Recommendations for adjusting diabetes medications during Ramadan fasting
| Medication | Recommendations |
|---|---|
| Metformin | Risk of hypoglycemia is low, so usually no dosage modification required Split the dose: one-third predawn, the rest at sunset |
| Sulfonylurea | High risk of hypoglycemia Glimepiride, gliclazide, and glipizide are preferred over conventional sulfonylureas such as glibenclamide because of comparatively fewer hypoglycemic events |
| Thiazolidinedione | Risk 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 inhibitor | Risk 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 agonist | Risk of hypoglycemia is low, so no dosage modification required if taken alone If taken with sulfonylurea, dose reduction required |
| Dipeptidyl peptidase 4 inhibitor | Risk of hypoglycemia is low, so no dosage modification required |
| Sodium-glucose cotransporter 2 inhibitor | Avoid during Ramadan fasting due to risk of osmotic diuresis, dehydration, and ketoacidosis |
| Insulin | High 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 |