Review

Diabetes control during Ramadan fasting

A. V. Raveendran, MBBS, MD and Abdul Hamid Zargar, MBBS, MD, DM
Cleveland Clinic Journal of Medicine May 2017, 84 (5) 352-356; DOI: https://doi.org/10.3949/ccjm.84a.16073

Article Figures & Data

Tables

  • TABLE 1

    Risk of complications during Ramadan fasting: International Diabetes Federation categories

    Category 1: very high risk
    One or more of the following:

    • Severe hypoglycemia within the 3 months before Ramadan

    • Diabetic ketoacidosis within the 3 months before

    • Ramadan

    • Hyperosmolar hyperglycemic coma within the 3 months before Ramadan

    • History of recurrent hypoglycemia

    • History of hypoglycemia unawareness

    • Poorly controlled type 1 diabetes

    • Acute illness

    • Pregnancy with preexisting diabetes, or gestational diabetes treated with insulin or a sulfonylurea

    • Chronic dialysis or stage 4 or 5 chronic kidney disease

    • Advanced macrovascular complications

    • Old age with ill health

    Category 2: high risk
    One or more of the following:

    • Type 2 diabetes with sustained poor glycemic control

    • Well-controlled type 1 diabetes

    • Well-controlled type 2 diabetes on multiple-dose insulin or mixed insulin

    • Pregnancy with type 2 diabetes or gestational diabetes controlled with diet only or with metformin

    • Stage 3 chronic kidney disease

    • Stable macrovascular complications

    • Comorbid conditions that present additional risk factors

    • Diabetes and intense physical activity

    • Treatment with drugs that may affect cognitive function

    Category 3: moderate/low risk
    Well-controlled type 2 diabetes treated with one or more of the following:

    • Lifestyle therapy

    • Metformin

    • Acarbose

    • Thiazolidinediones

    • Second-generation sulfonylurea

    • Incretin-based therapy

    • Sodium-glucose cotransporter 2 inhibitor

    • Basal insulin

  • TABLE 2

    Exemption from fasting during Ramadan

    Generally exempted from fasting:
    Children
    Elderly people
    People with acute illness
    Pregnant women
    Developmentally disabled people (with serious physical handicaps, intellectual disability)
    People with chronic illness with multiple complications
    People who must travel long distances daily
    Diabetes-related exemptions from fasting:
    Type 1 diabetes
    Type 2 diabetes with unstable disease
    Complications of diabetes
    Pregnancy and diabetes
    Older age with diabetes
    Breaking the fast is recommended in the following cases:

    • If blood glucose < 3.3 mmol/L (60 mg/dL) or symptoms of hypoglycemia

    • If blood glucose > 16.7 mmol/L (300 mg/dL)

    • If blood glucose < 3.9 mmol/L (70 mg/dL) in the morning, if patient is already on insulin or a sulfonylurea

  • TABLE 3

    Recommendations for adjusting diabetes medications during Ramadan fasting

    MedicationRecommendations
    MetforminRisk of hypoglycemia is low, so usually no dosage modification required
    Split the dose: one-third predawn, the rest at sunset
    SulfonylureaHigh risk of hypoglycemia
    Glimepiride, gliclazide, and glipizide are preferred over conventional sulfonylureas such as glibenclamide because of comparatively fewer hypoglycemic events
    ThiazolidinedioneRisk of hypoglycemia is low, so usually no dosage modification required
    If taken with other antidiabetic drugs, take one-fourth of the dose predawn, the rest at sunset
    Alpha glucosidase inhibitorRisk of hypoglycemia is low
    Gastrointestinal side effects can be problematic
    Nonsulfonylurea secretagogues (glinides)Low risk of hypoglycemia, so no adjustment required for twice-daily dosing
    Because of faster onset and shorter duration of action, nateglinide is preferred over repaglinide during Ramadan fasting as the risk of fasting hypoglycemia is low
    Glucagon-like peptide 1 receptor agonistRisk of hypoglycemia is low, so no dosage modification required if taken alone
    If taken with sulfonylurea, dose reduction required
    Dipeptidyl peptidase 4 inhibitorRisk of hypoglycemia is low, so no dosage modification required
    Sodium-glucose cotransporter 2 inhibitorAvoid during Ramadan fasting due to risk of osmotic diuresis, dehydration, and ketoacidosis
    InsulinHigh risk of hypoglycemia
    Premixed 70/30 insulin during Ramadan fasting more likely to cause hypoglycemic episodes than premixed 50/50
    Usual morning dose at sunset, and half of nighttime dose predawn
    Insulin analogues are associated with a lower risk of hypoglycemia than human insulin
    Reduce dose of long-acting insulin analogues by 20%
    During Ramadan fasting, a basal bolus regimen is preferred, including a long-acting basal insulin (eg, glargine, detemir, degludec) with a short-acting insulin (eg, glulisine, aspart, lispro) before meals
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