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

MAT-BH-2400060/v1/Feb 2024