Practical Guide to

Diabetes Management in Ramadan

Quick Reference Guide forHealth Care Providers

MINISTRY OF HEALTH MALAYSIA

MALAYSIA ENDOCRINE& METABOLIC SOCIETY

KEY MESSAGES

1. Many Muslims with diabetes choose to fast during Ramadan even though they are exempted from it due to their health conditions.

2. Fasting is associated with excessive glycogen breakdown, increased gluconeogenesis and ketogenesis leading to hyperglycaemia and ketoacidosis.

3. Fasting during Ramadan may be associated with improvements in glycaemic control, blood pressure, high-density lipoprotein (HDL) levels and body weight.

4. Diabetic patients who fast are at higher risk of hypoglycaemia, hyperglycaemia and ketoacidosis with increased rate of hospitalisation.

5. Risk stratification is important to identify patients who are at risk of developing complications during fasting.

7. Regular glucose monitoring is recommended during Ramadan.

6. Pre-Ramadan medical review and education concerning self-care during Ramadan is important.

8. a) Appropriate meal planning is important to avoid postprandial hyperglycaemia.

b) Appropriate modification in intensity and timing of physical activity is important to maintain optimal glycaemic control and optimal weight.

9. Adjustment for oral anti-diabetic medications and insulin should be individualised to lower the risk of hypoglycaemia when fasting during Ramadan.

This Quick Reference Guide provides key messages and a summary of the Practical Guide to Diabetes Management in Ramadan.

Details of the evidence supporting these recommendations can be found in the above Practical Guidelines, available on the following websites:Malaysian Endocrine & Metabolic Society: http://www.mems.my

RISK STRATIFICATION

Categories of risk in patients with Type 1 or Type 2 diabetes mellitus who fast during Ramadan

Note: This classification is based largely on expert opinion and not on scientific data derived from clinical studies.*Advised to abstain from fasting.

Very high risk* • History of severe diabetes complications within 3 months prior to

fasting » Severe hypoglycaemia » Ketoacidosis » Hyperosmolar hyperglycaemic coma » Recurrent hypoglycaemia • Hypoglycaemia unawareness • Acute illness • Sustained poor glycaemic control (HbA1c >9%) • Pregnancy • Advanced renal failure/chronic dialysisHigh risk* • Moderate hypoglycaemia (HbA1c 7.5-9.0%) • Moderate renal failure • Advanced macrovascular complications • Living alone and treated with insulin or sulfonylureas • Patients with co-morbid conditions that present additional

risk factors • Old age with ill health • Treatment with drugs that may affect mentationModerate risk • Well-controlled diabetes treated with short-acting insulin

secretagoguesLow risk • Well-controlled diabetes treated with lifestyle therapy,

metformin, acarbose, thiazolidinediones, and/or incretin-based therapies in otherwise healthy patients

Timing and frequency of SMBG based on treatment

TherapyOral anti-diabetic (OAD)

Insulin

Frequency of SMBGMonitor when symptomatic

Diabetic patients who are in the moderate to high risk categories are advised to monitor their blood glucose.• Pre-meal and 2-hour post pre-dawn meal (sahur)• Mid-day• Pre-meal and 2-hour post sunset-meal (iftar)• Bedtime

Timing of SMBG could reflect adequacy of insulin dose

Timing of SMBGMid-dayPre-iftar

2-hour post-iftar/ bedtime

Pre-sahur2-hour post-sahur

Insulin timingPre-sahurPre-sahurPre-sahur

Pre-iftar/Pre-bedPre-sahur

Type of insulinPremixed/bolus/basal insulin

Premixed/basal insulinPremixed/bolus insulin

Premixed/basal insulinPremixed/bolus insulin

When to end the fast during Ramadan

Conditions to stop fasting:• Blood glucose <3.3 mmol/l at any time during the fast• Blood glucose <3.9 mmol/l in the first few hours of fasting (especially if

the patient is taking sulfonylureas, meglitinides, or insulin)• Blood glucose >16.7 mmol/l• Experience symptoms of hypoglycaemia (patients without SMBG) • Symptoms suggestive of severe dehydration such as syncope

and confusion

LIFESTYLE, DIET AND EXERCISE

Adjustment of the diet protocol for Ramadan fasting

• Never skip sahur (dawn meal). Sahur should consist of balanced meals with adequate carbohydrate taken as late as possible just before Imsak to avoid unnecessary prolonged fasting.

• Do not delay “berbuka”. Limit intake of high-sugary foods e.g. “kuih”. However, 1-2 kurma (dates) as start of “berbuka” according to Sunnah may be taken as part of carbohydrate exchange. Main meal is encouraged after Maghrib prayers.

• Supper after Tarawih can be taken as replacement of pre-bed snack.

• Include fruits and vegetables at both sahur and “berbuka”. High fibre carbohydrates are encouraged at all meals.

• Limit fried or fatty foods.

• Limit intake of highly salted foods to reduce risk of dehydration.

• Sufficient fluid must be taken to replenish fluid loss during the day. Aim for 8 glasses a day. Choose sugar-free drinks. Drink adequately at sahur.

• Dietary indiscretion during the non-fasting period with excessive binging, or compensatory consumption of carbohydrates especially sweetened and fatty food contributes to the risk of hyperglycaemia and weight gain.

Physical activity

• Light and moderate intensity exercise on a regular basis.

• Avoid rigorous exercise during fasting time because of risk of hypoglycaemia.

• The timing of exercise is preferably 1-2 hours after the break of fast.

• Performance of Tarawih night prayers helps to maintain physical activity.

SELF-MONITORING BLOOD GLUCOSE (SMBG)

INSULIN THERAPY

Insulin adjustments during Ramadan

Insulin regimenBasal insulin only

Premixed insulin once dailyPremixed insulin twice daily

Basal bolus insulin• Basal insulin

• Bolus / Prandial insulin

Insulin pump

Type 1 diabetes mellitusNot applicable.

Not applicable.

Reverse doses – Morning dose given at iftar and evening doseat sahur.Insulin dose at sahur reduced by 20-50% to prevent daytime hypoglycaemia.

Taken at bedtime or any time after iftar meals. May require dose reduction if there is daytime hypoglycaemia.Sahur – Usual pre-Ramadan breakfast or lunch dose. May require dose reduction to avoid daytime hypoglycaemia.Lunch – Omit.Iftar – Usual pre-Ramadan dinner dose. May require dose increment.*Total insulin requirement for Type 1 diabetics who are on basal bolus regimen while fasting during Ramadan may require dose reduction by 15-30% of their pre-Ramadan dose requirements.

Basal insulin rate: Unchanged or may require reduction of up to 25%.Prandial bolus: According to individualised insulin to carbohydrate ratio (ICR).

Type 2 diabetes mellitusTaken at bedtime or after iftar meals.May need dose reduction if there is risk of daytime hypoglycaemia.Inject usual dose at iftar meals.Reverse doses –Morning dose given at iftar and evening dose at sahur.

Insulin dose at sahur reduced by 20-50% to prevent daytime hypoglycaemia.ORChange to short/rapid acting*.* Late afternoon hypoglycaemia

may occur.

ORAL ANTI-DIABETIC (OAD) THERAPY

Adjustments of oral anti-diabetic agents in patients with Type 2 diabetes who are fasting during Ramadan

Regimen

α-glucosidase inhibitors

Biguanides(Metformin)

Dipeptidyl peptidase-4 inhibitorsMeglitinides

Sulphonylureas

Sodium glucose co-transporter2 inhibitors*Thiazolidinediones

Sunset meal(iftar)

No changes

No changesTwo third of dose

Full doseNo changesNo changes

No changes

No changes

No changes

No changes

Pre-dawn meal (sahur)

No changes

No changesOne third of dose

NoneNo changesNo changes

Reduce/Omit

Sunset meal dosing

Sunset meal dosing

None

Immediate-releaseTwice dailyThrice dailyExtended-release

Glibenclamide,GliclazideGliclazide MR,Glimepiride

NON-INSULIN INJECTABLES

*Based on expert opinion.

Regimen

Glucagon-like peptide-1 receptors agonists (GLP1RA)

Sunset meal(iftar)

No changes

Pre-dawn meal (sahur)

No changes

SUMMARY OF TREATMENT ALGORITHM

Pre-Ramadan medical review• Performed 1-2 months before Ramadan• Approach should be individualised• Assessment of glycaemic control, blood pressure, and lipids

The development of this guide was supported by an educational grant from:

Follow-up is essential after Ramadan• HbA1c, blood pressure, lipid• Readjustment of medications where appropriate• Revert back to pre-Ramadan treatment regimen

Evaluate risk of developing complications during Ramadan

Structured Ramadan-focusedpatient education• Meal planning and dietary advice with a dietition• Appropriate timing and intensity of exercise• Blood glucose monitoring• Knowing when to end the fast• Recognising and managing acute complications

Treatment adjustmentsChanges to diabetes medication regimes:• Treatment choice• Timing and frequency of dosing• Dosage adjustments

• Moderate risk• Low risk

• Very high risk• High risk

Advised to abstain from

fasting