Safe Fasting with Diabetes during Ramadan


Safe Fasting with Diabetes during Ramadan

Ramadan Study Group from BIDE offers useful suggestions for diabetics
to modify the dosage
of Anti-diabetic preparations including Insulin

By Prof. M. Yakoob Ahmedani

Fasting in Ramadan is one of the five pillars of Islam. According to the 2009 estimates, Muslims constitute 1.57 billion of the world’s population and growing by 3% per year. Globally, around 50 million Muslims with diabetes fast during the month of Ramadan each year.
Ramadan specific education of patients with diabetes has been identified as the cornerstone of safe fasting. The data of prospective studies regarding fasting during Ramadan is scarce. Most of the studies are retrospective and observational. Recommendations and suggestions regarding safe fasting from expert physicians depend on their personal experiences and evidence based guidelines are missing. Hence, a Ramadan study group was formed by Baqai Institute of Diabetology and Endocrinology lead by Prof. Muhammad Yakoob Ahmedani to conduct research in the field of diabetes and Ramadan.

The aims and objectives of the Ramadan study group are as follows;

* To educate patients, doctors and diabetes educators about Ramadan specific recommendations.
* To develop Ramadan specific education material.
* To conduct research in the field of diabetes and Ramadan.
* To develop a website for educating people with diabetes regarding fasting in Ramadan.
* To conduct a multi-national, multi-centered study in order to develop evidence based guidelines for safe fasting in patients with diabetes.

A research article from this group was recently published in Diabetic Medicine, titled; “Ramadan Prospective Diabetes Study: Role of drug dosage and timing alteration, active glucose monitoring and patient education”. Based on the findings of the study following recommendations were made;

Ramadan specific guidelines for doctors

The Ramadan specific guidelines given below are based on our experience. The most important point is the realization that the patient care must be highly individualized and the management plan may differ for each patient.

Patients taking oral hypoglycemic agents

Patients on metformin alone: We suggest that patients on metformin and diet control should continue with their dosage as Pre Ramadan and take them at Sehar and Iftar. For example; patient taking 1 gram BD should continue with their dosage at Sehar and Iftar. For patients taking metformin 500 mg three times a day, we recommend 500 mg at Sehar and 1000 mg at Iftar.

Patients on Acarbose alone: We suggest continuing the prescribed dose(s) of Acarbose at Sehar and Iftar.

Sulphonylureas: During Ramadan change the timing of the once daily dose of Sulphonylurea (such as glimepiride) from the usual morning dose to the evening (at Iftar) and reduce the dose to 75% of the actual dosage. For patients on twice a day dosage regimen, reduce the morning dose to 75% and should be given at Iftar, reduce the night dose to 50% and should be taken at Sehar.

Thiazolidinediones alone: During Ramadan change the timing of the once daily dose of Thiazolidinediones (such as pioglitazone) from the usual morning dose to the evening (at Iftar) dose.

Dipeptidyl peptidase-4 inhibitors (DPP 4 inhibitors) alone: The same Pre Ramadan dose can be continued during Ramadan except for the change in timing.

Patients taking combination of oral hypoglycemic agents: Those on combination of secretagogues and other oral hypoglycemic agents would require adjustment in dosage and timing of all the drugs in the combination.
Patients taking insulin

Single basal insulin and oral combined treatment: Patients on combination either with metformin or with sulphonylureas or both, with insulin need to adjust their dosage. We suggest patients who take long acting basal insulin, such as glargine, to reduce the dose by 30%. i.e. 20 units to be reduced to 14 units and those taking with combination of sulphonylurea in addition of this reduction also need to reduce the dose of sulphonylurea to 75% of actual dosage, this means patients taking 4mg of glimepiride in morning should cut down to 3mg at Iftar.

Premixed Insulin’s: We suggest patients on 70/30 regime should do modification in their regime by taking 75% morning pre Ramadan dose at Iftar and shifting of pre Ramadan night dosage to pre Sehar and reducing it to half. For example patients taking 40 units of premixed in morning should cut down to 30 units at Iftar and taking 30 units at night should reduce to 16 units at Sehar.

Patients on R and N regime: We suggest that patients need modification in their dosage. Full dose of R and 75% of N of the morning pre Ramadan dose should be given at Iftar. Whereas, 50% reduced pre Ramadan evening dose of R and N should be given at Sehar.

First night of Ramadan: First night of Ramadan (that is the night before first fast) is very important. The pre-dinner dosage of OHA/ Insulin should be reduced to 75% of usual dose for eg. Patient taking 20 units at night should be given 16 units.


Normal levels of physical activity may be maintained. However, excessive physical activity may lead to a higher risk of hypoglycemia and should be avoided, particularly during the few hours before the sunset meal. Quite commonly, multiple prayers (Tarawih) are offered after the sunset meal; this generally involves repeated cycles of rising, kneeling and bowing and should be considered as part of the daily exercise program.

When to consider breaking the fast

All patients should understand that they must always and immediately end their fast if hypoglycemia (blood glucose of < 60mg/dl (3.3 mmol/l)) occurs because their blood glucose may drop further if they delay treatment. The fast should also be broken if blood glucose reaches < 70 mg/dl (3.9 mmol/l) in the first few hours after the start of fast, especially if insulin, sulphonylurea drugs or meglitinide are taken at Sehar.

Ramadan focused education

In our Ramadan study those who attended an education program focusing on Ramadan had a significant decrease in hypoglycemic events. We suggest that patients with diabetes should ideally attend some form of structured education to increase their chances of being well when fasting during Ramadan. Doctors should discuss the following aspects of fasting:
1. Hypo and Hyperglycemia symptoms
2. Self-monitoring of blood glucose, especially if they develop symptoms
3. Dosage and timing alteration
4. Diet and fluid intake during Ramadan
5. Physical activity
6. When to break the fast.

Diet in Ramadan

All patients should take at least 3 meals a day i.e. Sehri, Iftar and Dinner. Diet during Ramadan should not differ significantly from a healthy and balanced diet. It should aim at maintaining a constant body mass. The common practice of ingesting large amounts of food rich in carbohydrate and fat, especially at the sunset meal, (Iftar) should be avoided. Because of the delay in digestion and absorption, ingestion of food containing “complex” carbohydrates may be advisable at the predawn meal, while food with simple carbohydrates may be more appropriate at the sunset meal. Based on our recent study we recommend to reduce the intake of carbohydrates and spread the carbohydrate intake over 3 or 4 occasions (Sehri, Iftar, Dinner and Bedtime). It is also recommended that fluid intake should be increased during non-fasting hours and the predawn meal should be taken as late as possible before Sehar.
This year Ramadan study group organized Pre-Ramadan series of workshops for General Practitioners involved in the care of patients with diabetes with the support of Getz Pharma Pvt. Ltd. in different cities such as; Rawalpindi, Mardan, Peshawar, Multan, Faisalabad, Gujranwala, Lahore, Sukkur, Larkana, Hyderabad and Karachi. The workshops were conducted by Prof. Abdul Basit, Prof. Muhammad Yakoob Ahmedani, Dr. Zahid Miyan, Dr. Asim Bin Zafar, Dr. Asher Fawwad, Dr. Saif Ulhaque and Dr. Syed Faraz Danish Alvi.

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