Pharmacological approaches to the management of type 2 diabetes in fasting adults during Ramadan

Figures & data

Figure 1 Fact sheet on the fasting month of Ramadan.

Figure 2 Proposed steps for glycemic control during Ramadan fasting in people with type 2 diabetes mellitus.

Figure 3 Proposed algorithm for pre-Ramadan review and adjustments of lifestyle and therapeutic regimens.

Adapted and modified from AlMaatouq.²⁴ *Stable glycemic control with no major comorbidities on metformin, glitazones, alpha glucosidase inhibitors and incretin modulators.
**Fluctuating glycemia, major comorbidities esp. renal/hepatic insufficiency and/or use of insulin and sulfonylureas.

Figure 4 Principles of antihyperglycemic therapeutic regimen adjustments in people with type 2 diabetes mellitus who are fasting for Ramadan.

Figure 5 Site and mode of action of the most commonly used antidiabetic pharmacological agents, classified by their hypoglycemic risk potential and weight gain/loss characteristics.

Adapted and modified from AlMaatouq.²⁴

Table 1 Adjustments of noninsulin antidiabetic regimens in people with type 2 diabetes who are fasting for Ramadan

Regimen	Iftar (sunset) meal	Suhur (predawn) meal
Metformin	Two thirds of dose	One third of dose
Pioglitazone and other glitazones	Full dose with no change	None
Acarbose and other a-glucosidase inhibitors	Same dose	Same dose
Dipeptidylpeptidase-4 inhibitors	Same dose	Same dose
GLP, glucagon-like peptide-1 receptor agonists	Exenatide: same dose Liraglutide: full dose	Exenatide: same dose Liraglutide: none
Glinides	Same dose	Same dose
Sulfonylureas	Glibenclamide: same dose Gliclazide: same dose	Glibenclamide: half dose or none Gliclazide: same dose

Table 2 Insulin regimen adjustments in people with type 2 diabetes who are fasting for Ramadan

Regimen	Suggested adjustments
Single basal (or premixed) insulin	Take insulin before dinner (Iftar) Empirical reduction of dose by 30% (if blood glucose is well controlled pre-Ramadan) Adjust dose as per home blood glucose monitoring to avoid daytime (especially late in the day/pre-Iftar) hypoglycemia
Twice daily premixed (or basal) insulin	Take the usual larger dose at Iftar Reduce the smaller dose (usually before dinner) by 30% to coincide with pre-Suhur/early morning meal Adjust doses to avoid early morning and pre-sunset hypoglycemia
Twice daily premixed insulin plus bolus insulin before lunch	Take the usual larger dose at Iftar Omit the bolus dose unless the patient’s eating profile includes a large meal at midnight
Basal-bolus insulin	Basal insulin to be taken pre-Iftar without dose change Bolus dose taken before Iftar may need to be augmented Bolus dose taken before Suhur is either omitted or reduced to avoid daytime hypoglycemia
Premeal boluses	Adjust the pre-Iftar dose to avoid postprandial hyperglycemia Adjust the pre-Suhur dose to avoid daytime hypoglycemia

AlMaatouq MA Manual of Diabetes Practice Milton Keynes, UK AuthorHouse Publishing 2010

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