1. Position Statement for People with
Types 1 and 2 Diabetes Who Fast
during Ramadan
Harpreet Singh Bajaj MD, MPH, FACE; Tyceer Abouhassan
BEd, MD, MBA, FRCPC; Muhammad Rauf Ahsan, MD,
FRCSC; Amel Arnaout, MD, FRCPC; Mohamed Hassanein
FRCP, CCST, MPhil, MBCHB; Robyn L. Houlden MD, FRCPC;
Tayyab Khan MD, MASc, FRCPC; Hasnain Khandwala
MBBS, FRCPC, FACE; Subodh Verma MD, PhD, FRCSC

2. Objectives
• Discuss the need for a Canadian position
statement on diabetes and Ramadan
• Educate on key recommendations for risk
stratification and counseling prior to Ramadan
fasting for Muslims living with diabetes
• Highlight pharmacotherapy and glucose
monitoring approaches for safe diabetes
management during Ramadan fasting

3. Key Messages
• This statement is intended to guide Canadian
healthcare providers on management of people
with type 1 or type 2 diabetes who intend to fast
during Ramadan
• Adults with type 1 and type 2 diabetes who
intend to fast should receive an individualized
assessment pre-Ramadan, with risk
categorization and formulation of an
individualized diabetes management plan

4. Canadian Muslims
• 1,053,945 Muslims - 3.2% of Canadian
population
• Estimated 95,000 Muslims live with diabetes
in Canada
• Muslim population estimated to increase to
2.7 million or 6.6% of the Canadian
population by 2030
• Majority of the Muslims across the world fast
during Ramadan
Statistics Canada. 2011 National Household Survey – Data Tables
Public Health Agency of Canada. (2011). Diabetes in Canada: Facts and figures from a public health perspective. Ottawa, Ont. 2011
Ghani F. Most Muslims say they fast during Ramadan.
http://www.pewresearch.org/fact-tank/2013/07/09/global-median-of-93-of-muslims-say-they-fast-duringramadan/; 2013

5. Ramadan – basics
• One of the pillars of Islam
• Fasting from dawn to dusk – abstaining from water
and food
• Exceptions for those unable to fast (traveling, sick,
or at risk of serious harm to health) – many choose
to fast despite their medical condition
• Changes in sleeping and eating habits: pre-dawn
and sunset meals
• Each year, Ramadan occurs ~10 days earlier than
the previous year

6. World - Number of fasting hours
Ramadan rankings: Where in the world are Muslims fasting the most hours? The Globe and Mail 2017

7. Canada – Number of fasting hours
Ramadan rankings: Where in the world are Muslims fasting the most hours? The Globe and Mail 2017

8. IDF-DAR Practical Guidelines
IDF-DAR Practical Guidelines
Hassanein M et al. Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract (2017), http://dx.doi.
org/10.1016/j.diabres.2017.03.003

9. The Need for a Canadian Diabetes
& Ramadan Position Statement
Differences from Middle Eastern or South Asian,
Muslim dominant countries:
• hours of fasting
• work hours and peer support
• pharmacotherapy (insulin and non-insulin) in type 2
diabetes
• insulin pump use in type 1 diabetes
• Glucose, continuous/flash monitoring technology
usage
Muslims in Canada, Canada 2011 National Household Survey
The Profile of Muslims In Canada Archived 2012-02-03 at the Wayback Machine., Abdul Malik Mujahid.
Grenier, Éric (27 April 2016). "Muslim Canadians increasingly proud of and attached to Canada, survey suggests". CBC News. Retrieved 19 April 2017

10. Diabetes Canada Position
Statement
• Published in the Canadian Journal of Diabetes
• Dietary counseling not covered. Follow
International Diabetes Federation - Diabetes and
Ramadan International Alliance and Diabetes
Canada Clinical Practice Guidelines
• Medications or glucose monitoring devices with
Health Canada Notice of Compliance granted by
February 15, 2018 included
• Islamic Society of North America (ISNA) Canada
endorsed the position statement and provided
letter of support
https://doi.org/10.1016/j.jcjd.2018.04.007

11. Position Statement: Sections
• Pre-Ramadan diabetes management planning,
including risk stratification
• Non-insulin pharmacotherapy for type 2
diabetes during Ramadan
• Insulin management for type 2 diabetes during
Ramadan
• Type 1 diabetes management during Ramadan
• Monitoring glycemic control while fasting in
Ramadan

12. Pre-Ramadan Diabetes
Management Planning
Healthcare provider assessment is
recommended 1-3 months prior to
Ramadan for those intending to fast:
• Risk stratification
• Review of positive and adverse
experiences from previous fasting
• Formulate individualized treatment plan

13. Pre-Ramadan Diabetes
Management Planning
When to
break the
fast?
Risk
stratification
Blood
glucose
monitoring
Fluids and
dietary
advice
Medication
adjustments
Key
components of a
Ramadan-focused
educational
program
Exercise
advice

14. Risk stratification for fasting
during Ramadan for people
living with diabetes

15. Reproduced with permission
Hassanein M et al. Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract (2017)
Classification
of Risk
Risk Factors
Very
High
Risk
MUST
NOT
FAST
• Poorly controlled T1DM (defined as a pre-Ramadan A1C >9%)
• Severe hypoglycemia within 3 months, recurrent hypoglycemia,
and/or unawareness of hypoglycemia
• Ketoacidosis within 3 months
• Hyperosmolar hyperglycemic coma within 3 months
• Acute illness
• Advanced macrovascular complications, renal disease (on
dialysis, stage IV or V CKD), cognitive dysfunction, or
uncontrolled epilepsy
• Pregnancy in diabetes or GDM - treated with insulin
T1DM: Type 1 diabetes mellitus; GDM: Gestational diabetes mellitus; CKD: Chronic kidney disease
Be respectful of individual’s beliefs. Many Muslims, even those who could seek exemption,
have an intense desire to participate in fasting during Ramadan

16. **The level of glycemic control is to be agreed upon between healthcare provider and the person living with diabetes
CKD: Chronic kidney disease; DPP-4: Dipeptidyl peptidase GDM: Gestational diabetes mellitus; GLP-1 RA:
Glucagon-like peptide-1 receptor agonist; MDI: Multiple daily injections; SGLT2: Sodium glucose transporter-2;
SU: Sulfonylurea; T2DM: Type 2 diabetes mellitus; TZD: Thiazolidinediones
High
Risk
SHOULD
NOT
FAST
Medical
advice
if
fasting • T2DM with sustained poor glycemic control**
• Well-controlled T2DM on MDI or mixed insulin
• Pregnant T2DM or GDM controlled by diet only
• CKD stage 3 or stable macrovascular complications
• Performing intense physical labour
• Well-controlled T1DM
Classification of
Risk Risk Factors
Moderate/
Lo
w
Risk
Can
fast
with
medical
advice
• Well-controlled diabetes
• Treated with lifestyle alone, or with: metformin, acarbose, incretin-therapies
(DPP-4 inhibitors or GLP-1 RA), second generation SU, SGLT2 inhibitors, TZD
or basal insulin in otherwise healthy individuals
Reproduced with permission
Hassanein M et al. Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract (2017)

17. Non-insulin pharmacotherapy
for type 2 diabetes

18. Medications Considered Safe in
Ramadan
DPP-4: dipeptidyl peptidase-4; XR: extended release.
Drug Class Dose Recommendation
Biguanides
Metformin 500 –850-1000 mg BID No change
Metformin XR 500-2000mg OD No change
DPP-4 inhibitors
Sitagliptin 25-50-100 mg OD No change
Saxagliptin 2.5-5 mg OD No change
Linagliptin 5 mg OD No change
DPP-4 inhibitor/Metformin combination
Sitagliptin/Metformin 50/500, 850 or 1000 mg BID No change
Sitagliptin/Metformin XR 50/500, 50/1000, 100/1000 mg OD No change
Linagliptin/Metformin 2.5/500, 850 or 1000 mg BID No change
Saxagliptin/Metformin 2.5/500, 850 or 1000 mg BID No change
Alpha glucosidase inhibitor
Acarbose 25-50-100 mg TID No change
Thiazolidinediones
Pioglitazone 15-30-45 mg OD No change

19. Medications Safe to Continue but
Not to Start
SGLT: sodium glucose transporter; eGFR: estimated glomerular filtration rate
Drug Class Dose Recommendations
SGLT-2 Inhibitors
• Canagliflozin 100-300 mg OD 1. Reduce dose or hold temporarily
prior to fasting for those with
high risk for dehydration (>75
years, eGFR<60, loop diuretic).
2. Do not hold dose for those with
clinical cardiovascular disease
3. Do not initiate within 4 weeks
prior to or during Ramadan
4. Hold for vomiting, diarrhea or
orthostasis
• Dapagliflozin 5-10 mg OD
• Empagliflozin 10-25 mg OD
SGLT2 inhibitor/metformin combination
• Canagliflozin/Metfor
min
50 or 150/500, 850 or
1000 mg BID
• Dapagliflozin/Metfor
min
5/850 or 1000 mg BID
• Empagliflozin/Metfo
rmin
5 or 12.5/500, 850 or
1000 mg BID

20. Medications Safe to Continue but
Not to Start
GLP-1: glucagon-like peptide-1
Drug Class Dose Recommendations
GLP-1 Receptor Agonists
• Liraglutide 0.6-1.2-1.8 mg OD 1. No change if tolerating prior to
Ramadan
2. Do not initiate within 4 weeks
prior to or during Ramadan
3. Reduce dose or hold for
nausea, vomiting, diarrhea or
orthostasis
4. Exenatide should be taken
before two meals
5. Lixisenatide should be take
before sunset meal
6. Longer acting agents can be
taken anytime
• Exenatide 5-10 mg OD
• Exenatide Extended
Release
2 mg qweekly
• Dulaglutide 0.75-1.5 mg qweekly
• Lixisenatide 10-20 mg OD
• Semaglutide 0.25-0.5-1 mg
qweekly

21. Medications that may need to be
adjusted/changed due to risk of
hypoglycemia
Secretagogue Dose Recommendations
Glimepiride 1-2-3-4 mg OD 1. Consider switching to an alternate
drug class with lower risk of
hypoglycemia for the duration of
the fasting month
2. If continuing, consider switching to
safer agent within class with lower
risk of hypoglycemia and reduce
dose by 25-50%
3. Repaglinide may be safest in class.
Adjust according to alteration of
meal times and sizes during
Ramadan
Glyburide 2.5-5-10 mg BID
Gliclazide MR 30-60-120 mg OD
Repaglinide
0.5-1-2-4 mg AC
meals

22. Counseling for Sick Day
Management during Ramadan
Vomiting, diarrhea or orthostasis during
Ramadan
• Break the fast immediately,
• Hold certain antihyperglycemic medications
(metformin, secretagogues, GLP-1 receptor
agonists, SGLT2 inhibitors),
• Continue blood glucose monitoring and
• Seek immediate medical attention

23. Insulin adjustment/change
recommendations for type 2
diabetes

24. Insulin type Recommendations
Basal
degludec, detemir,
glargine U100,
glargine U300
1. Preferred options
2. Consider reducing dose by 15-30%
neutral protamine
Hagedorn (NPH)
1. Consider switching to longer acting basal
insulin analogs
2. If continuing, reduce dose by 25-50%
Insulin adjustment/change
recommendations for type 2 diabetes

25. Insulin type Recommendations
Short Acting
aspart/faster
aspart, glulisine,
lispro
1. Preferred options
2. Take usual evening meal dose at sunset
meal, reduce pre-dawn meal dose by 25-
50%, omit lunch time dose
human regular
insulin
1. Consider switching to rapid-acting bolus
insulin analogs
2. If continuing, follow the dose
recommendations above for insulin analogs
Insulin adjustment/change
recommendations for type 2 diabetes

26. Insulin type Recommendations
Premixed
1. Consider switching to an alternate regimen
(basal insulin-oral agents, basal insulin-GLP-
1 receptor agonist, basal insulin-plus one
mealtime bolus insulin or basal-bolus insulin
taken with each meal) depending on patient
and agent level characteristics
2. If continuing, reduce pre-dawn meal dose
by 25-50% and take usual evening meal
dose at sunset meal
Biphasic insulin
aspart, human
insulin mix 30,
lispro mix 25, lispro
mix 50
Insulin adjustment/change
recommendations for type 2 diabetes

27. Type 2 Diabetes: Insulin Dose
Recommendations
• For individuals managed on any insulin regimen, less intensive
glycemic targets during Ramadan, aiming for fasting and pre-
meal SMBGs of 5.5 to 7.5 mmol/L are preferred to reduce the
risk of hypoglycemia
• Insulin dose adjustment to achieve these conservative targets
should be individualized taking into consideration insulin
sensitivity and total daily insulin dose as well as the duration of
fast
• Individuals on a complex insulin regimen, especially those with
increased risk of hypoglycemia, should be evaluated by a
diabetes management team pre-Ramadan

28. Type 1 diabetes

29. Type 1 Diabetes: Basal-Bolus
Insulin Recommendations
• Basal analog insulin (detemir, glargine) is preferred
over NPH insulin during Ramadan
• Once daily ultra-long acting basal insulin
(degludec, glargine U300) may be preferred to
further reduce the risk of hypoglycemia and
minimize the chance of missed insulin doses or
periods of inadequate background insulin on board
during prolonged fasting periods
• Bolus: rapid-acting insulin analog is preferred
(aspart, faster acting aspart, glulisine, lispro) over
regular human insulin

30. Type 1 Diabetes: Insulin Dose
Recommendations
• All basal insulin doses (or daytime basal doses
on insulin pump therapy) should be reduced by
a minimum of 20% for fasting days to reduce
the risk of hypoglycemia and reassessed
weekly (physically or virtually) for further
adjustments
• Insulin-to-carbohydrate ratio and insulin
sensitivity factor should remain unchanged
during fasting if stable and well controlled

31. DKA during Ramadan
People with type 1 diabetes should monitor
blood ketones when SMBG readings are
elevated >14.0 mmol/L to screen for DKA. Those
with blood ketones > 0.6 mmol/L should:
• break their fast,
• take a supplemental dose of rapid-acting
insulin for correction of blood ketones and
• re-evaluate their ability to safely fast during
Ramadan in the future
DKA: Diabetic ketoacidosis; SMBG: Self-monitoring of blood glucose

32. Monitoring glycemic control while
fasting in Ramadan

33. Self-monitoring of Blood Glucose
(SMBG): Myths & Misconceptions
• Does pricking the skin invalidate the fast?
Response: Religious authorities agree that
glucose monitoring does not invalidate the
fast
• Will frequent SMBG checks increase the
chances to break the fast? Response:
frequent SMBG may reduce the frequency
and severity of hypoglycemic episodes so that
fasting can be performed safely

34. SMBG Frequency
• At least 5 times per day for type 1 diabetes
• 2-5 times per day for type 2 diabetes on insulin
• Type 2 diabetes not requiring insulin:
individualize SMBG frequency depending on
the type of therapy, risk of hypoglycemia or
hyperglycemia, level of glycemic control and
duration of fast
• Additional testing for periods of symptomatic
hyperglycemia or hypoglycemia

35. When to Break The Fast?
Counseling to break the fast, treat the
problem appropriately and seek immediate
medical attention for:
• Symptomatic or documented (< 4 mmol/L)
hypoglycemia or
• Symptomatic hyperglycemia or documented
blood glucose above 16.7 mmol/L

36. Continuous (CGM) or Flash (FGM)
Glucose Monitoring
During Ramadan fasting, real-time CGM or
FGM may be considered for people with type
1 or those with type 2 diabetes who are on
complex insulin regimen (defined as basal
plus at least one bolus insulin)

37. Visit guidelines.diabetes.ca

38. Or download the App

39. Diabetes Canada Clinical
Practice Guidelines
http://guidelines.diabetes.ca – for health-care
providers
1-800-BANTING (226-8464)
http://diabetes.ca – for people with diabetes