Every year prior to the Holy Month of Ramadan, I make some adjustments to my medication schedule. I suffer from Type-2 diabetes and take a number of medicines to regulate my sugar level.

Since my HbA1c level rarely reaches the satisfactory level, I am often reprimanded by my doctor. Due to this reason, I read a lot and even seriously consider some sure-shot suggestions prescribed by the social media. However, the scientist inside me always stops me from following those suggestions, and I end up adhering to my doctor’s suggestions.

This morning, my friend, who is a doctor, sent me a copy of an article by Dr H.S. Bajaj, that appeared in the latest edition of Canadian Journal of Diabetes (Feb 2019) regarding an advisory to healthcare providers concerning diabetic patients who fast during Ramadan.

In Canada, approximately 95,000 out of the total 3.5 million diabetics are Muslims. The set of guidelines was prepared by an adept panel consisting of seven Canadian experts and an international expert using evidence-based principles. The Canadian healthcare providers as well as the religious leaders endorsed the statement issued by the panel.

Everyone knows that fasting is mandatory in Islam except for those who are travelling and the sick. Therefore, it is necessary for diabetics to seek advice from their doctors before fasting. In most cases, people tend to adjust their medicine regime themselves. There is no provision to issue a health advisory for the susceptible group in developing countries. Even though the weather conditions in Canada differ from our weather conditions and the fasting duration also differs, we can still benefit from their guidelines.

In general, people with well-controlled diabetes who follow a healthy lifestyle, or are treated with metformin alone or with some other medicines such as DPP-4, GLP-1 R, GLT2, SU and TZD are considered to be at moderate risk, and can fast conveniently based on their doctors’ advice.

However, people whose type-2 diabetes are poorly controlled, have poor glycemic index, take multiple daily injections or suffer from chronic kidney failure are at a high risk and are advised to abstain from fasting. Even people with well-controlled type-1 diabetes and those involved in intense physical activities should abstain from fasting as per the guidelines of the International Diabetes Federation (IDF) and the Diabetes and Ramadan (DAR) International Alliance.

These guidelines also suggest certain sets of medications that do not create hypoglycemia like metformin and gliptins, and require no change in dosage during Ramadan. Others like glimepiride, glyburide, Gliclazide and Repaglinide can cause hypoglycemia and require dose modification or adjustments based on mealtimes or even switching to other sets of medications with lower risk of hypoglycemia. However, several other sets of medications such as sodium glucose cotransporter-2 inhibitors and those with high risk of dehydration require reduction in dosage or temporary withdrawal. People who are on insulin also require reduction in dosage especially for predawn meal at Suhoor time, while they may require normal dose or reduced dose of short-acting insulin for the sunset meal. It has been suggested to avoid introduction of any new medicine while fasting. Also, adjustment should be considered one-three months prior to the month of fasting.

Your doctor is the best judge. It has been recommended for health providers to refer to these latest recommendations and adopt it after taking into consideration the local food habits and the weather conditions.

Awareness about the undesired symptoms during fasting is also necessary for type-2 diabetics who are maintained on medicine. They must break their fast and consult a doctor if symptoms such as vomiting, diarrhea, and orthostasis (sudden fall in blood pressure when standing) develop.

Actually, self-monitoring the blood sugar is the key in management of diabetes especially when fasting. You don’t have to wait for any unwanted situation to occur in order to monitor the sugar levels. A small prick will not invalidate the fast. Moreover, highly sensitive blood sugar testing devices are available these days such that microliter blood drawn from a fingertip is enough for accurate measurement of the glucose level.

Take care of your health, eat proper food, take regular medicine, and fast. Allah will accept all your prayers.

By Dr Mirza Umair Beg

Senior Scientist, KISR