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 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.
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. Hassanein M et al. Diabetes and Ramadan: Practical guidelines
Hassanein M et al. Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract (2017), org/ /j.diabres

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 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

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

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

15. MUST NOT FAST Very High Risk Risk Factors
Classification of Risk
Risk Factors
MUST NOT FAST
Very High Risk
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
Reproduced with permission
Hassanein M et al. Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract (2017)

16. High Risk Moderate/Low Risk
Classification of Risk
Risk Factors
SHOULD NOT FAST
Medical advice if fasting
High Risk
• 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
Moderate/Low 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
**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
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
Drug Class
Dose
Recommendation
Biguanides
Metformin
500 – mg BID
No change
Metformin XR
mg OD
DPP-4 inhibitors 
Sitagliptin
mg OD
Saxagliptin
2.5-5 mg OD
Linagliptin
5 mg OD
DPP-4 inhibitor/Metformin combination
Sitagliptin/Metformin
50/500, 850 or 1000 mg BID
Sitagliptin/Metformin XR
50/500, 50/1000, 100/1000 mg OD
Linagliptin/Metformin
2.5/500, 850 or 1000 mg BID
Saxagliptin/Metformin
Alpha glucosidase inhibitor
Acarbose
mg TID
Thiazolidinediones
Pioglitazone
mg OD
DPP-4: dipeptidyl peptidase-4; XR: extended release.

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

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

21. Medications that may need to be adjusted/changed due to risk of hypoglycemia
Secretagogue
 Dose
Recommendations 
Glimepiride
mg OD
Consider switching to an alternate drug class with lower risk of hypoglycemia for the duration of the fasting month
If continuing, consider switching to safer agent within class with lower risk of hypoglycemia and reduce dose by 25-50%
Repaglinide may be safest in class. Adjust according to alteration of meal times and sizes during Ramadan
Glyburide
mg BID
Gliclazide MR
mg OD
Repaglinide
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 adjustment/change recommendations for type 2 diabetes
Insulin type
Recommendations
Basal
degludec, detemir, glargine U100, glargine U300
Preferred options
Consider reducing dose by 15-30%
neutral protamine Hagedorn (NPH)
Consider switching to longer acting basal insulin analogs
If continuing, reduce dose by 25-50%

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

26. Insulin adjustment/change recommendations for type 2 diabetes
Insulin type
Recommendations
Premixed
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
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

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
– for health-care providers
1-800-BANTING ( )
– for people with diabetes