This document discusses diabetes management during Ramadan. It begins by stating that most literature indicates fasting during Ramadan is safe for many type 2 diabetic patients if they receive proper education and management. It then notes the increasing fasting hours in northern hemispheres as Ramadan falls during summer months, which poses implications for Muslims with diabetes wishing to fast. The risks of fasting like hypoglycemia, hyperglycemia, dehydration and DKA are explained. Pre-Ramadan assessment of risk levels - high, moderate, low - and adjustment of diet, drugs and activity are recommended for safer fasting.

1. Diabetes
management in
Ramadan

2. 2
(183)ِ‫الص‬ ُ‫م‬ُ‫ك‬ْ‫ي‬‫ا‬‫ل‬‫ا‬‫ع‬ ‫ا‬‫ب‬ِ‫ت‬ُ‫ك‬ْ‫ا‬‫و‬ُ‫ن‬‫ا‬‫آم‬ ‫ا‬‫ين‬ِ‫ذ‬َّ‫ل‬‫ا‬ ‫ا‬‫ا‬‫ه‬ُّ‫اي‬‫أ‬ ‫ا‬‫َي‬‫ا‬‫ين‬ِ‫ذ‬َّ‫ل‬‫ا‬ ‫ى‬‫ا‬‫ل‬‫ا‬‫ع‬ ‫ا‬‫ب‬ِ‫ت‬ُ‫ك‬‫ا‬‫ا‬‫م‬‫ا‬‫ك‬ُ‫ام‬‫ا‬‫ي‬ْ‫م‬ُ‫ك‬ِ‫ل‬ْ‫ب‬‫ا‬‫ق‬ ‫ن‬ِ‫م‬
‫ا‬‫ن‬‫و‬ُ‫ق‬َّ‫ت‬‫ا‬‫ت‬ ْ‫م‬ُ‫ك‬َّ‫ل‬‫ا‬‫ع‬‫ا‬‫ل‬
(184)ْ‫او‬‫أ‬ ‫ا‬ً‫ض‬‫ي‬ِ‫ر‬َّ‫م‬ ‫م‬ُ‫ك‬‫ن‬ِ‫م‬ ‫ا‬‫ن‬‫ا‬‫ا‬‫ك‬‫ن‬‫ا‬‫م‬‫ا‬‫ف‬ ٍ‫ات‬‫ا‬‫ود‬ُ‫د‬ْ‫ع‬َّ‫م‬ ‫ا‬ً‫م‬َّ‫اَي‬‫أ‬‫ا‬‫أ‬ ْ‫ن‬ِ‫م‬ ٌ‫ة‬َّ‫د‬ِ‫ع‬‫ا‬‫ف‬ ٍ‫ر‬‫ا‬‫ف‬‫ا‬‫س‬ ‫ى‬‫ا‬‫ل‬‫ا‬‫ع‬‫ا‬‫ر‬‫ا‬‫خ‬ُ‫أ‬ ٍ‫م‬َّ‫َي‬
ٍ‫ي‬ِ‫ك‬ْ‫س‬ِ‫م‬ ُ‫ام‬‫ا‬‫ع‬‫ا‬‫ط‬ ٌ‫ة‬‫ا‬‫ي‬ْ‫د‬ِ‫ف‬ ُ‫ه‬‫ا‬‫ن‬‫و‬ُ‫ق‬‫ي‬ِ‫ط‬ُ‫ي‬ ‫ا‬‫ين‬ِ‫ذ‬َّ‫ل‬‫ا‬ ‫ى‬‫ا‬‫ل‬‫ا‬‫ع‬‫ا‬‫و‬ْ‫ي‬‫ا‬‫خ‬ ‫ا‬‫و‬ُ‫ه‬‫ا‬‫ف‬ ‫ا‬ً‫ر‬ْ‫ي‬‫ا‬‫خ‬ ‫ا‬‫ع‬َّ‫و‬‫ا‬‫ط‬‫ا‬‫ت‬ ‫ن‬‫ا‬‫م‬‫ا‬‫ف‬ْ‫ا‬‫و‬ُ‫وم‬ُ‫ص‬‫ا‬‫ت‬ ‫ان‬‫أ‬‫ا‬‫و‬ ُ‫ه‬َّ‫ل‬ ٌ‫ر‬
‫ا‬‫ن‬‫و‬ُ‫م‬‫ا‬‫ل‬ْ‫ع‬‫ا‬‫ت‬ ْ‫م‬ُ‫نت‬ُ‫ك‬‫ن‬ِ‫إ‬ ْ‫م‬ُ‫ك‬َّ‫ل‬ ٌ‫ر‬ْ‫ي‬‫ا‬‫خ‬
(185)ُ‫ه‬ ُ‫ن‬‫آ‬ْ‫ر‬ُ‫ق‬ْ‫ل‬‫ا‬ ِ‫يه‬ِ‫ف‬ ‫ا‬‫ل‬ِ‫ز‬‫ُن‬‫أ‬ ‫ا‬‫ي‬ِ‫ذ‬َّ‫ل‬‫ا‬ ‫ا‬‫ن‬‫ا‬‫ا‬‫ض‬‫ا‬‫م‬‫ا‬‫ر‬ ُ‫ر‬ْ‫ه‬‫ا‬‫ش‬‫ا‬ ‫ا‬‫ن‬ِ‫م‬ ٍ‫ات‬‫ا‬‫ن‬ِ‫ي‬‫ا‬‫ب‬‫ا‬‫و‬ ِ‫َّاس‬‫ن‬‫ل‬ِ‫ل‬ ‫ى‬ً‫د‬‫ى‬‫ا‬‫د‬ُْ‫ْل‬
ْ‫م‬ُ‫ص‬‫ا‬‫ْي‬‫ل‬‫ا‬‫ف‬ ‫ا‬‫ر‬ْ‫ه‬َّ‫الش‬ ُ‫م‬ُ‫ك‬‫ن‬ِ‫م‬ ‫ا‬‫د‬ِ‫ه‬‫ا‬‫ش‬ ‫ن‬‫ا‬‫م‬‫ا‬‫ف‬ ِ‫ان‬‫ا‬‫ق‬ْ‫ر‬ُ‫ف‬ْ‫ل‬‫ا‬‫ا‬‫و‬‫ا‬‫ف‬‫ا‬‫س‬ ‫ى‬‫ا‬‫ل‬‫ا‬‫ع‬ ْ‫او‬‫أ‬ ‫ا‬ً‫ض‬‫ي‬ِ‫ر‬‫ا‬‫م‬ ‫ا‬‫ن‬‫ا‬‫ا‬‫ك‬‫ن‬‫ا‬‫م‬‫ا‬‫و‬ ُ‫ه‬ْ‫ن‬ِ‫م‬ ٌ‫ة‬َّ‫د‬ِ‫ع‬‫ا‬‫ف‬ ٍ‫ر‬
‫ي‬ِ‫ر‬ُ‫ي‬ ‫ا‬‫ال‬‫ا‬‫و‬ ‫ا‬‫ر‬ْ‫س‬ُ‫ْي‬‫ل‬‫ا‬ ُ‫م‬ُ‫ك‬ِ‫ب‬ ُ‫اّلل‬ ُ‫د‬‫ي‬ِ‫ر‬ُ‫ي‬ ‫ا‬‫ر‬‫ا‬‫خ‬ُ‫أ‬ ٍ‫م‬َّ‫اَي‬‫أ‬ِ‫ْع‬‫ل‬‫ا‬ ْ‫ا‬‫و‬ُ‫ل‬ِ‫م‬ْ‫ك‬ُ‫ت‬ِ‫ل‬‫ا‬‫و‬ ‫ا‬‫ر‬ْ‫س‬ُ‫ْع‬‫ل‬‫ا‬ ُ‫م‬ُ‫ك‬ِ‫ب‬ ُ‫د‬‫ا‬‫اّلل‬ ْ‫ا‬‫و‬ُِ‫ّب‬‫ا‬‫ك‬ُ‫ت‬ِ‫ل‬‫ا‬‫و‬ ‫ا‬‫ة‬َّ‫د‬‫ى‬‫ا‬‫ل‬‫ا‬‫ع‬
‫ا‬‫ن‬‫و‬ُ‫ر‬ُ‫ك‬ْ‫ش‬‫ا‬‫ت‬ ْ‫م‬ُ‫ك‬َّ‫ل‬‫ا‬‫ع‬‫ا‬‫ل‬‫ا‬‫و‬ ْ‫م‬ُ‫ك‬‫ا‬‫ا‬‫د‬‫ا‬‫ه‬ ‫ا‬‫ا‬‫م‬

3. Can a diabetic patient fast during Ramadan?

4. The bulk of literature indicates that
fasting in Ramadan is safe for the
majority of type 2 diabetic patients
with proper education and diabetic
management.

5. DIABETES AND RAMADAN
THE PROBLEM..???

6. 6

7. 7
The Current decade…
Over the current decade, the number of
fasting hours will progressively increase
in the northern hemisphere as Ramadan
falls in the summer months.
This will have important implications for
Muslims with diabetes who wish to fast.

8. Diabetes and Ramadan
 Many patients with diabetes insist on fasting during Ramadan, thereby creating
a medical challenge for themselves and their health care providers
It is important that medical
professionals be aware of potential
risks associated with fasting during
Ramadan and with approaches to
mitigate those risks

9. The Risks of Fasting Include:
Hypoglycemia
Hyperglycemia
Diabetic ketoacidosis
Dehydration and thrombosis
M. al-Arouj et al, “Recommendations for management of diabetes during Ramadan,” Diabetes Care, 28(2005), 2305-2311.

11. Classification of Hypoglycemia
American Diabetes Association Standards of Medical Care in Diabetes.
Glycemic targets. Diabetes Care 2017; 40 (Suppl. 1): S48-S56

12. Severe and prolonged hypoglycemia
LOC/Coma Irreversible brain injury
Symptoms of Hypoglycemia

14. Management of hypoglycemia
The 15/15 Rule
1-Check your blood glucose.
If it is lower than 70 mg/dL, eat or drink 15 grams of carbohydrates.
If you can’t check your blood glucose right away, eat or drink 15 grams of
carbohydrates just to be safe.
2-Wait 15 minutes.
That’s how long it takes for sugar to get into the blood.
3-Check your blood glucose again.
4-Repeat steps 1, 2, and 3 if:
• Your blood glucose level is still lower than 70 mg/dL
OR
• You still have symptoms of hypoglycemia
5-If your blood glucose is lower than 70 mg/dL after you check it three
times, call help.

17. DKA :DEFINITION
A state of absolute or relative insulin
deficiency resulting in
hyperglycemia and an
accumulation of ketoacids in the
blood with subsequent metabolic
acidosis
DKA is clinically defined as an acute
state of severe uncontrolled
diabetes that requires emergency
treatment with insulin and
intravenous fluids
 Hyperglycemia
 Blood glucose
>250mg%
 Acidosis
 pH < 7.30
 Bicarb < 20 mmol/L
 Ketosis
 Elevated serum or urine
ketones
 Serum ketones
>5mEq/L

18. Dehydration and Thrombosis
• Patients with diabetes exhibit a hypercoagulable state
due to an increase in clotting factors, a decrease in
endogenous anticoagulants, and impaired fibrinolysis.
• Increased blood viscosity secondary to dehydration may
enhance the risk of thrombosis.
• A report from Saudi Arabia suggested an increased
incidence of retinal vein occlusion in patients who fasted
during Ramadan
M. al-Arouj et al, “Recommendations for management of diabetes during Ramadan,” Diabetes Care, 28(2005),

19. FLUIDS, FLUIDS, FLUIDS!
• Restores circulatory volume
• Diminish concentration of catecholamines, glucagon
• ↑ urinary glucose loss

20. DIABETES AND RAMADAN
THE SOLUTION

21. Pre-
Ramadan
Medical
Assessment
Management
of Diabetic
Patients
During
Ramadan
Safer
Fasting

22. Pre-Ramadan Medical
Assessment

23. High
Moderate
Low risk of
adverse events
•Poor glycemic control, Severe and recurrent
episodes of hypoglycemia.
• Experience ketoacidosis three months before
Ramadan.
• Elderly and Pregnant women
• Advanced complications
• Well controlled patients treated with short
acting insulin secretogogue,
sulphonylurea, insulin, or taking
combination oral or oral plus insulin
• Well controlled patients treated with
Metformin, Dipeptidyl peptidase-4
inhibitors, or thiazolidinediones who are
otherwise healthy
E Hui et al , BMJ 2010;340:c3053; Al-Arouj M. et al, Recommendations for management of diabetes during Ramadan. Diabetes Care. 2010;33: 1895-1902.
Categories of risks for patients fasting
Ramadan

24. The principles of Pre-Ramadan
considerations
(a) Physical well being assessment;
(b) assessment of metabolic control;
(c) adjustment of the diet protocol for Ramadan fasting;
(d) adjustment of the drug regimen (e.g. change long-acting
hypoglycemic drugs to short-acting drugs to prevent hypoglycemia);
(e) encouragement of continued proper physical activity;
(f) recognition of warning symptoms of dehydration,
hypoglycemia and other possible complications.

25. High
Moderate
Low risk of
adverse events
•Poor glycemic control, Severe and recurrent
episodes of hypoglycemia.
• Experience ketoacidosis three months
before Ramadan.
• Elderly and Pregnant women
• Advanced complications
• Well controlled patients treated with short
acting insulin secretogogue,
sulphonylurea, insulin, or taking
combination oral or oral plus insulin
• Well controlled patients treated with
Metformin, Dipeptidyl peptidase-4
inhibitors, or thiazolidinediones who are
otherwise healthy
E Hui et al , BMJ 2010;340:c3053; Al-Arouj M. et al, Recommendations for management of diabetes during Ramadan. Diabetes Care. 2010;33: 1895-1902.
Categories of risks for patients fasting
Ramadan

26.  Conditions related to diabetes:
- Advanced nephropathy
- Severe retinopathy
- Autonomic neuropathy
- Hypoglycemic unawareness
- Major macrovascular diseases
- Recent hyper-osmolar state or DKA
- Poorly controlled diabetes (Mean RBG> 300)
- Multiple insulin injections per day
Patients with one or more of the following
are advised not to fast
Physiological conditions:
- Pregnancy
- Lactation
Clinical Diabetes ( Middle East Edition)- Volume 3, Number 3, 2004

27. Recommendations – Pregnancy
 Muslim pregnant women are exempt from fasting during Ramadan
 type 1,
 type 2 or
 Gestational
 They should be strongly advised to not fast during Ramadan
 These women constitute a high-risk group and their management
requires intensified care
Diabetes Care. 2005; 28 (9).

28. Co-existing major medical conditions such as:
- Acute peptic ulcer
- Severe Pulmonary Tuberculosis
- Severe infection
- Severe bronchial asthma
- Recurrent stones formation
- Cancer with poor general condition
- Overt cardiovascular diseases (Recent MI)
- Severe psychiatric conditions
- Hepatic dysfunction (liver enzymes > 2 × ULN)
Clinical Diabetes ( Middle East Edition)- Volume 3, Number 3, 2004
Patients with one or more of the following
are advised not to fast

29. Management of Diabetic
Patients During
Ramadan

30. Management of Diabetic Patients
During Ramadan
Patients Education
T2DM Pharmaceutical
Management in
Ramadan

31. Four key areas in Ramadan focused
education
1-Meal planning and dietary advice
2-Exercise
3-Blood glucose monitoring
4-Recognizing and managing
complications
E Hui et al , BMJ 2010;340:c3053;

32. Recommendations during Ramadan
fasting
I. Nutrition and Ramadan fasting:
Abstain from the high-calorie and highly-
refined foods prepared during this month.
II. Physical activity and Ramadan fasting:
It has been shown that fasting does not
interfere with tolerance to exercise.
It is necessary to continue their usual
physical activity especially during non-fasting
periods Lancet. 1989; 1:1396
N Engl J Med. 1991; 325: 196-199.

33. Recommendations during Ramadan
fasting
lll. Diabetic home management that consists of:
Monitoring home blood glucose especially for IDDM
patients
Checking urine for acetone (IDDM patients);
Measuring daily weights and informing physicians of
weight reduction (dehydration, low food intake, polyuria)
or weight increase (excessive calorie intake) above two
kilograms;
Recording daily diet intake (prevention of excessive and
very low energy consumption).

34.  . Education about warning symptoms of
dehydration, hypoglycemia and hyperglycemia.
 . Education about breaking fast as soon as any
complication or new harmful condition occurs.
 . Immediate medical help for diabetics who need
medical help quickly, rather than waiting for
medial assistance the next day.
lV-Recognizing and managing complications

36. Oral hypoglycaemic agents
TZDs
No treatment adjustment
required 2–4 weeks to
exert substantial
antihyperglycemic
effects
DPP4 inhibitors
The best tolerated
drugs,
Consider DPP4i if
the risk of
hypoglycemia is high.
SUs
. Consider dose adjustment.
Metformin
Modify timing
of doses:
• Two thirds of
dose at iftar
• One third at
suhur.
T2DM Pharmaceutical Management in
Ramadan
E Hui et al , BMJ 2010;340:c3053; Al-Arouj M. et al, Recommendations for management of diabetes during Ramadan. Diabetes Care. 2010;33: 1895-
1902.
Short acting
insulin Sus
Take twice
daily at suhur
and iftar

37. Changes in treatment regimen
Before Ramadan During Ramadan
Patients on diet and exercise control
Patients on oral hypoglycemic agents
Biguanide, metformin 500 mg three times a day, or
sustained release metformin (glucophage R)
TZDs, pioglitazone or rosiglitazone once daily
Sulfonylureas once a day, e.g., glimepiride 4 mg daily,
gliclazide MR 60 mg daily
Sulfonylureas twice a day, e.g., glibenclamide 5 mg or
gliclazide 80 mg, twice a day
No change needed (modify time and intensity of
exercise), adequate fluid intake
Ensure adequate fluid intake
Metformin, 1,000 mg at the sunset meal (Iftar), 500 mg at
the predawn meal (Suhur)
No change needed
Dose should be given before the sunset meal (Iftar);
adjust the dose based on the glycemic control and the
risk of hypoglycemia
Use half the usual morning dose at the predawn meal
(Suhur) and the full dose at the sunset meal (Iftar),
e.g., glibenclamide 2.5 mg or gliclazide 40 mg in the
morning,glibenclamide 5 mg or gliclazide 80 mg in
evening.
DIABETES CARE, VOLUME 33, NUMBER 8, AUGUST 2010

38. Changes in treatment regimen
Before Ramadan During Ramadan
Patients on insulin
70/30 premixed insulin twice daily, e.g., 30
units in morning and 20 units in evening
Ensure adequate fluid intake
Use the usual morning dose at the sunset meal
(Iftar) and half the usual evening dose at
predawn (Saher), e.g., 70/30 premixed insulin,
30 units in evening and 10 units in morning; also
consider changing to glargine or detemir plus
lispro or aspart
DIABETES CARE, VOLUME 33, NUMBER 8, AUGUST 2010

39. 3939
Ensure adequate fluid intake.
70/30 premixed insulin twice daily, e.g., 30 units
in morning and 20 units in evening……
In Ramadan,,,,,Use the usual morning dose
at the sunset meal (Iftar) and half the usual
evening dose at predawn (Suhur), e.g., 70/30
premixed insulin, 30 units at Iftar and 10 units at
suhur.
Diabetes Care
September 2005 , pages 2305-11
Premixed insulin :

40. 40
Patients on Basal insulin analogue
glargine or detemir
It is advised that patients who take long
acting basal insulin, such as glargine, to
reduce the dose by 20% to avoid
hypoglycemia.
Continue taking the same doses of
repaglinide or short acting insulin

41. 4141
MOST patients will require short-acting
insulin administered in combination
with the intermediate, or long-acting
insulin at the sunset meal to cover
the large caloric load of Iftar & an
additional dose of short-acting insulin
at predawn.
1. ADA. Diabetes Care 2006;29(suppl 1):S4–S42.

42. 42
Remember
Careful use of intermediate- or long-acting
insulin preparations plus a short-acting
insulin administered before meals would be
an effective strategy.
Adjustment to treatment necessary: e.g.
 Reduce the dose of Basal insulin by 20%
 Use Mix 50 in the evening instead of Mix 30
to avoid post prandial hyperglycemia
Diabetes Care 28.9 (Sept 2005): p2305(7).

43. 43Aly A. Abdel-Rahim.
Treatment should be tailored and
adjusted

44. Safer Fasting

45. How to Help Patients Fast Safely ??
Patient Education Program.
Individualization of anti diabetic drugs
Select more safe drugs.
Adjust dose if needed
Ensure good non – sugar fluid intake.
Avoid heavy physical exercise at afternoon.
Ensure good calorie distribution.
Summary

46. Breaking the Fast
All patients must always and immediately end their
fast if:
1. Hypoglycaemia (blood glucose of <60mg/dl).
2. Blood glucose reaches <70 mg in the first few
hours after the start of the fast, especially if insulin,
sulfonylurea drugs, or neglitinide are taken at predawn.
3. Blood glucose exceeds 300 mg with symptoms of
hyperglycaemia.
Recommendations for Diabetic Individuals during Ramadan, Diabetes Care , vol 33, num. 8, August2010

47. Post-Ramadan supervision
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.

48. 48

49. Conclusion
 Majority of uncomplicated type 2 diabetic patients can fast
during Ramadan safely
 Pre-Ramadan medical assessment, education and motivation
are very important to prevent diabetic related complications
 Islam allows diabetics to have regular blood test while fasting
 Fasting along with regular prayer have been proved to aid in
better control of diabetes

50. 50
Some Parting Thoughts
“Fasting is for Me and I (Allah) only will
reward it” (Hadith Qudsi)
“While fasting , if one does not give up
falsehood in words and actions , then
Allah has no need of him giving up food
and drink (saying of Prophet
Muhammad-pbuh)”
HAVE A BLESSED RAMADAN

51. QUESTIONS…???