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Insulin and Other Medications Dose Adjustments for Type 1 and 2 Diabetes in Ramadan

Insulin dose adjustments for Type 1 Diabetes

Premixed (analogue or conventional)
  • Move usual morning dose to Iftar
  • Take 50% of pre-Ramadan evening dose at Suhoor
CSII/Insulin pump

Basal rate adjustment

  • Decrease 20–40% for last 3–4 hours of fast
  • Increase 10–30% for first few hours after iftar

Bolus doses

  • Apply same principles as before Ramadan
MDI (basal bolus) with conventional insulin

NPH insulin

  • Take usual morning dose in the evening during Ramadan
  • Take 50% of pre-Ramadan dose at Suhoor

Regular insulin

  • Evening meal dose remains unchanged - Take 50% of pre-Ramadan evening dose at Suhoor
  • Skip afternoon dose
MDI (basal bolus) with analogue insulin

Basal insulin

  • Reduce dose by 30–40%
  • Take at Iftar

Rapid analogue insulin

  • Reduce Suhoor dose by 30–50%
  • Skip pre-lunch dose
  • Adjust Iftar dose based on 2-hour post-Iftar glucose reading

CSII, continuous subcutaneous insulin infusion; MDI, multiple-dose injections; NPH, natural protamine Hagedorn
Diabetes and Ramadan: Practical Guidelines International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance. January 2021. Available at: www.idf.org/news/idf-dar-diabetes-in-ramadan guidelines

Insulin dose adjustments for Type 2 Diabetes

Long/intermediate-acting (basal) insulin

NPH/detemir/glargine/glargine 300/ degludec, once daily

  • Reduce dose by 15–30%
  • Take at Iftar

NPH/detemir/glargine, twice daily

  • Take usual morning dose at Iftar
  • Take 50% of evening dose at Suhoor
Short-acting insulin
  • Normal dose at Iftar
  • No lunch-time dose
  • Reduce Suhoor dose by 25–50%
Premixed insulin dosing

Once daily

  • Normal dose at Iftar

Twice daily

  • Take normal dose at Iftar
  • Reduce Suhoor dose by 20–50%

Three times daily

  • No afternoon dose
  • Adjust Iftar and Suhoor doses
  • Dose-titration every 3 days
Insulin pump dosing

Basal rate

  • Reduce dose by 20–40% in last 3–4 hours of fasting
  • Increase dose by up to 20% early after Iftar

Bolus rate

  • Normal carbohydrate counting and insulin sensitivity principles apply

For unit-specific titration recommendations as determined by individual blood glucose readings, see Chapter 10 of the IDF-DAR guidelines.
degludec, insulin degludec; detemir, insulin detemir; glargine, insulin glargine; NPH, neutral protamine Hagedorn 
Diabetes and Ramadan: Practical Guidelines International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance. January 2021. Available at: www.idf.org/news/idf-dar-diabetes-in-ramadan guidelines

Oral Anti-Diabetic drugs (OADs) recommended dose adjustments

Metformin Sulphonylureas Arcarbose

Once daily

  • No adjustment usually required
  • Take at Iftar

Twice daily

  • No adjustment usually required
  • Take at Iftar

Three times daily

  • Take morning dose before Suhoor
  • Combine afternoon dose with Iftar dose

Prolonged-release

  • No adjustment usually required
  • Take at Iftar

Once daily

  • Reduce dose for those well-controlled blood glucose
  • Take at Iftar

Twice daily

  • No adjustment at Iftar
  • Reduce Suhoor dose for those with well-controlled blood glucose

Older drugs e.g. glibenclamide

  • Should be avoided

Second generation sulphonylureas e.g. glicazide, glimepiride

  • Should be used in preference
  • No adjustment required
  • Take at Iftar

Thiazolidinediones

  • No adjustment
  • Take with Iftar rather than Suhoor

Short-acting insulin secretagogue

Three-meal dosing may be reduced/ redistributed to two doses

SGLT-2 inhibitors

  • No adjustment
  • Taken with Iftar
Incretin-based therapies
DPP-4 inhibitors GLP-1 RAs
No adjustment required No adjustment if appropiate dose titration prior to Ramadan (>2–4 weeks before) has occured

Adapted from IDF-DAR Guidelines (2021)

For patients on multiple types of medication, please see Chapter 10 of the IDF-DAR guidelines

DPP-4, dipeptidyl peptidase-4; GLP-1 RAs, glucagon-like peptide-1 receptor agonists; SGLT-2, sodium-glucose co-transporter-2

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