Diabetes Management in Ramdan

A very thorough evaluation of diabetes and guidelines on how diabetes should be managed during Ramdan. This group of physicians wrote an excellent group of guidelines on the management of diabetic patients in Ramdan. They just updated their guidelines this year. This is a must read for every physician with diabetic patients who want to fast in Ramadan.

Some of the highlights:

Management of patients with type 1 diabetes

Fasting at Ramadan carries a very high risk for people with type 1 diabetes. This risk is particularly exacerbated in poorly controlled patients and those with limited access to medical care, hypoglycemic unawareness, unstable glycemic control, or recurrent hospitalizations. In addition, the risk is also very high in patients who are unwilling or unable to monitor their blood glucose levels several times daily. It is currently recommended that treatment regimens aimed at intensive glycemia management be used in patients with diabetes. The DCCT and its follow up, the Epidemiology for Diabetes Interventions and Complications (EDIC) study, demonstrated that intensive glycemia management is protective against microvascular and perhaps macrovascular complications and that the benefits are long lasting (19,28). Glycemic control at near-normal levels requires use of multiple daily insulin injections (three or more) or use of continuous subcutaneous insulin infusion through pump therapy. Close monitoring and frequent insulin dose adjustments in this setting are essential to achieve optimal glycemic control and avoid hypo- or hyperglycemia in patients with type 1 diabetes.

Some patients with type 1 diabetes prefer to fast at Ramadan, and most of them change their insulin regimens immediately before, during, and a few days after this month. However, very few studies have documented the safety and/or efficacy of different insulin regimens in type 1 diabetic patients who fast during the month of Ramadan. The current understanding is that the basal-bolus regimen is the preferred protocol of management. It is thought to be safer, with fewer episodes of hyper- and hypoglycemia. A frequently used option is once- or twice-daily injections of intermediate or long-acting insulin along with premeal rapid-acting insulin. It is unlikely that other regimens, including one or two injections of intermediate-, long-acting, or premixed insulin, would provide adequate insulin therapy. A recent small study with insulin glargine suggests the relative safety and efficacy of this agent in 15 relatively well-controlled patients with type 1 diabetes who fasted for 18 h and experienced a minimal decline in mean plasma glucose from 125 to 93 mg/dl with only two episodes of mild hypoglycemia (29). Another study in patients with type 1 diabetes using insulin glulisine, lispro, or aspart instead of regular insulin in combination with intermediate-acting insulin injected twice a day led to improvement in postprandial glycemia and was associated with fewer hypoglycemic events (30). Clinical studies with other types of insulin in multiple daily injection regimens during fasting are limited.

Continuous subcutaneous insulin infusion (pump) management is an appealing alternative strategy, but at a substantially greater expense. Compared with those who did not fast during Ramadan, patients with type 1 diabetes on insulin pump therapy who fasted showed a slight improvement in A1C (3).

Management of patients with type 2 diabetes

Diet-controlled patients.

In patients with type 2 diabetes who are well controlled with lifestyle therapy alone, the risk associated with fasting is quite low. However, there is still a potential risk for occurrence of postprandial hyperglycemia after the predawn and sunset meals if patients overindulge in eating. Distributing calories over two to three smaller meals during the nonfasting interval may help prevent excessive postprandial hyperglycemia. Physical activity may be modified in its intensity and timing, e.g., ∼2 h after the sunset meal.

Patients treated with oral agents.

The choice of oral agents should be individualized. In general, agents that act by increasing insulin sensitivity are associated with a significantly lower risk of hypoglycemia than compounds that act by increasing insulin secretion.


Patients treated with metformin alone may safely fast because the possibility of severe hypoglycemia is minimal. However, perhaps the timing of the doses should be modified to provide two-thirds of the total daily dose with the sunset meal and the other third before the predawn meal.


The thiazolidinedione or glitazone agents (pioglitazone and rosiglitazone) are not independently associated with hypoglycemia, though they can amplify the hypoglycemic effects of sulfonylureas, glinides, and insulin. However, they are associated with weight gain and anecdotally can be associated with increased appetite. The longstanding concerns regarding cardiovascular safety, caused by the increased frequency of heart failure, continue despite greater understanding that the mechanism of this adverse effect seems to be related to renal tubular sodium and water reabsorption and not to an intrinsic affect on cardiac contractility. More recently, apprehension has emerged regarding reports of increased frequency of macular edema and of bone fractures, particularly in postmenopausal women. The recent controversy regarding the cardiovascular safety of rosiglitazone seems to have been largely mitigated by the Rosiglitazone Evaluated for Cardiovascular Outcomes and Regulation of Glycaemia in Diabetes (RECORD) study, which failed to demonstrate either harm or benefit. Nevertheless, most perceive a relative advantage of pioglitazone compared with rosiglitazone vis-à-vis lipid effects. A practical issue of significant importance with respect to the utility of glitazones in periods of fasting such as Ramadan is that these agents require 2–4 weeks to exert substantial antihyperglycemic effects. Therefore, these agents cannot be quickly substituted for agents associated with hypoglycemia during periods of fasting (31).
It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia. However, severe or fatal hypoglycemia is a relatively rare complication of sulfonylurea use. Nevertheless, their use should be individualized with caution. Use of chlorpropamide is relatively contraindicated during Ramadan because of the possibility of prolonged and unpredictable hypoglycemia. Similarly, it has been suggested that glyburide or glibenclamide may be associated with a higher risk of hypoglycemia than other second-generation sulfonylureas, specifically gliclazide, glimepiride, and glipizide (32,33). Finally, it should be noted that the sulfonylureas glyburide (glibenclamide) and gliclazide MR have played a central role in the long-term outcome studies UKPDS and ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation), both of which demonstrated microvascular benefits and at least trends toward improvements in cardiovascular disease without evidence of excess mortality (34). Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made. Nevertheless, because of their worldwide use and relatively low cost, these agents may be used in Ramadan, though with caution.
Short-acting insulin secretagogues.
Members of this group (repaglinide and nateglinide) are useful because of their short duration of action. They could be taken twice daily before the sunset and predawn meals. One study in patients with type 2 diabetes who fasted showed that use of repaglinide was associated with less hypoglycemia compared with glibenclamide (35). Nateglinide has the shortest duration of action and therefore the lowest risk of severe fasting hypoglycemia among the secretagogues.

Incretin-based therapy.

Therapies that affect the incretin system include glucagon-like peptide-1 receptor agonists (GLP-1ras) exenatide and liraglutide and dipeptidylpeptidase-4 inhibitors (DPP-4is) alogliptin, saxagliptin, sitagliptin, and vildagliptin. These classes of agents are not independently associated with hypoglycemia, though they can increase the hypoglycemic effects of sulfonylureas, glinides, and insulin. Exenatide in particular can be dosed before meals to minimize appetite and promote weight loss. With its short half-life of 2 h, it is not associated with a substantial effect on fasting glucose. Liraglutide is dosed once a day, independent of meals, and is more effective in controlling fasting glycemia. Both require titration to effective doses over a period of 2–4 weeks and are associated with mild to moderate nausea in almost half of those exposed on at least one occasion, particularly as therapy is initiated. DPP-4is are among the best tolerated drugs for the treatment of diabetes. They are moderately less effective in A1C lowering than GLP-1ras and, importantly vis-à-vis treatment during Ramadan, do not require titration. Many have touted their potential role as a substitute for sulfonylureas. However, there are no specific studies of these agents during periods of fasting with respect to either tolerability or efficacy (36).

α-Glucosidase inhibitors.

Acarbose, miglitol, and voglibose slow the absorption of carbohydrates when taken with the first bite of a meal. Because they are not associated with an independent risk of hypoglycemia, particularly in the fasting state, they may be particularly useful during Ramadan. However, they are only modestly effective and exert little or no effect on fasting glucose, and therefore are usually used in combination with other agents to control fasting glucose. α-Glucosidase inhibitors are associated with frequent mild to moderate gastrointestinal effects, particularly flatulence. Using modest doses and slowly initiating therapy are reported to minimize the frequency of these adverse effects (37).

Patients treated with insulin.
Problems facing patients with type 2 diabetes who administer insulin are similar to those with type 1 diabetes, except that the incidence of hypoglycemia is less. Again, the aim is to maintain necessary levels of basal insulin to prevent fasting hyperglycemia. An effective strategy would be judicious use of intermediate- or long-acting insulin preparations plus a short-acting insulin administered before meals. Although hypoglycemia tends to be less frequent, it is still a risk, especially in patients who have required insulin therapy for a number of years or in whom insulin deficiency predominates in the pathophysiology. Very elderly patients with type 2 diabetes may be at especially high risk.

Using one injection of a long-acting or intermediate-acting insulin can provide adequate coverage in some patients as long as the dosage is appropriately individualized; however, most patients will require rapid- or short-acting insulin administered in combination with the basal insulin at meals, particularly at the evening meal, which typically contains a larger caloric load. There is some evidence suggesting that use of a rapid-acting insulin analog instead of regular human insulin before meals in patients with type 2 diabetes who fast during Ramadan is associated with less hypoglycemia and smaller postprandial glucose excursions (38,39). In a recent study, the use of premixed lispro with neutral protamine lispro in a 50:50 ratio for the evening meal and regular human insulin with NPH in a 30:70 ratio at the early morning meal during Ramadan compared with regular human insulin at 30:70 twice daily was associated with moderate improvement in glycemic control and hypoglycemia (40).

Insulin pumps.

An insulin pump provides continuous insulin delivery over 24 h with basal infusion rates programmed and individualized for each patient. Patients self-administer boluses of insulin with meals or at times of hyperglycemia, often with mathematical support from the pump. The reliance on exclusively rapid-acting or short-acting insulin allows for flexibility over an extremely wide range of insulin doses with great precision. However, frequent glucose monitoring is required because failure of the pump or the infusion site can result in severe deterioration in control over a few hours. Theoretically, the combined risks of hypoglycemia from prolonged daytime fasting and hyperglycemia from excessive nighttime eating can be better managed by an insulin pump–based regimen than by multiple insulin dose–injection therapy. Hypoglycemia can be aborted, reduced, prevented, and even more readily treated in pump-treated patients by timely downward adjustments or even stopping insulin delivery from the pump. Such an advantage is not available to those treated with a conventional insulin injection in which insulin continues to be released from the site of injection throughout its predetermined duration of action. Any excess insulin action can only be counteracted by intake of carbohydrates.

Fasting at Ramadan may be successfully accomplished in people with type 1 diabetes if they are fully educated and facile with the use of the insulin pump and are otherwise metabolically stable and free from any acute illnesses. Prior to Ramadan, they should receive adequate training and education, particularly with respect to self-management and insulin dose adjustment. They should adjust their infusion rates carefully according to results of frequent home blood glucose monitoring. Most will need to reduce their basal infusion rate while increasing the bolus doses to cover the predawn and sunset meals.

Link to full guidelines:


You can download the PDF version too!