Ramadan

This leaflet explains what you need to know about Ramadan as someone with diabetes. It covers suggestions for people controlling their diabetes by diet and exercise, diet, exercise and tablets, and insulin (with or without tablets).

 

Ramadan is the Holy Month for Muslims - a time of worship, self-discipline, austerity and charity. Fasting is necessary for all healthy adult Muslims, with nothing being consumed between dawn and sunset.

Alterations to mealtimes, daily routine and use of special traditional foods occur during the Holy Month. People who are Muslim and have diabetes can be exempt from fasting, but you may wish to fast.

Fasting could cause problems for you if you have diabetes, as your blood sugar levels are closely linked with diet, meal timings and medications. This information gives you guidelines on what to do if you do want to fast, so that you can do so safely.

If you are in any doubt about what you should do with your treatment while fasting, contact your diabetes nurse or doctor or GP. There may be circumstances when you will be recommended not to fast for health or safety reasons. 

Group 1: People controlling their diabetes by diet and exercise

If you control your diabetes by diet and exercise, provided you continue to be careful with your diet, you can fast safely during Ramadan. If you are overweight, you can lose weight during the Holy Month, which can improve your diabetic control.

  • Divide your food into 2 meals – Sehri and Iftar 
  • Fill up on starchy food such as cereals, basmati rice, chapati or naan at either meal 
  • Include fruits, vegetables, dhal and yoghurt in your meals 
  • Only have small amounts of foods such as ladoo, jelaibi or burfi 
  • Avoid very fatty fried foods like samosa or pakora 
  • Stick to low calorie or 'diet' drinks or water and drink plenty 

You may feel tired when fasting during Ramadan, so although it is important that you continue your daily activity and prayer, try to rest at some point in the day. 

Group 2: People controlling their diabetes with diet, exercise and tablets

It is important that you follow the same guidelines as Group 1 regarding diet and resting.

The advice for fasting will vary slightly dependent on the diabetes medication being used (see below). Any changes to medication should be discussed with a health care professional and will be dictated by symptoms and blood glucose levels.

Metformin (Glucophage) or Acarbose 

If you feel unwell during the fast taking these tablets you can consider stopping or reducing them or switching the timing. If you continue to take them, the largest dose should be taken at Iftar, so that they work when you are eating.

Sulphonylurea

  • Glibenclamide 2.5 mg, 5mg 
  • Gliclazide (Diamicron) 40 mg and 80 mg tablets
  • Gliclazide MR 30 mg 
  • Glimepiride (Amaryl) 1mg, 2mg
  • Glipizide 5mg – 20mg
  • Tolbutamide 500mg
  • Prandial Glucose regulators
  • Repaglinide (Prandin) 0.5mg, 1mg, 2mg 
  • Nateglinide (Starlix) 60mg, 120mg, 180mg

These tablets can cause your blood sugar to go low (hypoglycaemia) when you are fasting which could make you feel ill. These should not be taken during fasting hours but a dose may be taken when you are eating (e.g. at Iftar) 

Pioglitazone

They do not cause hypoglycaemia when taken alone and are usually taken in the morning/once a day.  if you feel unwell during the fast, you may wish to switch to taking them at Iftar.

Dipeptidyl peptidase 4 (DPP4) inhibitors (also known as gliptins)

  • Alogliptin (Vipidia) 6.25mg, 12.5mg, 25mg 
  • Linagliptin (Trajenta) 5mg
  • Linagliptin + Metformin (Jentadueto) 2.5mg/850mg, 2.5mg/1000mg 
  • Sitagliptin (Januvia) 100mg, 50mg, 25mg
  • Sitagliptin + Metformin (Janumet)
  • Saxagliptin (Onglyza) 2.5mg, 5mg 
  • Vildagliptin + Metformin (Eucreas) 50mg/850mg, 50mg/1000mg

These tablets generally do not cause hypoglycaemia(low sugar) on their own, and are once daily medications, so can continue to be taken as normal or switched to be taken with food e.g at Iftar if easier.

SGLT2 (sodium-glucose transporter 2) inhibitors

  • Canagliflozin (Invokana) 100mg, 300mg 
  • Canagliflozin and Metformin (Vokanamet) 50mg/850mg, 50mg/1000mg, 150mg/850mg, 150mg/1000mg
  • Dapagliflozin (Forxiga) 5mg, 10mg 
  • Dapagliflozin and Metformin (Xigduo) 5mg/850mg, 5mg/1000mg
  • Empagliflozin (Jardiance) 10mg, 25mg 
  • Empagliflozin and metformin (Synjardy) 5mg/500mg, 5mg/1000mg, 12.5mg/850mg, 12.5mg/1,000mg

These tablets generally do not cause hypoglycaemia (low sugar) on their own so can continue to be taken as normal, reduced in dose or switched to be taken with food e.g. at Iftar if easier.

Non insulin injections - Glucagon- Like Peptide (GLP-1)

  • Exenatide (Byetta) 5mcg,10mcg twice daily pen injection
  • Exenatide Extended Release (Bydureon) 2mg once weekly
  • Liraglutide (Victoza) 0.6mg, 1.2mg once daily pen injection
  • Lixisenatide (Lyxumia) 10mcg, 20mcg once daily pen injection
  • Dulaglutide (Trulicity) 0.75mg,1.5mg weekly injection 
  • Albiglutide (Eperzan) 30mg weekly injection
  • Acarbose (Glucobay ) 50mg,100mg

These drugs on their own do not cause hypoglycaemia(low sugar) so it may be possible to continue to take these with close monitoring of blood glucose. They can however case some nausea. Whether these are continued or not will depend on blood sugar levels and symptoms. If you are in doubt about what to do with your tablets or injections when fasting, discuss this with your diabetes nurse or doctor or GP. 

Testing blood sugars when taking tablets and fasting

When you take tablets that can cause low blood sugar levels, it is a good idea to check your blood sugar more often when fasting to make sure it is not rising too high (more than 10) or dropping too low (less than 4). If your results worry you and you don't know what to do, contact your diabetes nurse or doctor or GP.

Group 3: People controlling their diabetes by taking insulin (with or without tablets)

It is important that you follow the same guidelines as Group 1 and 2 regarding diet and rest.

If you control your diabetes with insulin, it is vital that you know what to do when fasting to avoid high blood sugars (hyperglycaemia – more than 10) or low blood sugars (hypoglycaemia – less than 4).

In general, your insulin requirements will drop significantly when you are fasting and may rise during the hours when you are eating.  If you don’t adjust your insulin regime you will be at risk of hypoglycaemia (low blood glucose levels) during fasting.

Quick Acting insulins such as Novorapid, Humalog, Apidra in combination with Long Acting insulin’s (see below) provide a more flexible insulin regime, making it easier to change the timings of injections and alter doses. Your specialist may change you to a short acting insulin, so you inject only when you are eating.

Intermediate and Long acting insulins such as Lantus, Levemir, Glargine, Humulin I, Insulatard, Degludec are often used on their own or in combinations with short acting insulins. The dose of background insulin may need to be reduced if you are fasting.

Pre mixed insulins for example Novomix 30, Humalog mix 25 & mix 50 are not usually recommended during periods of fasting. If these insulins are to continue to be used, it is likely that the timing and dose will be adjusted to ensure that insulin is being taken in conjunction with eating.

You will need the help of your diabetes nurse or doctor to change your insulin so contact them for advice well in advance of the next Holy Month. If you fast and are taking insulin, it is important to check your blood sugar frequently to make sure you are not going 'hypo' (less than 4) or that your blood sugar is not rising too high (more than 10).

Hypoglycemia (blood glucose less than 4) 

IF YOU HAVE A HYPO WHEN FASTING, YOU MUST BREAK YOUR FAST OTHERWISE YOU MAY GO INTO A COMA.

Signs and symptoms

  • sweating 
  • shaking 
  • palpitations 
  • double vision 
  • hunger pangs 
  • slurred speech
  • odd behavior 

Treatment 

Take some rapid acting carbohydrate such as loosed, full fat coke, jelly babies. Then take some slow acting carbohydrate to eat like a sandwich or chapatti to keep your blood sugar up. If you can test your blood sugar. Try to work out why you had a hypo.

  • Was it because you fasted and didn't change your diabetes treatment? 
  • Was it because you were doing hard physical work and not resting? 

More information on hypoglycaemia treatment can be found here.

Exceptions to Fasting

The Quran allows you not to fast if you have an illness or medical condition. Woman who are pregnant are advised not to fast.  You can consider donating some money to charity as an alternative means of participating in Ramadam. But if you really want to fast, make sure you can do this safely.

Contact your diabetes nurse or doctor or GP for advice about your treatment if you have any doubts.

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