In this slide set we present recommendations on the management of Diabetes during the period of Ramadan. Preparations prior to fasting, management during the period and adjustments to be made.

1. Managing Diabetes During
Ramadan and Fasting During Lent
Alan Chang, MD, FPCP, FPSEM
Jeremy Robles, MD, FPCP, FPSEM

2. Objectives
• To understand the Religious Principles of Ramadan
and its significance to Islam
• To discuss the impact of Ramadan on individuals
• Psychological, Physiological & Biochemical
Changes
• To describe dose adjustments and revisions in
medications during prolonged fasting

3. Five Pillars of Islam
• Shahadah - The declaration of Faith
• Salah - Five compulsory daily prayers
• Zakat - Annual Alms Tax to the poor and needy
• Sawm - Fasting during the month of Ramadan
• Hajj - Pilgrimage to Mecca

4. Ramadan
• Islamic Calendar is 354 days
• Ramadan occurs in the 9th month (Hijra)
• Fasting last from dawn to dusk
• Variable time depending on geographical location
& season
• Duration of fasting 28-30 days
• Dawn “Sahur” - Dusk “Iftar”

5. Ramadan
• Fasting should be practiced by all healthy &
responsible Muslims
• Islamically Exempted from Fasting:
The Frail & Elderly
Children
Chronic Health Condition
Severe mental problems
Temporarily Exempted:
Travellers
Acutely Unwell
Pregnant & Breast feeding women

6. Epidemiology of Diabetes & Ramadan
(EPIDIAR) study
• 12,243 subjects in 13 countries ( 9% Type 1 DM - 91% Type 2 DM )
• Younger patients (31 - 54 yo) with short duration of DM (<10y)
• Mean BMI 24 kg/m2 in type 1 DM and 27 kg/m2 in type 2 DM
• Fasting during Ramadan among Muslim diabetic patients
• 43% for type 1 DM & 79% for type 2 DM (15 days fasting)
• 50% of diabetic population (type 1 & 2) did not change lifestyle
• 1/4 changed OAD dose while 1/3 changed insulin dose
Diabetes Care 27:2306 –2311, 2004

7. Epidemiology of Diabetes & Ramadan
(EPIDIAR) study
• Overall incidence of hypoglycemic events was low
• unawareness of symptoms
• limited use of intensive therapies
• insufficient monitoring
• restriction of the definition to hospitalization
• Severe hypoglycemia more frequent during Ramadan
associated with changes in treatment & activity
Diabetes Care 27:2306 –2311, 2004

8. Ramadan impact on
Individuals
• Psychological Changes
• Practice in self sacrifice & self appreciation
• Period of reflection, character improvement and
removal of fault - Spiritual Peace
• Increased prayer participation and Quarantic
Recitation
NHS Gilani A. Ramadan and your Diabetic patient: A resource pack for Healthcare Professional 2011

9. Ramadan impact on
Individuals
• Physiological Changes
• Fasting > 8 hours
• Reduced Glucose levels & Insulin Secretion
• Glycogenolysis & Gluconeogenesis occurs
• Increased counter regulatory hormones
(Glucagon & Cathecolamine)
• Increased fatty acid production & ketones
NHS Gilani A. Ramadan and your Diabetic patient: A resource pack for Healthcare Professional 2011

10. Ramadan impact on
Individuals
• Physiological Changes
• Fed > Fasting state
• Postabsorptive phase, 6–24 h after beginning fasting
• Gluconeogenic phase, from 2–10 days of fasting
• Protein conservation phase, beyond 10 days of fasting
NHS Gilani A. Ramadan and your Diabetic patient: A resource pack for Healthcare Professional 2011

11. Ramadan impact on Individuals
• Biochemical Changes
JAFES vol 28, No. 1:21–25, 2013
Parameters Expected Changes
HbA1c, plasma insulin,
insulin resistance
No significant change expected.
Decreased levels of fasting plasma insulin and
decreased insulin resistance in newer studies.
Lipid Metabolism
No significant change expected.
Increased total cholesterol & decreased TGL in new studies.
Micro & Macro
Complications
Variable and individualised

12. Case
• Abdul is a 56 year old Muslim diagnosed to have diabetes
on April 2014.
• His sugar is poorly controlled with an HbA1c of 9.4% & FBS
of 293 mg/dL.
• He is hypertensive on an ARB+ CCB combination.
• You started him on premixed insulin BID & metformin
+ DPP4 combination.
• You also started him on enteric coated aspirin & a statin

13. Case
• On his follow-up this first week of June, his blood sugar
is now better controlled at an HbA1c of 7.4% and FBS of
120 mg/dL.
• He now tells you that anticipating Ramadan, he would
like to ask if your advice about the changes in his
medications as he will likely fast.

14. Case Q1
• As a devout follower of Islam, he would like to fast during
Ramadan. What do you think?
A. Yes, he should because it is absolutely necessary in
their faith that he should follow
B. Yes, but he can modify the fasting
C. Yes, only for a few days
D. No, he is diabetic and is therefore is exempted

15. Pre-Ramadan
Assessment & Counselling
• 1 - 2 months before the onset of Ramadan
• Individualized life-style, diet & drug plan
• Full annual review & detection of complications
• Counselling should focus on patient / family
• awareness of symptoms , planning of meals
• management of acute complications
Hassan Chamsi-Pasha and Khalid S. Aljabri. Avicenna J Med. 2014 Apr-Jun; 4(2): 29–33.

16. Pre-Ramadan
Assessment & Counselling
• Monitor blood glucose levels multiple times daily
• Most problems arise from inappropriate diet or as a
consequence of overeating and insufficient sleep
• Excessive physical activity - higher risk of
hypoglycaemia
• End their fast if hypoglycaemia / hyperglycaemia
Hassan Chamsi-Pasha and Khalid S. Aljabri. Avicenna J Med. 2014 Apr-Jun; 4(2): 29–33.

17. Case Q2
• Before starting Ramadan, Abdul should undergo
rigorous physical assessment
A. True
B. False

18. Pre-Ramadan
Assessment & Counselling
• Physical well being assessment;
• Assessment of metabolic control;
• Adjustment of the diet protocol for Ramadan fasting;
• Adjustment of the drug regimen
• Encouragement of continued proper physical activity;
• Recognition of warning symptoms of dehydration,
hypoglycemia & other possible complications.

19. Case Q3
• What are the physiologic challenges that can occur to a
patient during Ramadan?
A. No changes, just the same as a regular overnight fast
B. Abdul may lose up to 4 kg while fasting

20. Changes in Lifestyle, Weight & meds
during Ramadan (EPIDIAR) Study
EPIDIAR
Physical Activity Same
Sleep Duration Same
Food Intake Same
Fluid Intake Same
Sugar Intake Same
Weight Changes No Change
Insulin Dose Maintained
OAD Dose Maintained

21. Diet & Exercise
during Ramadan
• Healthy balanced diet with complex carbohydrates
• Fiber rich food with mono saturated fats
• Light to moderate exercises are considered safe
• Taraweeh (night prayer ) is considered to be part of
an individual exercise regime
• Ample fluid intake; Avoid caffeine
NHS Gilani A. Ramadan and your Diabetic patient: A resource pack for Healthcare Professional 2011

22. Knowledge, Attitudes & Practices of muslims with diabetes
Mellitus during Ramadan Fasting in the Philippines
(Pala-Mohammad et. al.)
• 58.2% had Inadequate knowledge about physical
activity during Ramadan fasting
• 33% fasted for at least 15 days
• 37% had hypoglycemia during Ramadan Fasting
• 95% fasted >10 days
• 77% >50 years old
• 63% had diabetes >5 years

23. Case Q4
• Is Abdul allowed to monitor his blood sugar? How often
should he check?
A. Monitoring of blood sugar will break the fast
B. He should monitor only as symptoms occur
C.He should monitor before sahur, iftar & during the day
when required

24. South Asian Consensus Guideline: Use
of insulin in Diabetes during Ramadan
• Blood sugar monitoring
• Check 2 hours post-sahur & 30 mins post-iftaar
• to check for subclinical hypoglycaemia
• Check 2 hours post-iftar
• to check for subclinical hyperglycaemia
• Adjust insulin dose at 3 day intervals
Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4

25. Ramadan impact on
Individuals
Diabetes Care 27:2306 –2311, 2004
Increased Risk for
Hypoglycemia
Increased Risk for
Hyperglycemia
Type 1 Diabetes
Mellitus
4.7 Fold 5 Fold
Type 2 Diabetes
Mellitus
7.5 fold 3 Fold

26. Case Q5
• Having decided that Abdul will fast, how will you modify
his current regimen?
A. Discontinue the insulin & replace with an SU
B. Decrease the insulin dose
C. Shift to a long acting insulin analogue
D. Shift to NPH insulin BID

27. Medical Management
(Oral - Injectable Meds)

28. Medical Management
(Oral Medications)
• Metformin ( low risk )
• Two-thirds of the dose is taken at iftar & one-third at suhur
• Slow release formulations taken once daily after the sunset meal
• Alpha glucosidase inhibitors ( low risk )
• Taken with the first bite of a meal
• Short acting secretagouges ( low risk )
• Short duration of action
• Taken twice daily before sunset and predawn meals
Hassan Chamsi-Pasha and Khalid S. Aljabri. Avicenna J Med. 2014 Apr-Jun; 4(2): 29–33.

29. Medical Management
(Oral Medications)
• Glitazones (low risk)
• Amplify the hypoglycemic effects of SU, glinides, and insulin
• Require 2-4 weeks to exert substantial antihyperglycemic effects
• No adjustment in dosage required (monotherapy)
• Sulfonylureas ( high risk )
• Inherent risk of hypoglycemia use with caution
• Change the timing of the once daily dose of SU (such as glimepiride) from the
usual morning dose to the evening (at iftar)
• Long-acting oral hypoglycemic agents (OHA) must be used more caution
Hassan Chamsi-Pasha and Khalid S. Aljabri. Avicenna J Med. 2014 Apr-Jun; 4(2): 29–33.

30. Medical Management
(Oral & Injectable Medications)
• Incretin Based Therapy ( low risk )
• Less hypoglycemia as monotherapies & suitable for Ramadan
• Exenatide before meals to minimize appetite & promote weight loss
• Liraglutide given once a day, independent of meals, for fasting hyperglycemia
• DPP4 monotherapy do not require adjustments ( Sitagliptin & Vildagliptin )
• Insulin ( high risk )
• Newer insulin analogs more useful in managing diabetes during Ramadan
• Long-acting insulin (glargine and detemir) should be reduce by 20%
• Premix insulins - AM dose given at sunset & half of the PM dose given at dawn
Hassan Chamsi-Pasha and Khalid S. Aljabri. Avicenna J Med. 2014 Apr-Jun; 4(2): 29–33.

31. South Asian Consensus Guideline: Use
of insulin in Diabetes during Ramadan
• Assess glycemic status
• Assess complications & co-morbid conditions
• Change of diet & meal plan
• Consider dehydration and electrolyte imbalance
Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4

32. South Asian Consensus Guideline: Use
of insulin in Diabetes during Ramadan
Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4
Very High Risk
• Severe hypoglycemia
w/in the past 3 mos.
• Recurrent
hypoglycemia
• Hypoglycemia
unawareness
• Sustained poor
glycemia
• DKA or HHS 3 mos.
prior
• On dialysis
High Risk
• Renal insufficiency
• Advanced macro
vascular
complications
• Autonomic
neuropathy
• Living alone and
treated with multiple
insulin or SU
• Old age with ill health
Moderate Risk
Well controlled patients
treated with short acting
insulin secretagogues
Low Risk
Well controlled patients
treated with diet, MET,
TZD or otherwise
healthy

33. South Asian Consensus Guideline: Use
of insulin in Diabetes during Ramadan
• Premix Insulin (eg. 70/30 insulin)
Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4
Before
Ramadan
During
Ramadan
Morning Dose Pre-Breakfast Sahur
Half dose of
Pre-dinner
Evening Dose Pre Dinner Iftar
Full Pre-
Breakfast dose

34. South Asian Consensus Guideline: Use
of insulin in Diabetes during Ramadan
• Basal Bolus (eg. Basal Long Acting + Prandial)
Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4
Before Ramadan During Ramadan
Morning
Dose
Full prandial
dose
Sahur
Half prandial
dose
Lunch
Dose
Full prandial
dose
-
Evening
Dose
Full basal
Analog
Full prandial
dose
Iftaar
Full basal
Analog
Full prandial
dose x 2

35. South Asian Consensus Guideline: Use
of insulin in Diabetes during Ramadan
• Split Mix Insulin (eg.Intermediate + Short Acting)
Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4
Before Ramadan During Ramadan
option A option B option A option B
Morning
Dose
SA IA + SA Sahur
half SA +
half IA
half SA +
half IA
Lunch
Dose
SA - -
Evening
Dose
IA + SA IA + SA Iftaar SA x 2 IA + SA

36. South Asian Consensus Guideline: Use
of insulin in Diabetes during Ramadan
• Bi-phasic insulin (eg. Biphasic + Metformin)
Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4
Before
Ramadan
During Ramadan
Option A Option B
Morning
Dose
Biphasic
Insulin
Sahur Metformin
Half Biphasic
Dose + Met
Lunch
Dose
Evening
Dose
Metformin Iftaar
Biphasic
Insulin
Biphasic
Insulin

37. South Asian Consensus Guideline: Use
of insulin in Diabetes during Ramadan
• Rapid Acting over Regular Human Insulin
• Faster onset with higher peak with same dose
• Better post prandial control & Meal time flexibility
• Lesser hypoglycemia
• Safe in Renal & Hepatically impaired (aspart)
• Safe in Pregnancy (Aspart, Lispro)
Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4

38. South Asian Consensus Guideline: Use
of insulin in Diabetes during Ramadan
• Analog Premix over Human Premix Insulins
• Rapid onset of action
• Better postprandial control & meal flexibility
• Lesser night time hypoglycemia
• Can be started once daily before iftar and
uptitrated to twice daily
Indian Journal of Endocrinology and Metabolism / Jul-Aug 2012 / Vol 16 | Issue 4

39. Post Ramadan Follow-up
• The patients therapeutic regimen should be
changed back to its previous schedule.
• Patients should also be required to get an overall
education about the impact of fasting on their
physiology
• Degenerative complications check up
• Monthly weight, blood pressure, HbA1c and renal
function evaluation every six months.
Diabetes Care. 1997; 20:1925-1926.

40. Summary
• Fasting provides unique spiritual benefits in the life
of the believer.
• Management of the Diabetic patient during fasting is
complex and requires close medical follow-up
• Structured education enables patients to manage
their condition better
• Modifications in diet, exercise and medications need
to be discussed by the patient & doctor

41. Summary
• Recognition and management of complications is
essential to ensure patient well being
• Monitoring of blood sugar as well as other
biochemical parameters are vital in the management
• Tailored therapy with oral and injectable medications
may be used during the fasting period.

42. Thank you!
Alan Chang, MD, FPCP, FPSEM
Jeremy Robles, MD, FPCP, FPSEM

43. Credits to:
Dr. Patricia Gatbonton & Dr. Alan Chang
Who presented the original lecture in 2012
Dr. Aniza Pala-Mohammad for articles
used in updating this slide set.