoglycemia and with multiple diabetic complications should be advised against prolonged fasting.
Agents such as metformin, α-glucosidase inhibitors, TZDs, and DPP4 inhibitors appear to be safe and do not need major dose adjustments.
Sulfonylureas and insulin secretagogues should be used with extreme caution during Ramadan fasting, in particular chlorpropamide or glyburide, which are associated with increased risk of hypoglycemia. The dose of sulfonylureas should be reduced or the medication stopped before the start of the fast, depending on the degree of glycemic control, kidney function, and presence of diabetic complications. There is increasing knowledge on the efficacy and safety of DPP4 inhibitors as monotherapy or in combination with metformin therapy. The use of DPP4-inibitors appears to be safe and with low rates of hypoglycemia. The use of GLP-1 RA may also be of benefit in obese patients in improving glycaemic control and in reducing appetite during Ramadan. There is no data on the safety and efficacy of SGLT-2 inhibitors during the fasting period of Ramadan.
|Fasting pre-Iftar pre-Suhoor BG||Insulin adjustment|
|>16.6 mmol/L (300 mg/dL)||Increase insulin daily dose by 20%|
|>10 mmol/L (180 mg/dL)||Reduce insulin daily dose by 10%|
|5.5–10 mmol/L (100–180 mg/dL)||No change|
|<5.5 mmol/L (100 mg/dL) or symptoms||Reduce insulin daily dose by 10%|
|< 3.9 mmol/L (70 mg/dL)||Reduce insulin daily dose by 20%|
|<2.8 mmol/L (50 mg/dL)||Reduce insulin daily dose by 30–40%|
Patients with type 1 and type 2 diabetes treated with insulin should be educated on the appropriate use of insulin administration and the need for glucose monitoring during the fasting period. Most patients require a modification of the basal insulin dosage and on the use of premeal insulin to cover meals after breaking of the fast. In some patients, a larger insulin dose may be needed after a large evening meal. The use of basal insulin analogs and continuous insulin infusion may be of benefit as they cover basal requirements without significant peaks and may result in less hypoglycemia compared with human NPH and premixed insulin. The drawbacks of insulin analogs and insulin pump therapy are the cost and limitations of technology support in some countries. Finally, patients should be instructed that POC testing does not break the fast and that glucose monitoring may reduce the risks of hypoglycemia in patients receiving insulin secretagogues and insulin therapy.