Diabetes and Ramadan: pre-fasting assessment, risk stratification and glucose monitoring

What it is

Fasting the holy month of Ramadan is one of five main pillars of Islam, and most Muslims are passionate about fasting during this month. The Holy Quran exempts sick people from the duty of fasting, but many Muslims with diabetes may not perceive themselves as sick and are keen to fast. All people with diabetes who wish to fast during Ramadan should schedule a visit with HCP at 6-8 weeks before Ramadan. That visit does two things: it assesses their risk of fasting, and it gives education on the role of SMBG, when to break the fast, when to exercise, fluids and meals planning, and medications adjustment.

Causes and risk

Very High risk (Must not fast). Patients have one or more of the following:

• History of recurrent attacks of hypoglycemia
• History of hypoglycemia unawareness
• Severe hypoglycemia, unexplained DKA or HHS within the 3 months prior to Ramadan
• Poorly controlled T1DM
• Acute illness
• Pregnancy in pre-existing diabetes, or GDM treated with insulin or SUs
• Chronic dialysis or CKD stage 4 & 5
• Advanced macrovascular complications
• Old age with ill health

High risk (Should not fast). Patients have one or more of the following:

• T2DM with sustained poor glycemic control
• Well-controlled T1DM
• Well-controlled T2DM on MDI or mixed insulin
• Pregnant T2DM or GDM controlled by diet only or metformin
• CKD stage 3
• Stable macrovascular complications
• Patients with comorbid conditions that present additional risk factors
• People with diabetes performing intense physical labour
• Treatment with drugs that may affect cognitive function

Watch where type 1 diabetes falls. Poorly controlled T1DM sits in the group that must not fast; well-controlled T1DM sits in the group that should not fast. Good control moves the patient one group down, it does not let the patient fast. The same split runs through the CKD lines and the macrovascular lines: CKD stage 4 & 5 against CKD stage 3, and advanced macrovascular complications against stable ones.

Moderate/Low risk. Patients have one or more of the following: well-controlled T2DM treated with one or more of the following.

• Lifestyle therapy
• Metformin
• Acarbose
• Thiazolidinediones
• Second-generation SUs
• Incretin-based therapy (DPP-4 inhibitors or GLP-1 RAs)
• SGLT2 inhibitors
• Basal insulin

Basal insulin sits in this lowest group, while well-controlled T2DM on MDI or mixed insulin sits in the high risk group. It is the regimen, not the fact of taking insulin, that moves the patient.