The Holy month of Ramadan is a sacred month for Muslims. During this month, Muslims observe fast all over the world. Fasting is a ritual and one of the five pillars of Islam. It is an obligation for every Muslim adult.

The main purpose of fasting is to achieve spirituality and Taqwa and to refrain from sins. Fasting is a state of complete abstinence from food during the day time and is "Farz" (compulsory) on every adult Muslim except in the chronically ill.

Fasting is considered an obligation that purifies the soul. It is increasingly being recognized as having a lot of medical benefits. Intermittent fasting is advised by most clinical nutritionist to balance the metabolic and hormonal issues with continuous eating. However, in chronically ill and frail patients, where it can be harmful to the body, it is not recommended.

Who Should Not Observe a FAST?

From a medical point of view, fasting is not recommended in the following groups of patients:

• Patients with Diabetes Type 1:

  • Patients with Diabetes Type 1 who have very brittle diabetes, those on three or four times insulin injections, those with frequent hypoglycemia or hyperglycemia, diabetic ketoacidosis, and the elderly type 1 diabetic patient should not keep fast.
  • Patients with very well-controlled diabetes, who are on twice-daily insulin injections, and those patients who do not have any diabetes-related complications may be allowed to keep fast with caution.

• Diabetes Type 2:

  • Most patients with Diabetes Type 2 can keep fast. However, fasting in these patients should be pre-planned (at least 2 months prior to the Holy month of Ramadan).
  • Diabetes Type 2 patients who can not keep fast are those with uncontrolled blood sugars, frequent hypoglycemia, diabetic ketoacidosis, and other serious diabetes-related complications.
  • The "Unsafe for fasting" cut-off for blood sugars is 320 mg/dl and glycated hemoglobin of 11% or more.

• Other High-risk Patients:

  • Patients who have a recent hospitalization for an underlying serious disease such as heart failure or respiratory failure.
  • Those patients who have had a recent cardiac ischemic event, coronary intervention, or coronary artery bypass grafting (CABG) within the past three months.
  • Patients who have a history of stroke or other major cerebrovascular events within the past three months.
  • Patients with ESRD (end-stage renal disease) and those on hemodialysis.
  • Patients with advanced liver disease.
  • Those patients who have had recent major surgery (especially gastrointestinal or hepatobiliary surgery) within the past three months.

Other physiological states include menstruation, pregnancy, and breastfeeding.

Diabetes Management in Ramadan - How to adjust your treatment?

After the patient is considered fit to keep a Fast, his diabetic medicines should be adjusted as follows:

• Patients on Metformin alone:

  • Patients using metformin once or twice daily can continue the same doses at the same time.
  • Patients using thrice daily metformin should switch to twice daily metformin.

Examples:

• • Metformin 500 mg or 1000 mg twice daily: Continue the same dose
  • Metformin 500 mg thrice daily: Continue 500 mg at Sehri (pre-dawn meal) and 1000 mg at Iftari (after breaking the Fast).

• Patients on DPP-IV inhibitors or Thiazolidendiones monotherapy:

  • Since DPP-IV inhibitors (Sitagliptin, vildagliptin, and linagliptin) and thiazolidinediones (rosiglitazone and pioglitazone) are considered euglycemic drugs and are given once a day or twice daily, they can be continued as prescribed.

• Patients on Combination of metformin, DPP-IV inhibitors, or thiazolidinediones:

  • A combination of these drugs can be continued as prescribed.

• Patients on SGLT-2 inhibitors like Dapagliflozin, Empagliflozin, and Ertugliflozin:

  • Ideally, these medicines should not be initiated just prior to the month of Ramadan.
  • Those patients who are tolerating these medicines and have controlled blood sugars can continue the same doses.
  • However, SGLT-2 inhibitors should be switched to evening (after Iftari).

• Patients using Sulfonylureas:

  • Commonly used sulfonylureas include glimepiride, gliclazide, and glyburide.
  • Since sulfonylureas have the potential to induce severe hypoglycemia, these drugs need adjustments during the month of Ramadan.
  • Patients should be asked to switch the timings of their medications (switch the morning dose to Iftar time and the evening dose to Pre-Sehr time).

  • The doses should be reduced as follows:

    • Reduce the at-Iftar dose by one-third
    • Reduce the Sehr (Pre-dawn meal) dose by 50%.

Example:

A patient is using Glimepiride 4 mg once before breakfast. How should we adjust his dose?

• • First, switch glimepiride to "t-Iftar" time.
  • Second, reduce the dose by one-third i.e. 3 mg

Another example:

A person is using Glimepiride 4 mg in the morning and 2 mg in the evening. How should we adjust his dose?

• • First, switch the timings: 4 mg at Iftar and 2 mg at Sehr (Pre-dawn meal)
  • Second, reduce the "at-Iftar" dose by one-third and the Sehri (Pre-dawn meal) dose by 50%.
  • So, this patient's final prescription will be Tab. Glimepiride  3 mg at Iftar and 1 mg at Sehr (pre-dawn meal).

• Patients using Meglitinides:

  • Meglitinides (Repaglinide) are short-acting anti-diabetic drugs. These are insulin secretagogues.
  • because of their shorter half-life, these drugs are considered safe during Ramadan compared to sulfonylureas.
  •  These drugs are usually given prior to each meal.
  • During Ramadan, most patients will require only two doses (instead of three).

Examples:

A person is using Repaglinide 1 mg twice daily before the morning and evening meals:

• • This person can continue the same dose twice daily (at Iftar and pre-Sehr).

A person is using thrice daily repaglinide:

• • This person can discontinue the mid-day dose and continue the same doses at Iftar and Sehr as the morning and evening meals.

• A person using GLP-1 agonist:

  • These medicines include daily Liraglutide and Lixisenatide and weekly dulaglutide and Semaglutide. These medicines can be continued in the same doses as prescribed.

• A person on Insulin - Dose adjustment in Ramadan:

  • A person using insulin can follow the same protocol as patients who are using sulfonylureas.
  • However, patients on long-acting and ultra-long-term insulin can continue the same doses especially, if their pre-Ramadan blood sugars were slightly off-the-targets.

  • Short-acting and pre-mixed insulins should be adjusted as follows:

    • First, patients should be advised to switch the timings of insulin.
    • Second, the doses should be reduced by one-third at Iftar and 50% at Sehri.

Examples:

A person is on Humulin 70/30 (Insulin regular and NPH combined) using 30 units in the morning and 20 units in the evening.

• First, switch the timings: Switch 30 units to at-Iftar and 20 units to pre-Sehri (Pre-dawn meal).
• Second, reduce the evening dose by one-third and the Sehri dose by 50%.
• So, this patient will be using Injection humulin 70//30  - 20 units at Iftar and 10 units at Sehri (Pre-dawn meal).

Another example:

A person is using a basal-bolus regimen and injecting the following regimen:

• Regular Insulin

  • 16 units before breakfast
  • 12 units before lunch, and
  • 12 units before dinner

• Insulin NPH

  • 18 units before breakfast and
  • 12 units before dinner

How should this patient adjust his insulin?

1. Skip mid-day insulin.
2. Switch morning and evening insulins as
   1. Pre-dinner insulin to Pre-Sehr: 12 (R) + 12 (N)
   2. Pre-breakfast insulin dose to at-Iftar: 16 (R) + 18 (N)
   3. calculate the total morning and evening doses: 24 units at Sehr and 34 units at Iftar
   4. Next, reduce the doses by one-third at Iftar and 50% at Sehr: 12 units at Sehri and 22 units at Iftar.
   5. Finally, split the total dose in the original proportions to R and N insulins:
      • 12 units at Sehri will be split to 6 units R and 6 units N,
      • 22 units at Iftar will be split in a ratio of 16:18 to 10 units R and 12 units N

Diabetes Medications should be adjusted according to the patients' dietary habits and glycemic control.

Note - The ADA Recommendations:

The ADA workgroup recommends switching the insulin and sulfonylureas and reducing the Sehri (pre-dawn meal) dose to half while keeping the same dose at iftar as the pre-Ramadan dose at breakfast.

I would recommend the above regimen as the starting one to avoid the risks of hypoglycemia. If blood sugars remain high, the ADA regimen should be followed. The ADA regimen is the same as the above regimen except the "at-Iftar" dose is kept the same and is not reduced by one-third.

Adjustment in diabetes medications also depends on the length of the FAST, the weather, the pre-Ramadan glycemic control, the dietary habits of the person, exercise, and the pancreatic reserves of the patient.

When to Check Blood Sugars During Ramadan? 

It is also important to note that blood sugars should be checked frequently during the first few days of Ramadan to know the adequacy of diabetes control.

Patients should be asked to check blood sugars pre-Iftar and 2 hours post-Iftar, Pre-Sehri, and 2 hours post-Sehri, and at 09 Am. Patients should also check their blood sugars as and when needed especially if they develop symptoms of hypoglycemia and hyperglycemia.

When to Break the Fast?

Patients who have blood sugars of less than 70 mg/dl early in the morning should break their fast especially if they are on insulin and sulfonylureas. Similarly, patients who have blood sugars greater than 320 mg/dl should break their fast especially if they are aged and have comorbid conditions.

Does Checking Blood Sugars Break the Fast?

Another important point to note is that checking blood sugars does not break the fast. I hope this article answers most of your questions. If you have any queries, please feel free to ask in the comments section below. Don't forget me in your Duas and prayers. JazakAllah.