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A Quick Guide For Diabetes And Ramadan 2021
Introduction
● Fasting in Ramadan is one of the five pillars of Islam.
● Ramadhan is basically a lunar-based month, and its duration varies
between 29 and 30 days.
● Timing depends on geographical locations and duration of daily fast may
range from a few to more than 20 hours.
● Muslims who fast during Ramadan must abstain from eating, drinking, use
of oral medications, and smoking from dawn to dusk. However, no
restrictions on food or fluid intake between sunset and dawn.
● There are two main meals daily during this month; one after sunset
referred as Iftar in Arabic (breaking fast) and the other meal is before
dawn, referred as Sahur (predawn).
● In Surah Al-Baqarah 183-185, Quran specifically exempts the sick from the
duty of fasting, especially if fasting might lead to harmful consequences for
the individual.
● Diabetic patients fall under this category because their chronic metabolic
disorder may place them at high risk for various consequences and
complications if the amount of their meal and fluid intake are significantly
altered.
● Poorly controlled Type 1 DM patients have higher risk of hyperglycemia
because of their dependence on insulin, on the other hand poorly
controlled Type 2 DM patients have higher risk of hypoglycaemia due to
maladjustment of insulin.
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Fluids and Dietary Advice
● Complex carbohydrates are more preferred taken at pre dawn meal rather
than at sunset meal because of the delay in digestion and absorption.
Foods with simpler carbohydrates may be advisable during breaking fast.
● It is advisable that fluid intake is increased during non-fasting hours and at
pre dawn meal be taken as late as possible before the start of daily fast.
The reason for this matter is to prevent dehydration and reduce the risk of
thrombosis in DM patients.
● Avoid caffeinated and sweetened drinks
● Keep hydrated between sunset and sunrise by drinking water and other
non-sweetened beverages
● Use small amount of oil when cooking
● Avoid sugary desserts
● Minimise foods that are high in saturated fats
● Eat plenty of fruits, vegetables and salads
● Take low glycaemic index, high-fibre foods that release energy slowly
before and after fasting. For example; rice and beans
● Ensure meals are well-balanced
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Glycaemic Targets During Ramadhan Exercise

● Depends on comorbid conditions and whether patients have type 1 or type ● Normal levels of physical activities may be maintained. Patients with Type
2 DM. 1 DM have high risk of rebound hyperglycemia because high intensity
● This aims to prevent hypoglycemia. exercise is a stressful form of training which potentially increases blood
● When is the right time to conduct Self Monitoring Blood Glucose (SMBG): glucose levels. Insulin levels consequently fail to rise and compensate for
1. Pre-dawn meal (suhoor) the increased production of glucose-raising hormones in DM patients.
2. Morning ● For patients with type 1 DM, aerobic exercise usually causes blood
3. Midday concentration to drop quickly, while anaerobic exercise may cause it to
4. Mid-afternoon
rise, thereby making glycaemic control challenging.
5. Pre-sunset meal (iftar)
6. 2 hours after iftar ● During aerobic exercise, a failure in circulating insulin levels to decrease in
7. At any time when there are symptoms of hypoglycaemia/ individuals with type 1 DM limits glucose production by the liver while
hyperglycaemia or feelings of being unwell. facilitating an increase in glucose disposal into skeletal muscles. Because of
• Target: the mismatch in glucose production and utilization, circulating glucose
○ Pre-meal glucose level: Between 5 – 6 mmol/l levels drop and hypoglycemia can occur.
○ 2 hours after meals: Between 6 – 9 mmol/l ● In contrast, during anaerobic exercise, a rise in catecholamines and a
● Revert back to tight glucose control after Ramadan. failure in circulating insulin levels to increase at the end of vigorous
exercise in type 1 DM increases glucose production by the liver and at the
same time limits the disposal of glucose into skeletal muscle. Hence, due
to this mismatch in glucose production and utilisation, circulating glucose
Diabetes-related Risks
levels rise and hyperglycemia occurs.
1. Hypoglycaemia, especially during the late period of fasting before Iftar ● For type 2 DM patients, regular exercise improves glucose levels because it
2. Severe hyperglycemia after each of the main meals enhances insulin sensitivity, increases cardiorespiratory fitness, improves
3. Dehydration, especially in countries with longer fasting hours and hot glycaemic control, reduces the risk of cardiovascular mortality and
climates enhances psychosocial well-being.
4. Significant weight gains due to an increased caloric intake and a reduction ● Rigorous exercise should be avoided during the last hours of fasting
in physical activity especially before iftar because of the high risk of hypoglycaemia and
5. Electrolyte imbalances dehydration. Diabetic patients are encouraged to maintain their normal
6. Acute renal failure in individuals prone to severe dehydration, particularly physical activity during Ramadan. Taraweeh prayers performed in
the elderly and those with impaired kidney function. Ramadan should be also considered as a part of their daily exercise
activities, as bowing, kneeling and rising are the physical exertions they are
taking.
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Insulin Regimen
Insulin Bolus (Rapid Acting)
● SC Insulin Aspart Flexpen
300iu/3ml (Novorapid®)
Insulin Bolus (Short Acting)
● Humulin R
● SC Actrapid
Insulin Basal
● SC Insulin Detemir 300
iu/3ml Injection In Prefilled
Pen (Levemir®)
● SC Insulin Glargine
450iu/3ml Prefilled Pen
(Toujeo®)
Premixed Insulin Once Daily
● SC Aspart 30% And
Protaminated Insulin Aspart
70% 30 iu/3ml Prefilled Pen
(Novomix®)
Premixed Insulin Twice Daily
● SC Aspart 30% And
Protaminated Insulin Aspart
70% 30 iu/3ml Prefilled Pen
(Novomix®)
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Insulin
Normal Type 1 Diabetes Type 2 Diabetes Gestational Diabetes Mellitus
Inject immediately ● Dose at Sahur to be reduced by
before three main 30-50%
meals ● Omit lunch dose
● Maintain dose at iftar and can
Inject 30 minutes On ICR/ISF On Fixed Doses be adjusted based on 2hr post
before meal Correction
iftar glucose reading
Continue the same No change at iftar but
for iftar and sahur reduce sahur dose by
20 – 30%
Inject before sleep HBA1c < 7.5% HBA1c > 7.5% SC Glargine: Can be taken any time
(Last injection at 10 Reduce dose by Keep same dose and after iftar.
pm) 20-30% follow up SC Levemir and NPH: Can be given
Take at iftar or Take at iftar or late either at bedtime or divided into BD
late evening or evening or that of during sahur and iftar.
that of pre- pre- Ramadan
Ramadan bedtime bedtime May need to reduce dose if the risk
of daytime hypoglycaemia is high
Inject once daily; No changes Take usual dose at iftar Take usual dose at iftar
either before dinner
or before breakfast
Inject twice daily; Reverse doses – Morning dose given at Reduce Sahur dose by 20-50% Premixed (analogue or conventional)
before breakfast and iftar and evening dose at sahur. AND ● Shift pre-Ramadan morning
dinner Take normal dose at Iftar dose to iftar
But it is encouraged to: ● Inject 50% of the pre-Ramadan
Reverse doses between morning and evening dose at Sahur
evening dose and 50% of pre Ramadan
evening dose shifted to the pre-sahur dose.
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Insulin Regimen
Insulin Basal Bolus
● Basal Insulin
● Bolus/ Prandial Insulin
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Insulin
Normal Type 1 Diabetes
Inject basal insulin Taken at bedtime or any time after Iftar meals. May require a dose reduction if there
before bedtime. is daytime hypoglycaemia.
Inject bolus/prandial Sahur – Usual pre-Ramadan breakfast or lunch dose. May require a dose reduction
insulin before main to avoid daytime hypoglycaemia.
meals Lunch – Omit.
Iftar – Usual pre-Ramadan dinner dose. May require dose increment if meals are heavy
Basal Bolus with analogue insulin:
Basal insulin:
● 30-40% reduction in dose and to
be taken at Iftar
Rapid Analogue Insulin:
● Dose at Sahur to be reduced by
30%-50%
● Omit pre-lunch dose
● Remain same at Iftar, and dose
can be adjusted based on 2-hour
post iftar glucose reading.
Basal Bolus with conventional insulin:
NPH insulin:
● The usual pre-Ramadan morning
dose to be taken at iftar
● 50% of the pre-Ramadan evening
dose to be taken at Sahur
Regular insulin:
● Sahur dose will be 50% of the pre-
Ramadan evening dose
● Omit lunch dose
● Dose at evening meals remains
the same.
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Type 2 Diabetes
Bolus insulin:
● Reduce sahur dose by 25%- Basal insulin:
50%.
● Omit lunch dose
● Normal dose at Iftar
Basal Insulin:
NPH/detemir/glargine/degludec
ONCE DAILY:
● Reduce dose by 15%-30%
and take at iftar
NPH/detemir/glargine TWICE DAILY: Basal Bolus with conventional insulin:
● Reverse doses – Morning
dose given at iftar and
evening dose at sahur AND
reduce evening dose by
50% and take at Sahur to
avoid daytime
hypoglycemia.
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Gestational Diabetes Mellitus
Basal Bolus with analogue insulin:
● 30-40% reduction in dose and to
be taken at Iftar
Rapid Analogue Insulin:
● Dose at Sahur to be reduced by
30%-50%
● Omit pre-lunch dose
● Remain same at Iftar, and dose
can be adjusted based on 2-
hour post iftar glucose reading.
NPH insulin:
● The usual pre-Ramadan
morning dose to be taken at
iftar
● 50% of the pre-Ramadan
evening dose to be taken at
Sahur
Regular insulin:
● Sahur dose will be 50% of the
pre-Ramadan evening dose
● Omit lunch dose
● Dose at ifar to be adjusted
based on 2hr post iftar glucose
reading.

Insulin Regimen
Insulin Pump Therapy
Glucagon-like peptide-1
Receptor Agonists (GLP-1 RA)
● SC Dulaglutide 0.75mg,
1.5mg (Trulicity)
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Insulin
Normal Type 1 Diabetes Type 2 Diabetes Gestational Diabetes Mellitus
Inject / Pump insulin Basal rate adjustment: Basal rate adjustment: Basal rate adjustment:
as planned ● Reduce dose by 20-40% in the ● Reduce dose by 20-40% in ● Reduce dose by 20-40% in the
last 3-4 hours of fasting the last 3-4 hours of fasting last 3-4 hours of fasting
● Increase dose by 10-30% in the ● Increase dose by 0-20% ● Increase dose by 10-30% in the
first few hours after iftar early after iftar. first few hours after iftar
Bolus doses: Bolus doses: Bolus doses:
● Same principles as prior to ● Same principles as prior to ● Same principles as prior to
Ramadan Ramadan. However, normal Ramadan, and reduce dose
carbohydrate counting and post-Sahur by 20%.
insulin sensitivity principles
still apply.
Injectable Anti-Diabetic Agents
Inject once weekly Non-insulin injectable like SC Trulicity does not need a dose adjustment. However, Not applicable
injections may preferably be switched timing to Iftar.
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Oral Anti-diabetic Agents

Regimen Normal Sunset meal / Iftar Pre-dawn meal / Sahur
Alpha-glucosidase inhibitors Take orally as usual Due to its lower efficacy compared to MTF and the occurrence of SE eg flatulence, its clinical use has been limited.
● Acarbose • No change

Biguanides Immediate Take orally OD Take at iftar Not applicable

● Metformin release Take orally BD No dose modification
● Twice daily • Take after iftar and sahur
● Thrice Take orally TDS Two third of dose • Morning dose taken before sahur
daily • Combine afternoon dose with
dose taken at iftar

Extended Take orally at evening, Full dose No dose modification

release (SR, XR) or BD Take at iftar
Dipeptidyl peptidase-4 inhibitors Take orally as usual No dose modification No dose modification
● Sitagliptin
● Vildagliptin
● Saxagliptin

Meglitinides Take orally as usual No dose modification

● Repaglinide ● Take before iftar and sahur.
● Nateglinide However if a patient takes three daily doses, then daily dose can be reduced or redistributed to two doses during Ramadan
according to meal sizes.
Sulphonylureas Take orally as usual Once daily dosing:
● Gliclazide ● Take at iftar
● Glibenclamide ● If BG is well-controlled, dose may be reduced accordingly.

● Gliclazide MR Twice daily dosing:

● Glimepiride ● Iftar dose remains the same
● If BG is well-controlled, Sahur dose should be reduced.

Older drugs in SU class e.g. glibenclamide carry a higher risk of hypoglycaemia. Use second generation e.g. gliclazide, gliclazide
MR or glimepriride instead.

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Oral Anti-diabetic Agents

Regimen Normal Sunset meal / Iftar Pre-dawn meal / Sahur
Sodium glucose co-transporter 2 Take orally as usual No dose modification Switch timing to iftar
inhibitors • Take at iftar
● Empagliflozin
● Dapagliflozin
● Canagliflozin

Thiazolidinediones Take orally as usual No dose modification No dose modification

● Pioglitazone • Take at iftar • Should be taken with iftar rather than sahur. Individuals should not be
● Rosiglitazone switched onto this class close to Ramadan as it can take up to 3 months
to reach an optimum level.

Extras on T1DM patients:

1. In T1DM patients, basal-bolus regimen using a long-acting insulin analogue and a prandial rapid acting insulin analogue, has a lower risk of hypoglycaemia
compared to conventional twice-daily insulin regimen. It is the preferred treatment option for paediatric and adolescent individuals.
2. To minimise risk of hypoglycaemia for T1DM patients using long-acting insulin analogues such as SC Glargine, many studies recommended a reduction of 20% from
pre-Ramadan basal dose and given earlier in the evening for example after iftar. Some studies however recommend a reduction up to 40%, depending on patients’
diet during Ramadan.
3. Injecting bolus of rapid-acting insulin 20 minutes before a meal results in a significantly better postprandial glucose control than when it is given just prior to the
meal or after meal initiation. Timing is important especially for high-fat and high-protein meals, which are often associated with iftar.
4. Premixed insulin regimens are incompatible with safe fasting and should be discouraged. This is due to the requirements of a fixed intake of carbohydrates at set
times to counteract the two peaks of activities associated with insulin profile. It can be difficult for adolescents that have the tendency to eat erratically during
Ramadan and are therefore not advised.
5. Insulin pump therapy has proved to be beneficial in all paediatric groups with T1DM.

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Extras on T2DM patients:

1. Basal insulin combined with oral hypoglycaemic agents in T2DM patients proved to have low incidence of symptomatic hypoglycemia.
2. In terms of prandial insulin, rapid-acting analogue insulin lispro is more preferred than short-acting soluble human insulin in lowering postprandial blood glucose
level during iftar and the rate of hypoglycaemia is significantly lower in patients taking rapid-acting.
3. Although premixed insulin can be more convenient, the risk of hypoglycaemia is still higher than basal-bolus regimen. However, comparing two premixed insulin
formulations ie premixed analogue and premixed conventional, it is shown that premixed analogue insulin has lower risk of hypoglycaemia.
4. Dose adjustments for long or short-acting insulins in T2DM patients:

Fasting/pre-iftar/pre-sahur blood Pre-Iftar Pre-Iftar/Post-Sahur* Pre-Iftar

glucose
Basal Insulin Short-Acting Insulin Premixed Insulin

< 3.9 mmol/L or hypoglycemic Reduce by 4 units Reduce by 4 units Reduce by 4 units
symptoms

< 5.0 mmol/L Reduce by 2 units Reduce by 2 units Reduce by 2 units

5.0 - 7.0 mmol/L No change No change No change

> 7.0 mmol/L Increase by 2 units Increase by 2 units Increase by 2 units

> 16.7 mmol/L Increase by 4 units Increase by 4 units Increase by 4 units

* post-sahur blood glucose level reflects the dose adjustment required to be done before injecting at iftar. Hence reduce insulin dose taken before iftar.

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Risk score, based on IDF DAR Practical Guidelines 2021 :

High risk → should not fast

Moderate risk → advised not to fast

Low risk → should be able to fast

• The risks of fasting include hypoglycaemia, hyperglycaemia, DKA

and dehydration.
• Physicians must quantify these risks and stratify each individual
accordingly.
• With the correct guidance, many people with diabetes can fast
during Ramadan safely but they must be under the close
supervision of healthcare professionals and made aware of the
risks of fasting.
• The new IDF-DAR risk stratification defines three risk categories
and provides a risk score that includes multiple factors that plays
an important role in the fasting decision recommended for each.
• Individuals who fast against the advice provided by their
healthcare professionals should follow expert and detailed
guidance to avoid the development of serious complications.

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References:

1. Al-Arouj et al. Recommendations for Management of Diabetes During Ramadan. Diabetes Care, Vol 28, No 9, SEP 2005. Page 2305-2311. Available at
https://care.diabetesjournals.org/content/diacare/28/9/2305.full.pdf
2. Riddell et al. Exercise and Glucose Metabolism in Persons with Diabetes Mellitus: Perspectives on the Role for Continuous Glucose Monitoring. Journal of Diabetes
Science and Technology Volume 3, Issue 4, July 2009. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769951/pdf/dst-03-0914.pdf
3. Practical Guide to Diabetes Management in Ramadan. Malaysia Endocrine & Metabolic Society. Ministry of Health Malaysia. July 2019
4. Diabetes and Ramadan. Practical Guidelines 2021. International Diabetes Federation and DAR International Alliance. January 2021.

Remarks:

This quick guide for Diabetes and Ramadan is mainly extracted from the latest updates from Diabetes and Ramadan Practical Guidelines 2021 published in January 2021
in order to aid pharmacists and pharmacy assistants in making any intervention or recommendation to patients or healthcare professionals during Ramadan.
Further information may be obtained from the latest guidelines or any available and trusted resources.

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