Red Flags
- Severe hypoglycaemia within 3 months of Ramadan, recurrent hypoglycaemia unawareness, or DKA in last 3 months — fast not recommended (very-high-risk)[1]
- Pregnancy with diabetes during Ramadan — very-high-risk; counsel against fasting; intensive monitoring if patient chooses to fast[1]
- T1DM or insulin-pump users — high-risk; pre-Ramadan structured education with insulin dose adjustments mandatory[1]
- CKD stage 3b or worse, dialysis-dependent — very-high-risk; fast not recommended without specialist clearance[1]
First-line treatment
Interventions
- Pre-Ramadan structured education[1]Risk assessment, glucose targets during fast, sick-day rules (when to break the fast), regimen modifications, exercise timing, hydration
- Break the fast (mandatory) for[1]Glucose <70 mg/dL OR >300 mg/dL OR symptoms of hypoglycaemia / hyperglycaemia / dehydration / acute illness
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Metformin (no dose change typically)[1] | Biguanide | Reverse timing: morning dose at iftar, evening dose at suhoor; no total dose change | — | Low hypoglycaemia risk; safe to fast |
| SGLT2 inhibitor (caution)[1] | SGLT2 inhibitor | Continue but emphasise hydration during non-fasting hours; pause if dehydration / vomiting; consider stopping pre-Ramadan in high-risk patients | — | Risk of euglycaemic DKA and dehydration with prolonged fasting |
| Sulfonylurea (modify timing and dose)[1] | Insulin secretagogue | Newer agents (gliclazide MR, glimepiride) preferred over glibenclamide; reduce morning equivalent at suhoor by 25–50%; full dose at iftar | — | Hypoglycaemia risk; avoid glibenclamide; consider switching to DPP-4 inhibitor pre-Ramadan if previously on glibenclamide |
| Basal-bolus insulin[1] | Insulin therapy | Reduce basal dose by 15–30%; switch timing to evening; reduce prandial dose at suhoor by 25–50%; full prandial at iftar adjusted to carbohydrate | — | Detailed individualised plan; CGM strongly recommended; pre-Ramadan training mandatory |
Metformin (no dose change typically)[1]
Biguanide
- Adult
- Reverse timing: morning dose at iftar, evening dose at suhoor; no total dose change
- Paediatric
- —
Low hypoglycaemia risk; safe to fast
SGLT2 inhibitor (caution)[1]
SGLT2 inhibitor
- Adult
- Continue but emphasise hydration during non-fasting hours; pause if dehydration / vomiting; consider stopping pre-Ramadan in high-risk patients
- Paediatric
- —
Risk of euglycaemic DKA and dehydration with prolonged fasting
Sulfonylurea (modify timing and dose)[1]
Insulin secretagogue
- Adult
- Newer agents (gliclazide MR, glimepiride) preferred over glibenclamide; reduce morning equivalent at suhoor by 25–50%; full dose at iftar
- Paediatric
- —
Hypoglycaemia risk; avoid glibenclamide; consider switching to DPP-4 inhibitor pre-Ramadan if previously on glibenclamide
Basal-bolus insulin[1]
Insulin therapy
- Adult
- Reduce basal dose by 15–30%; switch timing to evening; reduce prandial dose at suhoor by 25–50%; full prandial at iftar adjusted to carbohydrate
- Paediatric
- —
Detailed individualised plan; CGM strongly recommended; pre-Ramadan training mandatory
Safety-net
- Break the fast immediately if glucose <70 or >300 mg/dL, or if you feel unwell — this is religiously permitted and clinically necessary[1]
- Drink plenty of fluids during non-fasting hours; avoid sugary drinks at iftar (rapid glucose spikes)[1]
- If on insulin or SGLT2, check ketones if glucose >250 or feeling unwell — euglycaemic DKA possible on SGLT2[1]
Referral criteria
- Severe hypoglycaemia or DKA during RamadanEmergency department; reassess fasting safety post-recovery[1]
- Very-high-risk patient choosing to fast against adviceDiabetes specialist for individualised plan, intensive monitoring, CGM[1]
- Pregnancy with diabetes during RamadanJoint diabetes-obstetric care; counsel against fasting[1]
Clinical summary
Pre-Ramadan risk stratification and intra-Ramadan adjustments to glucose-lowering therapy for adults with diabetes who choose to fast.