The Ramadan specific guidelines given below are based on our experience. The most important point is the realization that the patient care must be highly individualized and the management plan may differ for each patient.
We suggest that patients on metformin and diet control should continue with their dosage as Pre Ramadan and take them at Sehar and Iftar. For example; patient taking 1 gram BD should continue with their dosage at Sehar and Iftar. For patients taking metformin 500 mg three times a day, we recommend 500 mg at Sehar and 1000 mg at Iftar.
We suggest continuing the prescribed dose(s) of Acarbose at Sehar and Iftar.
During Ramadan change the timing of the once daily dose of sulphonylurea from the usual morning dose to the evening (at Iftar) and reduce from its actual dose to 75% of the total dosage at start and then adjust according to the glycemic control, the dosage is not constant and change it accordingly. For patients on twice a day dosage regimen, reduce the morning dose to 75% and should be given at Iftar, reduce the night dose to 50% and should be given at Sehri.
During Ramadan change the timing of the once daily dose of Thiazolidinediones (such as pioglitazone) from the usual morning dose to the evening (at Iftar) dose.
The same Pre Ramadan dose can be continued during Ramadan except for the change in timing.
Those on combination of secretagogues and other oral hypoglycemic agents would require adjustment in dosage and timing of all the drugs in the combination.
Patients on combination either with metformin or with Sulphonylureas or both, with insulin need to adjust their dosage.
We suggest patients who take long acting basal insulin, such as glargine, to reduce the dose by 30%. i.e. 20 units to be reduced to 14 units and those taking with combination of sulphonylurea in addition of this reduction also need to reduce the dose of sulphonylurea to 75% of the total dosage at start and then adjust according to the glycemic control, the dosage is not constant and change accordingly this means patients taking 4mg of glimepiride in morning should cut down to 3mg at Iftar.
We suggest patients on 70/30 regime should do modification in their regime by taking 75% of the total dosage at start and then adjust according to the glycemic control, the dosage is not constant and change accordingly For example patients taking 40 units of premixed insulin in morning should cut down to 30 units at Iftar and taking 30 units at night should reduce to 16 units at Sehar.
We suggest that patients need modification in their dosage. Their overall dosage should be reduced to 75% of the total dosage at start and then adjust according to the glycemic control, the dosage is not constant and change accordingly.
First night of Ramadan (that is the night before first fast) is very important. The pre-dinner dosage of OHA / Insulin should be reduced to 75% of the total dosage at start and then adjust according to the glycemic control, the dosage is not constant and change accordingly for eg. Patient taking 20 units at night should be given 16 units.
Normal levels of physical activity may be maintained. However, excessive physical activity may lead to a higher risk of hypoglycemia and should be avoided, particularly during the few hours before the sunset meal. Taraweeh should be considered as part of the daily exercise program.
All patients should understand that they must always and immediately end their fast if hypoglycemia (blood glucose of <60mg/dl (3.3 mmol/l)) occurs because their blood glucose may drop further if they delay treatment. The fast should also be broken if blood glucose reaches <70 mg/dl (3.9 mmol/l) in the first few hours after the start of fast, especially if insulin, sulphonylurea drugs or meglitinide are taken at Sehar.
In our Ramadan study (characteristic of fasting and Ramadan specific diabetes education trends in patients with diabetes; a multinational survey 2014) Ramadan-specific diabetes education was identified as the cornerstone of safe fasting. Patients who received Ramadan-specific diabetes education not only followed Ramadan-specific diabetes management recommendations better but also had lesser severe acute complications of diabetes during Ramadan compared to patients who did not receive education.
Ramadan-specific diabetes management recommendations were followed more by the educated group. It was summarized that Ramadan-specific diabetes education of any mode (one to one session, group session or written education material) was far better than non-educated group.
Doctors should discuss the following aspects of fasting before Ramadan:
Diet during Ramadan should not differ significantly from a healthy and balanced diet. It should aim at maintaining a constant body mass. The common practice of ingesting large amount of food rich in carbohydrate and fat, especially at the sunset meal, (Iftar) should be avoided. Because of the delay in digestion and absorption, ingestion of food containing “complex” carbohydrates may be advisable at the predawn meal, while food with simple carbohydrates may be more appropriate at the sunset meal. It is recommended that fluid intake should be increased during non-fasting hours and the predawn meal should be taken as late as possible before Sehar. All patients should take at least 3 meals a day i.e. Sehri, Iftar and Dinner. It is also recommended that patients should monitor their blood glucose before Sehri, two to three hours after Sehri, Mid day, before Iftar and two to three hours after Iftar.
Meals should be based on healthy choices of starch carbohydrate, protein and vegetables (mixed meal for slow release of energy). Make sure early Iftar and late Sehri should be taken to prevent hypoglycemia during fasting. Avoid salty and excessive spices. Avoid refined foods such as breads made with white flour, fruit juice. Keep to the portion sizes. Serve variety of foods from each group. Butter and margarine are high in calories. Increase the amount of salads and vegetables as they are healthy options and low in calories. Avoid excessive amounts of sugary drinks and replace with water (as first choice) or no added sugar drinks.