Management of diabetes during Ramadan fasting is a challenge for many people with diabetes and healthcare professionals. The IDF-DAR guidelines intend to help people with diabetes achieve a safer Ramadan. All people with diabetes wishing to fast should have a detailed medical history including the person's glycaemic control, risk of hypoglycaemia and self-management capabilities. If the patient decides to fast, which may be against the advice of the HCP, an individualised management plan must be produced. An integral part of this is diet, exercise and the frequency of self-monitoring of blood glucose (SMBG) levels. 

When to break the fast?

• When a person with diabetes has symptoms of hypoglycaemia
• If SMBG is 70 mg/dl (3.9 mmol/l) regardless of the presence or absence of symptoms
• When blood glucose is too high
• During acute illness

Medication adjustment

Metformin and Acarbose:
No dose adjustments is required for metformin modified release formulations or for those on once daily tablet. Other wise split the dose between iftar and suhoor for thos taking it 2-3 times daily

Short-acting insulin secretagogues
These are relatively low risk of fasting hypoglycaemia. They are taken with meals and the dose could be modified according to meal size.

Sulphonylureas
Patients with T2DM may continue to use 2nd generation SUs and fast safely during Ramadan. The use of older drugs within this class, such as, glibenclamide should be avoided in favour of gliclazide and glimepiride which carry a much lower risk of hypoglycaemia. Once daily preparation should be given with iftar and dose reduced by 50%. Twice daily preparation, suhoor dose should be reduced by 50% while no change is required for Iftar dose.

Dipeptidyl peptidase-4 (DPP-4) inhibitors
Studies on vildagliptin in Ramadan indicates that it is effective in improving glycaemic control and that both vildagliptin and sitagliptin are associated with low rates of hypoglycaemia during fasting Ramadan. No treatment modifications is required.

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs)
Studies demonstrate that liraglutide is safe as an add-on treatment to pre-existing antidiabetic regimens, including metformin, SU and insulin, and can be effective in reducing weight and HbA1c levels during Ramadan. Data on exenatide is limited to one study. The drug is best to be taken at iftar.

Sodium-glucose co-transporter-2 (SGLT2) inhibitors
One study is available and it shows lower hypoglycaemia on dapagliflozin compared to SU. Incidences of postural hypotension and urinary tract infections were greater in the dapagliflozin group but did not reach significance. Patients that are deemed more at risk of complications such as the elderly, patients with renal impairment, hypotensive individuals or those taking diuretics should not be treated with SGLT2 inhibitors. No dose adjustment is required.

Insulin treatment for T2DM
The use of insulin analogues (both basal, prandial and premix) is recommended over regular human insulin. Target BG premeals in Ramadan is 90-130 mg/dl and insulin dose should be reduced by 15-30%. This needs further adjustments during Ramadan according to SMBG data. More details to be provided during the discussion.

Discussion points

1. Myths in Ramadan
2. What to eat in Ramadan
3. When and why to do SMBG
4. Treatment adjustments in Ramadan

Information about the discussion leader

The discussion will be moderated by Dr Mohamed Hassanein,  Senior Endocrinologists, Dubai Hospital, Dubai Health Authority (Dubai, UAE); Associate Director, Postgraduate Diabetes Education, Cardiff University, UK and Chair of Diabetes and Ramadan International Alliance.

References

1. www.daralliance.org
2. IDF-DAR Practical guidelines
3. ADA diabetes and Ramadan recommendations