Practical Guide to

Diabetes Management
in Ramadan
 Contents

Background

Pathophysiology of fasting during Ramadan

Medical benefits of fasting during Ramadan

Risks of fasting in diabetes during Ramadan

Patients who are at risk of developing complications during fasting

Preparation prior to Ramadan

Self-monitoring of blood glucose (SMBG) during Ramadan

Lifestyle and diet management during Ramadan

Oral anti-diabetic therapy during Ramadan

Insulin therapy during Ramadan

2
BACKGROUND

3
 Background

Fasting with Patients Healthcare

diabetes choose to fast professionals
Associated with adverse EPIDIAR study showed
outcomes1,2 42.8% of patients with
Dehydration Type 1 and 78.7% with Pre-fasting education and
Type 2 diabetes mellitus planning2
Hypoglycaemia fasting at least 15 days
Hyperglycaemia during Ramadan3

High risk of developing To lower incidence of

Hence, not obliged to fast1,2
hypoglycaemia4 adverse outcomes2

References:
1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update 2010. Diabetes Care. 2010; 33(8): 1895-902.
2.
3.
Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010; 103(4): 139-147.
Salti I, Bénard E, Detournay B, et al. A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care. 2004; 27(10): 2306-
4
2311.
4. Loke SC, Rahim KF, Kanesvaran R, et al. A prospective cohort study on the effect of various risk factors on hypoglycaemia in diabetics who fast during Ramadan. Med J Malaysia. 2010; 65(1): 3-6.
PATHOPHYSIOLOGY OF FASTING
DURING RAMADAN

5
 Physiology of Fasting during Ramadan

Gluconeogenesis
Increased glucose uptake

Glucose

Liver
Peripheral
tissues (muscle)

Glycogen stores depleted • In normal healthy individuals, eating stimulates the secretion
of insulin from the islet cells of the pancreas.
Pancreas • This in turn results in glycogenesis and storage of glucose as
glycogen in liver and muscle.
Insulin secretion • During fasting secretion of insulin is reduced while counter-
regulatory hormones glucagon and catecholamines are
decreased increased. This leads to glycogenolysis and gluconeogenesis.
• The low levels of insulin in circulation also lead to increased
fatty acid release and oxidation that generates ketones which
are used for nutrition by the body.
Adapted from Figure 1 Pathophysiology of fasting in normal individuals: Karamat et al.

6
References:
1. Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010; 103(4): 139-147.
 Pathophysiology of Fasting in Diabetics during
Ramadan
Gluconeogenesis & ketogenesis
Increased glucose uptake

Glucose
Liver
Peripheral tissues
Glycogen stores depleted
(muscle)
Excessive breakdown Pancreas
Insulin secretion
decreased or absent

• In the normal fed state, glycogen is the body’s main source Type 1 diabetes
of energy. • In patients with Type 1 diabetes, glucose homeostasis is affected by
• Secretion of insulin is reduced while counter-regulatory underlying disease and by insulin therapy.
hormones glucagon and catecholamines are increased. • Glucagon secretion may fail to increase appropriately in response
• During a fast, these glycogen stores are utilised first to to hypoglycaemia, and in patients with severe insulin deficiency, a
produce energy. The liver glycogen is depleted in the first prolonged fast in the absence of adequate basal insulin can lead to
18 to 24 hours via glycogenolysis. excessive glycogen breakdown and increased gluconeogenesis and
• Later in the fasting state, once glycogen stores are ketogenesis leading to hyperglycaemia and eventual ketoacidosis.
depleted, fat becomes the next source of energy for the
body. Fats are mobilised in the form of triglycerides which
further undergo lipolysis into free fatty acids and glycerol.
• With prolonged periods of fasting (days to weeks), protein Type 2 diabetes
becomes the source of energy and will be released from • Patients with Type 2 diabetes may suffer similar consequences,
the catabolism of muscle. however ketoacidosis is uncommon.

Adapted from Figure 2 Pathophysiology of fasting in diabetes: Karamat et al.

References: 7
1. Ministry of Health Malaysia. Practical guide to Insulin Therapy in Type 2 Diabetes Mellitus. 2010.
2. Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010; 103(4): 139-147.
MEDICAL BENEFITS OF FASTING
DURING RAMADAN

8
 Medical Benefits of Fasting during Ramadan

Reduction in body mass With or without any Improvement of HbA1c

index (BMI) changes in total level
cholesterol and
triglycerides levels

Decrease in body Increase in high-density Improvement in

weight1 lipoprotein (HDL)2 glycaemic control3

Decrease in daytime Elimination of toxins Reduction in high

average systolic and Reducing insulin-like sensitive C-reactive
diastolic blood pressures growth factor 1 (IGF-1) protein (hs-CRP)
in hypertensive patients which allows the Reduction in plasminogen
regeneration of stem activator inhibitor type-1
cells in the bone marrow (PAI-1)

Decrease in blood Improvement in Reduced cardiovascular

pressure4,5 immunity6 disease markers7

References:
1. Mafauzy M, Mohammed WB, Anum MY, et al. A study of the fasting diabetic patients during the month of Ramadan. Med J Malaysia. 1990; 45(1): 14-17.
2. Benaji B, Mounib N, Roky R, et al. Diabetes and Ramadan: review of the literature. Diabetes Res Clin Pract. 2006; 73(2): 117-125.
3. Chamakhi S, Ftouhi B, Rahmoune NB, et al. Influence of the fast of Ramadan on the balance glycaemic to diabetics. Medicographia. 1991; 13: 27-29.
4.
5.
Perk G, Ghanem J, Aamar S, et al. The effect of the fast of Ramadan on ambulatory blood pressure in treated hypertensives. J Hum Hypertens. 2001; 15(10): 723-725.
Akturk IF, Biyik I, Kocas C, et al. PP-014 The effect of Ramadan fasting on blood pressure levels of hypertensive patients with combination therapy. Int J Cardiol. 2012; 155(Suppl 1): S103.
9
6. Cheng CW, Adams GB, Perin L, et al. Prolonged fasting reduces IGF-1/PKA to promote hematopoietic-stem-cell-based regeneration and reverse immunosuppression. Cell Stem Cell. 2014; 14(6): 810-823.
7. Ibrahim O, Kamaruddin N, Wahab N, et al. Ramadan Fasting And Cardiac Biomarkers In Patients With Multiple Cardiovascular Disease Risk Factors. The Internet Journal of Cardiovascular Research. 2010; 7(2).
 Changes in Average SBP and DBP for
Hypertensive Patients
Ramadan fasting in Islamic populations of the world may cause significant reductions on daytime and twenty four hour
average systolic and diastolic blood pressures in hypertensive patients with combination therapy.

Average 24-h Average awake Average asleep

160
140.3 138.9
140 134.2
129.3 129.9 128.6
Blood pressure (mm Hg)

120

100
82.1 83.3
80 77.3 77.0 76.8 74.1

60

40

20

0
Systolic BP Diastolic Systolic BP Diastolic Systolic BP Diastolic
BP BP BP
Before Ramadan During Ramadan
Abbreviation: BP: Blood pressure; SBP: Systolic blood pressure; DBP: Diastolic blood pressure
10
Reference:
1. Akturk IF, Biyik I, Kocas C, et al. PP-014 The effect of Ramadan fasting on blood pressure levels of hypertensive patients with combination therapy. Int J Cardiol. 2012; 155(Suppl 1): S103.
 Decrease in Body Weight

It was observed that the body weight decreased from 60.5 ± 12.6 kg before Ramadan to 59.8
± 12.3 kg with a mean decrease in of 0.7 ± 1.3 kg, p=0.01.

0.7 kg decrease of
80 mean body weight

70

60.5 59.8
60
Body weight (kg)

50

40

30

20

10

0
Before Ramadan After Ramadan

11
Reference:
1. Mafauzy M, Mohammed WB, Anum MY, et al. A study of the fasting diabetic patients during the month of Ramadan. Med J Malaysia. 1990; 45(1): 14-17.
 Improve in Glycaemic Control

The significant fall in the serum fructosamine level implied that the overall glycaemic control
was significantly better during the fasting month than before.
7 6.64 2.3 mmol/l decrease 12
of mean body weight 10.7 10.9
6 10
Mean value change (mmol/l)

Mean value change (mmol/l)

5
4.34 8
4
6
3
4
2

1 2

0 0
Fructosamine Fasting plasma glucose

Before Ramadan During Ramadan

12
Reference:
1. Mafauzy M, Mohammed WB, Anum MY, et al. A study of the fasting diabetic patients during the month of Ramadan. Med J Malaysia. 1990; 45(1): 14-17.
 Changes in Total Cholesterol and
Triglycerides Levels
7 HDL (mM) 7 Apo A-1/HDL ratio
6 6

Mean value change (ratio)

Mean value change (mM)

5 5
The total cholesterol and
4 4 triglycerides was maintained
3 3 until post-Ramadan. For
diabetic patients apo
2 2
1.08 0.99 1.14
1.48
A-1/HDL ratios level
1 1
increased after Ramadan and
0 0 this parameter as determined
from this study, would
Total cholesterol (mM) Triglycerides (mM)
suggest a reduced CHD risk
6.9 7
7 6.7 with Ramadan fasting.
6
6
Mean value change (mM)
Mean value change (mM)

5 5 4.6 4.6 Pre-Ramadan

4
4
Post-Ramadan
3 3
CHD: Coronary heart disease
2 2
HDL: High density lipoprotein
1 1

0 0
13
Reference:
1. Akanji AO, Mojiminiyi OA, Abdella N. Beneficial changes in serum apo A-1 and its ratio to apo B and HDL in stable hyperlipidaemic subjects after Ramadan fasting in Kuwait. Eur J Clin Nutr. 2000; 54: 508-513.
RISKS OF FASTING IN DIABETES DURING
RAMADAN

14
 Risks of Fasting during Ramadan

Hyperglycaemia/
Hypoglycaemia Dehydration
ketoacidosis
• Increase in • Increase in • Occurs due to limitation
hospitalisation due to hospitalisation due to in fluid intake
hypoglycaemia1 hyperglycaemia1 (prolonged fasting and
those who perform hard
• Diabetics with HbA1c • Patients who are poorly and physical labour)3
<8% and the elderly controlled before
have more than twice Ramadan are at an • Orthostatic hypotension
the risk of developing increased risk of may occur leading to
hypoglycaemia during diabetic ketoacidosis syncope, falls, injuries
the fasting month2 (DKA)3 and fractures3

• Hypercoagulable state
in diabetes might be
exacerbated, enhancing
the risk of thrombosis
and stroke3

References:
1. Salti I, Bénard E, Detournay B, et al A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care. 2004; 27(10): 2306-
2311. 15
2. Loke SC, Rahim KF, Kanesvaran R, et al. A prospective cohort study on the effect of various risk factors on hypoglycaemia in diabetics who fast during Ramadan. Med J Malaysia. 2010; 65(1): 3-6.
3. Ministry of Health Malaysia. Practical guide to Insulin Therapy in Type 2 Diabetes Mellitus. 2010.
 Risk of Hypoglycaemia during Ramadan
Overall population Before Ramadan During Ramadan
0.16 0.035
0.14 0.030
0.14 Among the overall population, the number

complications per month

0.03
complications per month

Severe hypoglycaemia
Severe hypoglycaemia

0.12
of severe hypoglycaemic episodes per
0.025 month and per patient was significantly
0.1 higher during Ramadan than during the
0.02
0.08 preceding year for patients with Type 1
0.015
0.06 diabetes as well as for patients with Type 2
0.04 0.03
0.01 diabetes.
0.005 0.004
0.02
P = 0.0174 P < 0.0001
0 0
Type 1 diabetes Type 2 diabetes

Patient who fasted ≥15 days Among patients who fasted for at least 15
days, the frequency of severe
0.14 0.025
0.12
hypoglycaemia complications was slightly
0.12 0.020 lower than in the overall population. For
complications per month

complications per month

Severe hypoglycaemia

Severe hypoglycaemia

0.02
0.1
these patients, significant differences were
reported in frequency of severe
0.08 0.015
hypoglycaemia complications per patient
0.06 per month between Ramadan and the
0.01
preceding year for patients with Type 2
0.04 diabetes but not Type 1 diabetes.
0.02 0.005 0.003
0.02
P = 0.9896 P = 0.0034
0 0
Type 1 diabetes Type 2 diabetes
16
Reference:
1. Salti I, Bénard E, Detournay B, et al A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care. 2004; 27(10): 2306-
2311..
 Risk of Hyperglycaemia/Ketoacidosis
during Ramadan
Overall population Before Ramadan During Ramadan
0.18 0.06
0.16
Among the overall population, the 0.16 0.05
0.05

Severe complications per

Severe complications per

number of severe hyperglycaemic 0.14
episodes with or without ketoacidosis 0.12 0.04
per month showed a significant
0.1

month

month
difference between Ramadan and the 0.03
preceding year only for patients with 0.08
Type 2 diabetes. 0.06 0.05 0.02
0.04 0.01
0.01
0.02
P = 0.1635 P < 0.0001
0 0
Type 1 diabetes Type 2 diabetes

Patient who fasted ≥15 days

Among patients who fasted for at least 0.16 0.15 0.045
0.04
15 days, the frequency of severe 0.14 0.04
Severe complications per

Severe complications per

hyperglycaemia complications was 0.035
0.12
slightly lower than in the overall 0.03
population. Type 2 diabetes reported 0.1
0.025
month

month
higher severe complications per month 0.08
0.02
than Type 1 diabetes. 0.06 0.05 0.015
0.04 0.01 0.009
0.02 0.005
P = 0.6701 P = 0.0015
0 0
Type 1 diabetes Type 2 diabetes
17
Reference:
1. Salti I, Bénard E, Detournay B, et al A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care. 2004; 27(10): 2306-
2311..
PATIENTS WHO ARE AT RISK OF
DEVELOPING COMPLICATIONS DURING
FASTING
18
 Patients Who Are at Risk of Developing
Complications during Fasting
Categories of risk in patients with Type 1 or Type 2 diabetes mellitus who fast during Ramadan 1
a) Very high risk*
Severe Severe Ketoacidosis Hyperosmolar Recurrent
complications hypoglycaemia hyperglycaemic hypoglycaemia
within 3 months coma
prior to fasting

Hypoglycaemia Acute illness Sustained poor Pregnancy Advanced renal

unawareness glycaemic control failure / Chronic
(HbA1c >9%) dialysis

b) High risk*
Moderate Moderate renal Advanced Living alone and treated with insulin or
hyperglycaemia failure macrovascular sulfonylureas
(HbA1c 7.5–9.0%) complications

Old age with ill Treatment with drugs that may affect Patients with co morbid conditions that present
health mentation additional risk factors

c) Moderate risk
Well-controlled diabetes treated with short-acting insulin secretagogues
d) Low risk
Well-controlled diabetes treated with lifestyle therapy, metformin, acarbose, thiazolidinediones, and/or incretin-based therapies in
otherwise healthy patients

* advised to abstain from fasting 19

Reference:
1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update 2010. Diabetes Care. 2010; 33(8): 1895-902.
 Patients Who Are at Risk of Developing
Complications during Fasting
Categories of risk in patients with Type 1 or Type 2 diabetes mellitus who fast during Ramadan 1
a) Very high risk*
Severe Severe Ketoacidosis Hyperosmolar Recurrent
complications hypoglycaemia hyperglycaemic hypoglycaemia
within 3 months coma
prior to fasting

Hypoglycaemia Acute illness Sustained poor Pregnancy Advanced renal

unawareness glycaemic control failure / Chronic
(HbA1c >9%) dialysis

b) High risk*
Moderate Moderate renal Advanced Living alone and treated with insulin or
hyperglycaemia failure macrovascular sulfonylureas
(HbA1c 7.5–9.0%) complications

Old age with ill Treatment with drugs that may affect Patients with co morbid conditions that present
health mentation additional risk factors

c) Moderate risk
Well-controlled diabetes treated with short-acting insulin secretagogues
d) Low risk
Well-controlled diabetes treated with lifestyle therapy, metformin, acarbose, thiazolidinediones, and/or incretin-based therapies in
otherwise healthy patients

20
Reference:
* advised to abstain from fasting
1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update 2010. Diabetes Care. 2010; 33(8): 1895-902.
 Patients Who Are at Risk of Developing
Complications during Fasting
Categories of risk in patients with Type 1 or Type 2 diabetes mellitus who fast during Ramadan 1
a) Very high risk*
Severe Severe Ketoacidosis Hyperosmolar Recurrent
complications hypoglycaemia hyperglycaemic hypoglycaemia
within 3 months coma
prior to fasting

Hypoglycaemia Acute illness Sustained poor Pregnancy Advanced renal

unawareness glycaemic control failure / Chronic
(HbA1c >9%) dialysis

b) High risk*
Moderate Moderate renal Advanced Living alone and treated with insulin or
hyperglycaemia failure macrovascular sulfonylureas
(HbA1c 7.5–9.0%) complications

Old age with ill Treatment with drugs that may affect Patients with co morbid conditions that present
health mentation additional risk factors

c) Moderate risk
Well-controlled diabetes treated with short-acting insulin secretagogues
d) Low risk
Well-controlled diabetes treated with lifestyle therapy, metformin, acarbose, thiazolidinediones, and/or incretin-based therapies in
otherwise healthy patients

* advised to abstain from fasting

21
Reference:
1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update 2010. Diabetes Care. 2010; 33(8): 1895-902.
 Fasting in Special Populations with Diabetes

• Strongly advised against fasting during Ramadan 1

• Fasting pregnant patients should be managed in high-risk clinics staffed by an

obstetrician, diabetologist, a nutritionist, and diabetes nurse educators 1

• The management of pregnant patients during Ramadan is based on an

appropriate diet and intensive insulin therapy 1
Pregnant women

• Adolescents with good glycaemic control who do regular self-monitoring can

fast safely during Ramadan2
• This is provided that a well structured program of education for both children
and their families is completed prior to Ramadan, and that they receive close
follow up during the month of Ramadan2
Children and
adolescents

References:
22
1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update 2010. Diabetes Care. 2010; 33(8): 1895-902.
2. Azad K, Mohsin F, Zargar AH, et al. Fasting guidelines for diabetic children and adolescents. Indian J Endocrinol Metab. 2012; 16(4): 516-518.
 Fasting in Special Populations with Diabetes

• Most stable patients on haemodialysis and peritoneal dialysis can fast,

provided that they strictly adhere to their medications and dialysis therapy in
addition to the dietary restrictions1,2

• These patients should be followed-up closely to detect any complications and

to ensure that adequate fluid and electrolyte balance are maintained 1,2
Dialysis patients

• Elderly patients are exempted from fasting. Many may wish to observe the
fast3

• Those with diabetes having any degree of cognitive dysfunction, dehydration,

or an increased risk of thrombosis are advised against fasting 3
Elderly patients

References:
23
1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update 2010. Diabetes Care. 2010; 33(8): 1895-902.
2. Azad K, Mohsin F, Zargar AH, et al. Fasting guidelines for diabetic children and adolescents. Indian J Endocrinol Metab. 2012; 16(4): 516-518.
3. Al Wakeel J, Mitwalli AH, Alsuwaida A, et al. Recommendations for fasting in Ramadan for patients on peritoneal dialysis. Perit Dial Int. 2013; 33(1): 86-91.
 Glycaemic Control among Pregnant Diabetic
Women on Insulin Fasting during Ramadan
Level of HbA1c Level of Fructosamine
Onset Ramadan Middle Ramadan After Ramadan
7 250
225.0 219.5
5.8 5.8 5.8 210.0
6
200

Fructosamine (mmol/L)
5
150 There was no statistically significant difference
4
HbA1c (%)

between the T2DM and GDM groups in terms of

glycaemic control at one week before Ramadan.
3 100 However, serum level of HbA1c tended to be higher in
2 the GDM group and serum fructosamine levels tended
to be lower in T2DM group. Compared to pre-Ramadan
50 measurements, serum fructosamine levels in both
1
groups (T2DM and GDM) were lower after Ramadan.
0 0
T2DM T2DM
7 250
6.2 6.1 218.0 214.0
6 5.6 195.0 Therefore, the findings of this study indicate that
200
Fructosamine (mmol/L)

pregnant diabetic women on insulin were able to fast

5
during Ramadan and their glycaemic control was
4 150 improved during the fasting period.
HbA1c (%)

3 100
2 T2DM: Type 2 diabetes mellitus;
50 GDM: Gestational diabetes mellitus
1
0 0
GDM GDM 24
Reference:
1. Ismail MNA, Raji HO, Wahab NA et al. glycaemic Control among Pregnant Diabetic Women on Insulin who fasted during Ramadan. IJMA; 2011; 36(4): 254-259.
 Fasting during Ramadan in Children and
Adolescents with Diabetes
*Children with Type 1 diabetes mellitus who completed Ramadan fasting
Pre-Ramadan Post-Ramadan

9 8.57 60 20
8.19 18.42
8 51.45 51.25 18
50 16.39
7 16

Mean insulin dose (IU)

14
6 40

Mean weight (kg)

Mean HbA1c (%)

12
5
30 10
4
8
3 20
6
2
4
10
1 2
0 0 0
Glycaemic control Weight Insulin dose
Conclusion
Comparing pre-Ramadan to post-Ramadan: • It is safe for diabetic children over the age of 11 years
• Glycemic control/A1c showed slight improvements to fast
• No weight changes • A well-structured program of education for both
• Insulin dose was increased in those who completed the children and their families is needed
Ramadan fasting • Close follow-up during the month of Ramadan is
needed
25
Reference:
1. Zabeen B, Tayyeb S, Benarjee B, Baki A, Nahar J, Mohsin F, Nahar N, Azad K. Fasting during Ramadan in adolescents with diabetes. Indian J Endocr Metab 2014;18:44-7.
 Glycaemic Control in T2DM patients
on Peritoneal Dialysis

The findings in the present study concluded that most stable patients on PD can fast for Ramadan provided that they
are followed closely and that strict fluid and electrolyte balances are maintained. However, patients who intend to
fast need comprehensive education and follow-up in the PD unit.

900 2.5 80
843
71.67
800 70 65.1
1.95
Average daily urine output (mL)

697
Weekly creatinine clearance (L)

Weekly creatinine clearance (L)

700 2 1.91
60
600
1.5 50
500
40
400
1 30
300
20
200 0.5
100 10

0 0 0
Average daily urine output Total weekly Kt/V Total weekly creatine

Abbreviations: T2DM: Type 2 diabetes; PD: Peritoneal dialysis Pre-Ramadan Post-Ramadan 26

Reference:
1. Al Wakeel J, Mitwalli AH, Alsuwaida A, et al. Recommendations for fasting in Ramadan for patients on peritoneal dialysis. Perit Dial Int. 2013; 33(1): 86-91.
 Fasting during Ramadan in
Haemodialysis Patients
Haemodialysis patients Before Ramadan During Ramadan After Ramadan
240 226.9 220.2 224.1 1.4
1.20 1.23
1.16
Duration of haemodialysis

200 1.2
1.0 During Ramadan, dialysis period was set to
160 after sunset, from 7:00 PM to 10:30 PM and
0.8 from 11:00 PM to 3:00 AM. Duration of the
(min)

Kt/V
120
0.6 dialysis sessions was reduced to 3 to 3.5
80 hours.
0.4
40 0.2 The mean duration of dialysis sessions
p = 0.005 p = 0.22 during Ramadan was significantly different
0 0.0 from those before and after Ramadan.
Duration of Total Kt/V
haemodialysis session Despite the shorter duration of
haemodialysis sessions, Kt/V did not differ
significantly. Significant changes before,
30 1200 during, and after Ramadan fasting were
26.4 25.5 1022.3 observed in the mean values of blood urea
Serum creatinine (μmol/L)

23.6 1000 928.7 931.6 and serum creatinine.

Blood urea (mmol/l)

20 800
The main finding of our study was that the
600 fasting haemodialysis patients in our
cohort tolerated fasting for long hours
10 400 during Ramadan. Haemodialysis must be
performed after sunset and before sunrise
200 in order for the fast to take place.
p = 0.02 p < 0.001
0 0
Blood urea Serum creatinine
27
Reference:
1. Al Wakeel; JS. Kidney function and metabolic profile of Chronic Kidney Disease and Hemodialysis patients during Ramadan fasting. IJKD. 2014; 8: 321-328.
 Long-term Ramadan Fasting on
Glucose Regulation in Elderly with T2DM
HbA1c Fasting plasma glucose
9 9 Pre-Ramadan Post-Ramadan
7.9 7.7 7.94
8 8 7.40
7 7
6 6

FPG (mmol/l)
HbA1c (%)

5 5
4 4
• No disruption of glucose control
3 3
2 2
when fasting during Ramadan
1 1
p = 0.37 p = 0.047 • No weight changes
0 0

• No significant increase in adverse

Postprandial plasma glucose Weight events like hypoglycaemia,
12 11.2
10.5
90 82.6 82.7 hyperglycaemia, and diabetic
10
80 coma.
70
8 60
PPG (mmol/l)

Weight (kg)

50
6
40
4 30
20
2
10
p = 0.15 p = 0.73
0 0

28
Reference:
1. Karatopak C, Yolbas S, Cakirca M, Cinar A, Zorlu M, Kiskac M et al. The effects of long term fasting in Ramadan on glucose regulation in Type 2 Diabetes Mellitus. Eur Rev Med Phamaco Sci. 2013; 17: 2512-2516.
PREPARATION PRIOR TO RAMADAN

29
 Pre-Ramadan Medical Review

c) Pre-Ramadan consultation

Overall • To reinforce healthy living advice to diabetic patients 1

Lipid control
wellbeing • To encourage diabetic patients to stop smoking 2

d) Medical administration
a) • Anti-hypertensive dose may need to be adjusted 1
Assessment: Diabetes-related
Glycaemic 1-2 months • Lipid lowering medications should be continued 1
control complications
before
Ramadan
e) Potential risk of fasting
• Patients to be informed regarding the potential
risk of fasting1
Diabetes-
Blood pressure unrelated
control comorbidities
f) Risk stratification of diabetic patients
• Recommended based on the presence of various
risk factors1

b) Changes in diet and medication regimen

• To establish a safe and effective anti-diabetic g) Fasting practice
regimen1
• Diabetic patients may start to practise fasting in
• To provide stable glycaemic control prior to start of
the months prior to Ramadan 1
Ramadan fast1
References:
1. Bashir MI, Pathan MF, Raza SA, et al. Role of oral hypoglycaemic agents in the management of Type 2 diabetes mellitus during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 503-507.
30
2. Benaji B, Mounib N, Roky R, et al. Diabetes and Ramadan: review of the literature. Diabetes Res Clin Pract. 2006; 73(2): 117-125.
3. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.
 Pre-Ramadan Medical Review

c) Pre-Ramadan consultation
• To reinforce healthy living advice to diabetic patients 1
• To encourage diabetic patients to stop smoking 2

Overall
Lipid control
wellbeing
d) Medical administration

• Anti-hypertensive dose may need to be adjusted 1

• Lipid lowering medications should be continued 1
a)
Assessment: Diabetes-related
Glycaemic 1-2 months
control before e)complications
Potential risk of fasting
Ramadan
• Patients to be informed regarding the potential
risk of fasting1

Diabetes-
f) Risk stratification of diabetic patients
Blood pressure unrelated
control •
comorbidities Recommended based on the presence of various
risk factors1
b) Changes in diet and medication regimen
• To establish a safe and effective anti-diabetic g) Fasting practice
regimen1
• To provide stable glycaemic control prior to start of • Diabetic patients may start to practise fasting in
Ramadan fast1 the months prior to Ramadan 1

References:
1. Bashir MI, Pathan MF, Raza SA, et al. Role of oral hypoglycaemic agents in the management of Type 2 diabetes mellitus during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 503-507.
31
2. Benaji B, Mounib N, Roky R, et al. Diabetes and Ramadan: review of the literature. Diabetes Res Clin Pract. 2006; 73(2): 117-125.
3. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.
 Pre-Ramadan Medical Review

c) Pre-Ramadan consultation
Overall • To reinforce healthy living advice to diabetic patients 1
Lipid control
wellbeing
• To encourage diabetic patients to stop smoking 2

d) Medical administration
a)
Assessment: • Anti-hypertensive dose may need to be adjusted 1
Glycaemic Diabetes-related
1-2 months b)complications
Changes in diet and medication
• regimen
Lipid lowering medications should be continued 1
control before
Ramadan • To establish a safe and effective anti-diabetic
regimen1
To provide stable glycaemic control prior to start of
• e) Potential risk of fasting
Ramadan fast1 • Patients to be informed regarding the potential
Diabetes- risk of fasting1
Blood pressure unrelated
control comorbidities
f) Risk stratification of diabetic patients
• Recommended based on the presence of various
risk factors1

g) Fasting practice
• Diabetic patients may start to practise fasting in
the months prior to Ramadan 1

References:
1. Bashir MI, Pathan MF, Raza SA, et al. Role of oral hypoglycaemic agents in the management of Type 2 diabetes mellitus during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 503-507.
32
2. Benaji B, Mounib N, Roky R, et al. Diabetes and Ramadan: review of the literature. Diabetes Res Clin Pract. 2006; 73(2): 117-125.
3. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.
 Pre-Ramadan Medical Review

Overall
Lipid control
wellbeing

d) Medical administration
a)
Assessment: • Anti-hypertensive dose may need to be adjusted 1
Glycaemic Diabetes-related
1-2 months complications • Lipid lowering medications should be continued 1
control before c) Pre-Ramadan consultation
Ramadan
• To reinforce healthy living advice to diabetic patients 1
• To encourage diabetic patients to stope) Potential
smoking 2 risk of fasting
• Patients to be informed regarding the potential
Diabetes- risk of fasting1
Blood pressure unrelated
control comorbidities
f) Risk stratification of diabetic patients
• Recommended based on the presence of various
risk factors1
b) Changes in diet and medication regimen
• To establish a safe and effective anti-diabetic g) Fasting practice
regimen1
• To provide stable glycaemic control prior to start of • Diabetic patients may start to practise fasting in
Ramadan fast1 the months prior to Ramadan 1

References:
1. Bashir MI, Pathan MF, Raza SA, et al. Role of oral hypoglycaemic agents in the management of Type 2 diabetes mellitus during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 503-507.
33
2. Benaji B, Mounib N, Roky R, et al. Diabetes and Ramadan: review of the literature. Diabetes Res Clin Pract. 2006; 73(2): 117-125.
3. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.
 Pre-Ramadan Medical Review

c) Pre-Ramadan consultation
Overall • To reinforce healthy living advice to diabetic patients 1
Lipid control
wellbeing
• To encourage diabetic patients to stop smoking 2

a)
Assessment: Diabetes-related
Glycaemic 1-2 months
control complications
before d) Medical administration
Ramadan
• Anti-hypertensive dose may need to be adjusted 1
e) Potential risk of fasting
Lipid lowering medications should be continued 1
•
• Patients to be informed regarding the potential
Diabetes- risk of fasting1
Blood pressure unrelated
control comorbidities
f) Risk stratification of diabetic patients
• Recommended based on the presence of various
risk factors1
b) Changes in diet and medication regimen
• To establish a safe and effective anti-diabetic g) Fasting practice
regimen1
• To provide stable glycaemic control prior to start of • Diabetic patients may start to practise fasting in
Ramadan fast1 the months prior to Ramadan 1

References:
1. Bashir MI, Pathan MF, Raza SA, et al. Role of oral hypoglycaemic agents in the management of Type 2 diabetes mellitus during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 503-507.
34
2. Benaji B, Mounib N, Roky R, et al. Diabetes and Ramadan: review of the literature. Diabetes Res Clin Pract. 2006; 73(2): 117-125.
3. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.
 Pre-Ramadan Medical Review

c) Pre-Ramadan consultation
Overall • To reinforce healthy living advice to diabetic patients 1
Lipid control
wellbeing
• To encourage diabetic patients to stop smoking 2

d) Medical administration
a)
Assessment: • Anti-hypertensive dose may need to be adjusted 1
Glycaemic Diabetes-related
1-2 months complications
control before e) Potential risk of fasting • Lipid lowering medications should be continued 1
Ramadan • Patients to be informed regarding the potential
risk of fasting1

Diabetes-
Blood pressure unrelated
control comorbidities
f) Risk stratification of diabetic patients
• Recommended based on the presence of various
risk factors1
b) Changes in diet and medication regimen
• To establish a safe and effective anti-diabetic g) Fasting practice
regimen1
• To provide stable glycaemic control prior to start of • Diabetic patients may start to practise fasting in
Ramadan fast1 the months prior to Ramadan 1

References:
1. Bashir MI, Pathan MF, Raza SA, et al. Role of oral hypoglycaemic agents in the management of Type 2 diabetes mellitus during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 503-507.
35
2. Benaji B, Mounib N, Roky R, et al. Diabetes and Ramadan: review of the literature. Diabetes Res Clin Pract. 2006; 73(2): 117-125.
3. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.
 Pre-Ramadan Medical Review

c) Pre-Ramadan consultation
Overall • To reinforce healthy living advice to diabetic patients 1
Lipid control
wellbeing
• To encourage diabetic patients to stop smoking 2

d) Medical administration
a)
Assessment: • Anti-hypertensive dose may need to be adjusted 1
Glycaemic Diabetes-related
1-2 months
control before f) Risk complications •
stratification of diabetic patients Lipid lowering medications should be continued 1
Ramadan
• Recommended based on the presence of various
risk factors1 e) Potential risk of fasting
• Patients to be informed regarding the potential
Diabetes- risk of fasting1
Blood pressure unrelated
control comorbidities

b) Changes in diet and medication regimen

• To establish a safe and effective anti-diabetic g) Fasting practice
regimen1
• To provide stable glycaemic control prior to start of • Diabetic patients may start to practise fasting in
Ramadan fast1 the months prior to Ramadan 1

References:
1. Bashir MI, Pathan MF, Raza SA, et al. Role of oral hypoglycaemic agents in the management of Type 2 diabetes mellitus during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 503-507.
36
2. Benaji B, Mounib N, Roky R, et al. Diabetes and Ramadan: review of the literature. Diabetes Res Clin Pract. 2006; 73(2): 117-125.
3. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.
 Pre-Ramadan Medical Review

c) Pre-Ramadan consultation
Overall • To reinforce healthy living advice to diabetic patients 1
Lipid control
wellbeing
• To encourage diabetic patients to stop smoking 2

d) Medical administration
a)
Assessment: • Anti-hypertensive dose may need to be adjusted 1
Glycaemic Diabetes-related
1-2 months complications • Lipid lowering medications should be continued 1
control before g) Fasting practice
Ramadan
• Diabetic patients may start to practise fasting in
the months prior to Ramadan 1 e) Potential risk of fasting
• Patients to be informed regarding the potential
Diabetes- risk of fasting1
Blood pressure unrelated
control comorbidities
f) Risk stratification of diabetic patients
• Recommended based on the presence of various
risk factors1
b) Changes in diet and medication regimen
• To establish a safe and effective anti-diabetic
regimen1
• To provide stable glycaemic control prior to start of
Ramadan fast1

References:
1. Bashir MI, Pathan MF, Raza SA, et al. Role of oral hypoglycaemic agents in the management of Type 2 diabetes mellitus during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 503-507.
37
2. Benaji B, Mounib N, Roky R, et al. Diabetes and Ramadan: review of the literature. Diabetes Res Clin Pract. 2006; 73(2): 117-125.
3. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.
 Patient Education

Hypoglycaemia – symptoms During fasting Timing

and signs During non-fasting hours Dosing
Hyperglycaemia –
symptoms and signs
Dehydration

Blood glucose Medication

Risk of fasting1,2,3
monitoring1,2,3 administration1,2,3

Timing When to stop the fast

Intensity Hydration
Meal planning and food
choices
Management of acute
complications

Physical activity1,2,3 Others1,2,3

References:
1. Bashir MI, Pathan MF, Raza SA, et al. Role of oral hypoglycaemic agents in the management of Type 2 diabetes mellitus during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 503-507.
38
2. Benaji B, Mounib N, Roky R, et al. Diabetes and Ramadan: review of the literature. Diabetes Res Clin Pract. 2006; 73(2): 117-125.
3. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.
 Proposed Algorithm for Pre-Ramadan Review
and Therapeutic Regimens Adjustments
Current regimen

Acceptable control Poor control

Glycaemia

Moderate/
Low risk* Assess risk for High risk**
Consider:
hypoglycaemia 1. Dietary review and advice
2. Exercise and physical activity
review and advice
3. Address compliance issues, if any
Adjust current regimen 4. Intensify SMBG
Continue same
• Patients on non-insulin 5. Adjust regimen
regimen
agents
• Patients with T2DM on
insulin

Acceptable control Poor control

Glycaemia

Adjusted Ramadan
regimen
* Stable glycaemic control with no major comorbidities on metformin, glitazones, alpha glucosidase inhibitors and incretin modulators.
** Fluctuating glycaemia, major comorbidities esp. renal/hepatic insufficiency and/or use of insulin and sulfonylureas.
39
Reference:
1. Almaatouq MA. Pharmacological approaches to the management of Type 2 diabetes in fasting adults during Ramadan. Diabetes Metab Syndr Obes. 2012; 5: 109-119.
SELF-MONITORING OF BLOOD GLUCOSE
(SMBG) DURING RAMADAN

40
 Timing and Frequency of SMBG
based on Treatment

Therapy Timing and frequency SMBG

Oral anti-diabetic (OAD) Monitor when symptomatic1

Diabetic patients who are in the moderate to high risk categories are advised to
monitor their blood glucose 5 times per day2
Pre-meal and 2-hour post pre-dawn meal (sahur)
Insulin Mid-day
Pre-meal and 2-hour post sunset meal (iftar)
Bedtime

References:
41
1. Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan 2015.
2. Hui E, Bravis V, Hassanein M, et al. Management of people with diabetes wanting to fast during Ramadan. BMJ. 2010; 340:c3053.
 When to End the Fast during Ramadan

Conditions to stop fasting:

• Blood glucose <3.3 mmol/l at anytime during the fast1

• Blood glucose <3.9 mmol/l in the first few hours of fasting (especially if the
patient is taking sulfonylureas, meglitinides, or insulin)2,3

• Blood glucose >16.7 mmol/l1

• Experience symptoms of hypoglycaemia (patients without SMBG)4

• Symptoms suggestive of severe dehydration such as syncope and confusion 4

References:
1.
2.
Pathan MF, Sahay RK, Zargar AH, South Asian Consensus Guideline: Use of insulin in diabetes during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 499-502.
Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.
42
3. Ibrahim MA. Managing diabetes during Ramadan. Diabetes voice. 2007; 52(2): 19-22.
4. Ministry of Health Malaysia. Practical guide to Insulin Therapy in Type 2 Diabetes Mellitus. 2010.
 Timing of SMBG Could Reflect Adequacy of
Insulin Dose

Time of glucose monitoring Insulin timing Insulin type

Mid-day Pre-sahur Premixed / bolus / basal insulin

Pre-iftar Pre-sahur Premixed / basal insulin

2-hour post-iftar or bedtime Pre-iftar Premixed / basal insulin

Pre-sahur Pre-iftar / Pre-bed Premixed / basal insulin

2-hour post-sahur Pre-sahur Premixed / bolus insulin

43
Reference:
1. Pathan MF, Sahay RK, Zargar AH, South Asian Consensus Guideline: Use of insulin in diabetes during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 499-502.
LIFESTYLE AND DIET MANAGEMENT
DURING RAMADAN

44
 Meal Planning

Appropriate meal planning is important to avoid postprandial hyperglycaemia 1

The diet during Ramadan should not differ from a healthy balanced diet 1

Distribute calories over two to Consume slow-energy food3

three smaller meals during the non- (i.e. wheat, beans and rice)
fasting interval2

References:
1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update 2010. Diabetes Care. 2010; 33(8): 1895-902.
45
2. Persatuan Dietitian Malaysia. Medical Nutrition Therapy Guidelines for Type 2 Diabetes Mellitus. 2013. Second Edition.
3. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.
 Dietary Advice

Food that should be limited

Good “buka puasa” meal
during “buka puasa”

A B

46
Reference:
1. Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan 2015.
 Adjustment of Diet Protocol for
Ramadan Fasting

Never skip sahur (dawn meal)

Do not delay “berbuka”

Supper after Tarawih can be taken as replacement of pre-bed snack

Include fruits and vegetables at both sahur and iftar

Limit fried and fatty foods

Limit intake of highly salted foods to reduce risk of dehydration

Drink adequately at sahur, choose sugar-free drinks, aim for 8 glasses per day

Avoid excessive binging of carbohydrates during non–fasting period

47
Reference:
1. Persatuan Dietitian Malaysia. Medical Nutrition Therapy Guidelines for Type 2 Diabetes Mellitus. 2013. Second Edition.
 Physical Activity

Light and moderate intensity exercise on a regular basis1,2

Avoid rigorous exercise during fasting time1,2

The timing of exercise is preferably 1-2 hours after the break of fast1,2

Performance of Tarawih night prayers3

References:
1. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.
48
2. Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010; 103(4): 139-147.
3. Ibrahim MA. Managing diabetes during Ramadan. Diabetes voice. 2007; 52(2): 19-22.
 Management of Hypoglycaemia
during Ramadan

Patients need to end their fast if they experience symptoms

of hypoglycaemia or have low blood glucose values*

Take simple carbohydrates

*Blood glucose < 3.3 mmol/l at anytime during the fast.

*Blood glucose < 3.9 mmol/l in the first few hours of fasting (especially if the patient
is taking sulfonylureas, meglitinides, or insulin).
*Experience symptoms of hypoglycaemia (patients without SMBG).
*Symptoms suggestive of severe dehydration such as syncope and confusion.
*Refer to Section 7: Self-monitoring of blood glucose during Ramadan: Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan 2015.

49
Reference:
1. Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan 2015.
ORAL ANTI-DIABETIC THERAPY DURING
RAMADAN

50
 Oral Anti-Diabetic Therapy
during Ramadan

Oral anti-diabetic (OAD) therapies should be individualised during

fasting1

OAD therapies that act by increasing peripheral insulin

sensitivity may be preferred due to a low risk of hypoglycaemia2

Insulin secretagogues have higher risk of hypoglycaemia than

the insulin sensitizers3

Newer sulphonylureas can be safely used during Ramadan 4

Incretin based therapies such as dipeptidyl peptidase-4

inhibitors and GLP-1 receptor analogues have low risk of
hypoglycaemia and do not require dose adjustments 5

References:
1. Al-Arouj M, Hassoun AA, Medlej R, et al. The effect of vildagliptin relative to suAl-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update 2010; Diabetes Care. 2010; 33(8): 1895-902
2. Bashir MI, Pathan MF, Raza SA, et al. Role of oral hypoglycaemic agents in the management of Type 2 diabetes mellitus during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 503-507. 51
3. Mafauzy M. Repaglinide versus glibenclamide treatment of Type 2 diabetes during Ramadan fasting. Diabetes Res Clin Pract. 2002; 58(1): 45-53.
4. Glimepiride in Ramadan (GLIRA) Study Group. The efficacy and safety of glimepiride in the management of Type 2 diabetes in Muslim patients during Ramadan. Diabetes Care. 2005; 28(2): 421-422.
5. Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan 2015.
 Adjustment of Oral Anti-Diabetic Therapy
during Ramadan
Regimen Sunset meal (iftar) Pre-dawn meal (sahur)

α-glucosidase inhibitors No changes No changes

Immediate-release
Twice daily No changes No changes
Biguanides
Thrice daily Two third of dose One third of dose
(Metformin)

Extended-release Full dose None

Dipeptidyl peptidase-4 inhibitors No changes No changes

Meglitinides No changes No changes

Glibenclamide, Gliclazide Reduce / Omit

Sulphonylurea No changes
Gliclazide modified-release,
Sunset meal dosing
Glimepiride

Sodium glucose co-transporter 2 inhibitors* No changes Sunset meal dosing

Thiazolidinediones No changes None

* Based on expert opinion 52
Reference:
1. Almaatouq MA. Pharmacological approaches to the management of Type 2 diabetes in fasting adults during Ramadan. Diabetes Metab Syndr Obes. 2012; 5: 109-119.
 Safety and Efficacy of Vildagliptin
during Ramadan (VIRTUE study)
Vildagliptin therapy was associated with significantly fewer patients
experiencing hypoglycaemia compared with SU therapy in this large Number of patients with hypoglycaemic
representative cohort of fasting Muslim patients with Type 2 diabetes mellitus.
This outcome is particularly meaningful when viewed in the context of good events during Ramadan
glycaemic and weight control observed in vildagliptin-treated patients who 140
123
fasted in this study. Vildagliptin was well-tolerated in this patient population. 120

hypoglycaemic event (n)

100

Patients with 1
Mean change HbA1c pre- to post-Ramadan
0.5 80
P < 0.001 60
Mean changes in

40 36
HbA1c (%)

0.02
0 20
P < 0.001
0
Hypoglycaemia events
-0.24
4.5
-0.5 4
4

hypoglycaemic event (n)

3.5

Patients with grade 2

Mean change body weight pre- to post-Ramadan 3
0.5 2.5
P < 0.001
2
Mean change in body

1.5
0
weight (kg)

1
-0.13 0.5
P = 0.053
0
-0.5 0
Hypoglycaemia events
-0.76
-1 Vildagliptin Sulphonylurea
53
Reference:
1. Al-Arouj M et al. The effect of vildagliptin relative to sulphonylureas in Muslim patients with Type 2 diabetes fasting during Ramadan: the VIRTUE study. Int J Clin Pract. 2013; 67(10): 957-963.
 The Incidence of Hypoglycaemia with T2DM
Treated with Sitagliptin during Ramadan
The proportion of patients with either symptomatic or asymptomatic hypoglycaemic events was 8.5% in the sitagliptin group and 17.9% in
the gliclazide group. The incidence of hypoglycaemic events requiring non-medical assistance was low, with 0.2% of patients in the
sitagliptin group and 0.8% in the gliclazide group. In Muslim patients with Type 2 diabetes who observed the fast during Ramadan,
switching treatment to a sitagliptin-based regimen decreased the risk of hypoglycaemia compared with a sulphonylurea-based regimen.
Both treatment regimens were generally well tolerated during the month of Ramadan.

Symptomatic or asymptomatic hypoglycaemic events Hypoglycaemic events requiring non-medical assistance

17.9% 0.8%
5
100
92
90 4
4
80

Number of patients (n)

Number of patients (n)

70
3
60 8.5%
50 43
40 2
0.2%
30
1
20 1
10
0 0
During Ramadan During Ramadan

Sitagliptin Sulphonylurea 54
Reference:
1. Al Sifri, Basiounny A., Echtay A., Al Omari M., Harman-Boehm I., Kaddaha G. et al. The incidence of hypoglycaemia in Muslim patients with Type 2 diabetes treated with sitagliptin or a sulponylurea during Ramadan: a randomised trial. Int J Clin Pract. 2011; 65(11):
1132-1140.
 Safety and Efficacy of Gliclazide during
Ramadan (STEADFAST study)
Glycaemic control, assessed as changes in HbA1c remained stable pre- to post-Ramadan with both treatments, indicate that similar efficacy can
be achieved during the Ramadan fasting period with vildagliptin and gliclazide. In both treatment groups, a small decrease in body weight from
pre- to post-Ramadan was observed. The proportion of patients who reported any hypoglycaemia events during the Ramadan fasting period was
numerically lower in the vildagliptin compared with the gliclazide; however, the difference between treatments did not reach statistical
significance.

The results suggest that the lower hypoglycaemia rate for gliclazide seen in
Mean change HbA1c pre- to post-Ramadan the present study may be linked to the special conditions of the STEADFAST
study, in which the particular attention to each patient, Ramadan-focused
0.2 advice, the recent switch in treatment, as well as the patients’ very good
p = 0.165
glycaemic control have created a setting that is often not reflected in real
life.
Mean changes in

0.1 0.05
HbA1c (%)

0 Number of patients with hypoglycaemic

-0.03 events during Ramadan
-0.1
8
-0.2 P = 0.039 7.0
7

Proportion of patients (%)

6
Mean change body weight pre- to post-Ramadan
p = 0.423 5
-0.2 4
Mean change in body

3.0
-0.7 3
weight (kg)

2
-1.2
1
-1.7
-1.7 0
-2.2 -1.9 Hypoglycaemia events
Vildagliptin Gliclazide 55
Reference:
1. Hassanein M, Abdallah K, Schweizer A. A double-blind, randomized trial, including frequent patient-physician contacts and Ramadan focused advice, assessing vildagliptin and gliclazide in patients with Type 2 diabetes fasting during Ramadan: the STEADFAST study.
Vasc Health Risk Management. 2014; 4(10): 319-326.
 Safety and Efficacy of Glimepiride
during Ramadan (GLIRA study)
HbA1c value (%)
10 10
9.2
9 9 8.4
7.7 8 7.7
8 7.3
7.1
7 7
6 6

HbA1c (%)
HbA1c (%)

5 5
4 4
3 3
2 2
1 1
0 0
V0 V1 V3 V0 V1 V3
The efficacy and safety of glimepiride in Type 2 diabetic patients is not
FBG value (mmol/l) altered during the month-long daylight fast of Ramadan, when the time
of administration of glimepiride is changed from the morning to the
0 evening. It can be concluded that with careful dietary management and a
change in the time of drug administration from morning to evening,
Muslim Type 2 diabetic patients taking glimepiride who are normally
Mean change FBG

-1
well controlled can fast during Ramadan if they wish to do so, with no
(mmol/l)

deterioration of glycaemic control.

-2
-2
V0: Baseline
-3
V1: Just before, or no more than 5 days after, the start of Ramadan,
-3.5 V3: Between 45 and 75 days after the end of Ramadan
-4
Newly diagnosed subjects Already treated subjects
56
Reference:
1. GLIRA Study Group. The Efficacy and Safety of Glimepiride in the Management of Type 2 Diabetes in Muslim Patients During Ramadan. Diab Care. 2005; 28(2): 9421-422.
INSULIN THERAPY DURING RAMADAN

57
 Insulin Adjustment during Ramadan
– Basal Insulin

Insulin regimen Type 1 diabetes mellitus Type 2 diabetes mellitus

Basal insulin only1-4

Not applicable. Taken at bedtime or any time after iftar
meals.
May require dose reduction if there is risk
of daytime hypoglycaemia.

Insulin glargine can be given once daily any time after iftar.

Insulin levemir and NPH insulin can be given either once daily at bedtime or divided into twice daily during
pre-dawn meal (sahur) and iftar.1

References:
1.
2.
Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update. 2010. Diabetes Care. 2010; 33(8): 1895-902.
Ministry of Health Malaysia. Practical guide to Insulin Therapy in Type 2 Diabetes Mellitus. 2010.
58
3. Pathan MF, Sahay RK, Zargar AH, South Asian Consensus Guideline: Use of insulin in diabetes during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 499-502.
4. Hui E, Devendra D. Diabetes and fasting during Ramadan. Diabetes Metab Res Rev. 2010; 26(8): 606-610.
 Insulin Adjustment during Ramadan
– Premixed Insulin

Insulin regimen Type 1 diabetes mellitus Type 2 diabetes mellitus

Premixed insulin once daily1-4

Not applicable. Inject usual dose at iftar meals.

Premixed insulin twice daily1-5

Reverse doses
Morning dose given at iftar and evening dose given at sahur.

Sahur Insulin dose reduced by 20-50% to Insulin dose reduced by 20-50% to

prevent daytime hypoglycaemia. prevent daytime hypoglycaemia.
OR
Change to short/rapid acting.*
* Late afternoon hypoglycaemia may
occur

Iftar Switch to mid/high premixed (ie. Mix50) insulin

References:
1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update. 2010. Diabetes Care. 2010; 33(8): 1895-902.
2. Ministry of Health Malaysia. Practical guide to Insulin Therapy in Type 2 Diabetes Mellitus. 2010. 59
3. Pathan MF, Sahay RK, Zargar AH, South Asian Consensus Guideline: Use of insulin in diabetes during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 499-502.
4. Hui E, Devendra D. Diabetes and fasting during Ramadan. Diabetes Metab Res Rev. 2010; 26(8): 606-610.
5. Hui E, Bravis V, Salih S, et al. Comparison of Humalog Mix 50 with human insulin Mix 30 in type 2 diabetes patients during Ramadan. Int J Clin Pract. 2010; 64(8): 1095–1099.
 Insulin Adjustment during Ramadan
– Basal Bolus Insulin and Insulin Pump
Insulin regimen Type 1 diabetes mellitus Type 2 diabetes mellitus

Basal bolus insulin1-4

Basal insulin Taken at bedtime or any time after iftar meals. May require dose
reduction if there is daytime hypoglycaemia.

Bolus/Prandial insulin Sahur Usual pre-Ramadan breakfast or lunch dose. May require dose reduction to avoid
daytime hypoglycaemia.
Lunch Omit.
Iftar Usual pre-Ramadan dinner dose. May require dose increment.
* Total insulin requirement for Type 1 diabetics who are on basal bolus insulin regimen while fasting
during Ramadan may require dose reduction 15‒30% of their pre-Ramadan dose requirements.

Insulin pump5-7
Basal insulin rate Unchanged or may require reduction of up to 25%.
Prandial bolus According to individualised insulin to carbohydrate ratio (ICR).

References:
1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update. 2010. Diabetes Care. 2010; 33(8): 1895-902.
2. Ministry of Health Malaysia. Practical guide to Insulin Therapy in Type 2 Diabetes Mellitus. 2010.
3. Pathan MF, Sahay RK, Zargar AH, South Asian Consensus Guideline: Use of insulin in diabetes during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 499-502.
4. Hui E, Devendra D. Diabetes and fasting during Ramadan. Diabetes Metab Res Rev. 2010; 26(8): 606-610.
5.
6.
Bin-Abbas BS. Insulin pump therapy during Ramadan fasting in Type 1 diabetic adolescents. Ann Saudi Med. 2008; 28(4): 305-306.
Hawli YM, Zantout MS, Azar ST. Adjusting the basal insulin regimen of patients with Type 1 diabetes mellitus receiving insulin pump therapy during the Ramadan fast: A case series in adolescents and adults. Curr Ther Res Clin Exp. 2009; 70(1): 29-34. 60
7. Benbarka MM, Khalil AB, Beshyah SA, et al. Insulin pump therapy in Moslem patients with Type 1 diabetes during Ramadan fasting: an observational report. Diabetes Technol Ther. 2010; 12(4): 287-290.
8. Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan 2015.
 Basal Insulin Regimen Adjustment
during Ramadan
Basal insulin dose -25.0%
60 56
-9.4%
50
0% 41.3 -24.1%
42 Appropriate adjustment of
Insulin Dose (U)

40 37.4
32.6 32.6 -5.5% basal insulin dosing in
29
30 patients with T1DM who
22 21.7 20.5
20 desire to fast can help them
maintain glycaemic control.
10
It is recommended to
0 No. of decrease the basal
1 2 3 4 5 Patients
requirement by 5.5% to 25%
under physician supervision.
HbA1c value
9 0.5%
0.9% 0%
7.8 7.9 7.9 0.1%
8 7.4 0.3%
6.9 6.9 6.9 7.0
7 6.5 6.8
6 Pre-Ramadan
HbA1c (%)

5
4
3 Post-Ramadan
2
1
0 No. of
1 2 3 4 5 Patients
61
Reference:
1. Hawli YMA et al. Adjusting the Basal Insulin Regimen of Patients With Type 1 Diabetes Mellitus Receiving Insulin Pump Therapy During the Ramadan Fast: A Case Series in Adolescents and Adults. Curr Ther Res. 2009; 70(1): 29-34.
 Insulin Pump Therapy during Ramadan

HbA1c value
10

8.4 8.4 Nearly half of the patients decreased their

8 basal insulin rate by 5–50%; median
reduction was 14%. The HbA1c value was
HbA1c value (%)

maintained before and during Ramadan. In

conclusion, fasting during Ramadan is
6 feasible for patients with Type 1 diabetes on
insulin pumps with adequate counseling and
support.
4

0
Before Ramadan After Ramadan

62
Reference:
1. Benbarka MM et al. Insulin Pump Therapy in Moslem Patients with Type 1 Diabetes During Ramadan Fasting: An Observational Report. Diab Tech Ther. 2010; 12(4): 287-290.
 Summary of Treatment Algorithm

Pre-Ramadan medical review

• Performed 1-2 months before Evaluate risk of developing complications during Ramadan
Ramadan
• Approach should be
individualised
• Assessment of glycaemic
control, blood pressure, and • Moderate risk • Very high risk
lipids • Low risk • High risk

Structured Ramadan-focused patient education

• Meal planning and dietary advice with a dietitian
• Appropriate timing and intensity of exercise
• Blood glucose monitoring Advised to abstain from fasting
• Knowing when to end the fast
• Recognising and managing acute complications

Treatment adjustments
Changes to diabetes medication regimes:
• Treatment choice
• Timing and frequency of dosing
• Dosage adjustments

Follow-up is essential after Ramadan

• HbA1c, blood pressure, lipids
• Readjustment of medications where appropriate
• Revert back to pre-Ramadan treatment regimen
63
Reference:
1. Ministry of Health (MOH) Malaysia. Practical Guide to Diabetes Management in Ramadan 2015.
 Key Messages

1. Many Muslims with diabetes choose to fast during Ramadan even though they are exempted from it due to their
health conditions.1
2. Fasting is associated with excessive glycogen breakdown, increased gluconeogenesis and ketogenesis leading to
hyperglycaemia and ketoacidosis.2,3
3. Fasting during Ramadan may be associated with improvements in glycaemic control, blood pressure, high-density
lipoprotein (HDL) levels and body weight. 4-8
4. Diabetic patients who fast are at higher risk of hypoglycaemia, hyperglycaemia and ketoacidosis with increased rate
of hospitalisation.9,10
5. Risk stratification is important to identify patients who are at risk of developing complications during fasting. 2
6. Pre-Ramadan medical review and education concerning self-care during Ramadan is important. 2,3, 11-14
7. Regular glucose monitoring is recommended during Ramadan. 2
8. a) Appropriate meal planning is important to avoid postprandial hyperglycaemia. 14
b) Appropriate modification in intensity and timing of physical activity is important to maintain optimal
glycaemic control and optimal weight. 3,14
9. Adjustment for oral anti-diabetic medications and insulin should be individualised to lower the risk of hypoglycaemia
when fasting during Ramadan.2,16
References:
1. Salti I, Bénard E, Detournay B, et al. A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care. 2004; 27(10): 2306-2311.
2. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update. 2010. Diabetes Care. 2010; 33(8): 1895-902.
3. Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010;103(4): 139-147.
4. Mafauzy M, Mohammed WB, Anum MY, et al. A study of the fasting diabetic patients during the month of Ramadan. Med J Malaysia. 1990; 45(1): 14-17.
5. Benaji B, Mounib N, Roky R, et al. Diabetes and Ramadan: review of the literature. Diabetes Res Clin Pract. 2006;73(2): 117-125.
6. Chamakhi S, Ftouhi B, Rahmoune NB, et al. Influence of the fast of Ramadan on the balance glycaemic to diabetics. Medicographia. 1991; 13: 27-29.
7. Perk G, Ghanem J, Aamar S, et al. The effect of the fast of Ramadan on ambulatory blood pressure in treated hypertensives. J Hum Hypertens. 2001; 15(10): 723-725.
8. Akturk IF, Biyik I, Kocas C, et al. PP-014 The effect of Ramadan fasting on blood pressure levels of hypertensive patients with combination therapy. Int J Cardiol. 2012; 155(Suppl 1): S103.
9. Salti I, Bénard E, Detournay B, et al A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care. 2004; 27(10): 2306-2311.
10. Loke SC, Rahim KF, Kanesvaran R, et al. A prospective cohort study on the effect of various risk factors on hypoglycaemia in diabetics who fast during Ramadan. Med J Malaysia. 2010; 65(1): 3-6.
11. Bashir MI, Pathan MF, Raza SA, et al. Role of oral hypoglycaemic agents in the management of Type 2 diabetes mellitus during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 503-507.
12. Benaji B, Mounib N, Roky R, et al. Diabetes and Ramadan: review of the literature. Diabetes Res Clin Pract. 2006;73(2): 117-125.
13.
14.
Hui E, Devendra D. Diabetes and fasting during Ramadan. Diabetes Metab Res Rev. 2010; 26(8): 606-610.
Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.
64
15. Persatuan Dietitian Malaysia. Medical Nutrition Therapy Guidelines for Type 2 Diabetes Mellitus. 2013. Second Edition.
16. Almaatouq MA. Pharmacological approaches to the management of Type 2 diabetes in fasting adults during Ramadan. Diabetes Metab Syndr Obes. 2012; 5: 109-119.
References
1. Akanji AO, Mojiminiyi OA, Abdella N. Beneficial changes in serum apo A-1 and its ratio to apo B and HDL in stable
hyperlipidaemic subjects after Ramadan fasting in Kuwait. Eur J Clin Nutr. 2000; 54: 508-513.
2. Akturk IF, Biyik I, Kocas C, et al. PP-014 The effect of Ramadan fasting on blood pressure levels of hypertensive patients with
combination therapy. Int J Cardiol. 2012; 155(Suppl 1): S103.
3. Al Sifri S, Basiounny A, Echtay A, et al. The incidence of hypoglycaemia in Muslim patients with Type 2 diabetes treated with
sitagliptin or a sulphonylurea during Ramadan: a randomised trial. Int J Clin Pract. 2011; 65(11): 1132-1140.
4. Al Wakeel J, Mitwalli AH, Alsuwaida A, et al. Recommendations for fasting in Ramadan for patients on peritoneal dialysis. Perit
Dial Int. 2013; 33(1): 86-91.
5. Al-Arouj M et al. The effect of vildagliptin relative to sulphonylureas in Muslim patients with Type 2 diabetes fasting during
Ramadan: the VIRTUE study. Int J Clin Pract. 2013; 67(10): 957-963.
6. Almaatouq MA. Pharmacological approaches to the management of Type 2 diabetes in fasting adults during Ramadan.
Diabetes Metab Syndr Obes. 2012; 5: 109-119.
7. Azad K, Mohsin F, Zargar AH, et al. Fasting guidelines for diabetic children and adolescents. Indian J Endocrinol Metab. 2012;
16(4): 516-518.
8. Bashir MI, Pathan MF, Raza SA, et al. Role of oral hypoglycaemic agents in the management of Type 2 diabetes mellitus during
Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 503-507.
9. Benaji B, Mounib N, Roky R, et al. Diabetes and Ramadan: review of the literature. Diabetes Res Clin Pract. 2006; 73(2): 117-
125.
10. Benbarka MM et al. Insulin Pump Therapy in Moslem Patients with Type 1 Diabetes During Ramadan Fasting: An
Observational Report. Diab Tech Ther. 2010; 12(4): 287-290.
11. Benbarka MM, Khalil AB, Beshyah SA, et al. Insulin pump therapy in Moslem patients with Type 1 diabetes during Ramadan
fasting: an observational report. Diabetes Technol Ther. 2010; 12(4): 287-290
12. Beshyah S, Benbarka M, Sherif I. Practical Management of Diabetes during Ramadan Fast. Libyan J Med. 2007; 2(4):185-189.

65
References
13. Bin-Abbas BS. Insulin pump therapy during Ramadan fasting in Type 1 diabetic adolescents. Ann Saudi Med. 2008; 28(4): 305-
306.
14. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2
diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.
15. Chamakhi S, Ftouhi B, Rahmoune NB, et al. Influence of the fast of Ramadan on the balance glycaemic to diabetics.
Medicographia. 1991; 13: 27-29.
16. Cheng CW, Adams GB, Perin L, et al. Prolonged fasting reduces IGF-1/PKA to promote hematopoietic-stem-cell-based
regeneration and reverse immunosuppression. Cell Stem Cell. 2014; 14(6): 810-823.
17. Dikensoy E, Balat O, Cebesoy B, Ozkur A, Cicek H, Can G. The effect of Ramadan fasting on maternal serum lipids, cortisol
levels and fetal development. Arch Gynecol Obstet 2009; 279: 119–23.
18. Glimepiride in Ramadan (GLIRA) Study Group. The efficacy and safety of glimepiride in the management of Type 2 diabetes in
Muslim patients during Ramadan. Diabetes Care. 2005; 28(2): 421-422.
19. GLIRA Study Group. The Efficacy and Safety of Glimepiride in the Management of Type 2 Diabetes in Muslim Patients During
Ramadan. Diab Care. 2005; 28(2): 9421-422.
20. Hassanein M, Abdallah K, Schweizer A. A double-blind, randomized trial, including frequent patient-physician contacts and
Ramadan focused advice, assessing vildagliptin and gliclazide in patients with Type 2 diabetes fasting during Ramadan: the
STEADFAST study. Vasc Health Risk Management. 2014; 4(10): 319-326.
21. Hawli YM, Zantout MS, Azar ST. Adjusting the basal insulin regimen of patients with Type 1 diabetes mellitus receiving insulin
pump therapy during the Ramadan fast: A case series in adolescents and adults. Curr Ther Res Clin Exp. 2009; 70(1): 29-34.
22. Hui E, Devendra D. Diabetes and fasting during Ramadan. Diabetes Metab Res Rev. 2010; 26(8): 606-610.
23. Hui E, Bravis V, Salih S, et al. Comparison of Humalog Mix 50 with human insulin Mix 30 in type 2 diabetes patients during
Ramadan. Int J Clin Pract. 2010; 64(8): 1095–1099.
24. Ibrahim MA. Managing diabetes during Ramadan. Diabetes voice. 2007; 52(2): 19-22.

66
References

25. Ibrahim O, Kamaruddin N, Wahab N, et al. Ramadan Fasting And Cardiac Biomarkers In Patients With Multiple Cardiovascular
Disease Risk Factors. The Internet Journal of Cardiovascular Research. 2010; 7(2).
26. Ismail MNA, Raji HO, Wahab NA et al. Glycaemic Control among Pregnant Diabetic Women on Insulin who fasted during
Ramadan. IJMA; 2011; 36(4): 254-259.
27. Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010; 103(4): 139-
147.
28. Karatopak C, Yolbas S, Cakirca M, Cinar A, Zorlu M, Kiskac M et al. The effects of long term fasting in Ramadan on glucose
regulation in Type 2 Diabetes Mellitus. Eur Rev Med Phamaco Sci. 2013; 17: 2512-2516.
29. Loke SC, Rahim KF, Kanesvaran R, et al. A prospective cohort study on the effect of various risk factors on hypoglycaemia in
diabetics who fast during Ramadan. Med J Malaysia. 2010; 65(1): 3-6.
30. Mafauzy M, Mohammed WB, Anum MY, et al. A study of the fasting diabetic patients during the month of Ramadan. Med J
Malaysia. 1990; 45(1): 14-17.
31. Ministry of Health Malaysia. Practical guide to Insulin Therapy in Type 2 Diabetes Mellitus. 2010.
32. Pathan MF, Sahay RK, Zargar AH, South Asian Consensus Guideline: Use of insulin in diabetes during Ramadan. Indian J
Endocrinol Metab. 2012; 16(4): 499-502.
33. Perk G, Ghanem J, Aamar S, et al. The effect of the fast of Ramadan on ambulatory blood pressure in treated hypertensives. J
Hum Hypertens. 2001; 15(10): 723-725.
34. Persatuan Dietitian Malaysia. Medical Nutrition Therapy Guidelines for Type 2 Diabetes Mellitus. 2013. Second Edition.
35. Salti I, Bénard E, Detournay B, et al A population-based study of diabetes and its characteristics during the fasting month of
Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care.
2004; 27(10): 2306-2311.
36. Zabeen B, Tayyeb S, Benarjee B, Baki A, Nahar J, Mohsin F, Nahar N, Azad K. Fasting during Ramadan in adolescents with
diabetes. Indian J Endocr Metab 2014;18:44-7.
37. Ziaee V, Razaei M, Ahmadinejad Z, et al. The changes of metabolic profile and weight during Ramadan fasting. Singapore Med J
2006; 47: 409–14.
67
THANK YOU

68