Professional Documents
Culture Documents
Diabetes Management
in Ramadan
MINISTRY OF HEALTH
MALAYSIA
MALAYSIA ENDOCRINE
& METABOLIC SOCIETY
FOREWORD BY
THE DIRECTOR GENERAL OF HEALTH OF MALAYSIA
Many people around the world observe fasting as an important religious ritual. Healthy Muslims
are obligated to fast during the Holy Month of Ramadan, while those suffering from poorly
controlled diabetes or with major diabetes-related complications are exempted from doing so.
However due to strong personal beliefs, many of them still fast during Ramadan. Malaysia is one
of the countries with a high prevalence of diabetes with an estimated 1.2 million Malaysians who
have high blood sugars. Patients with diabetes who fast during Ramadan will require additional
attention by their healthcare providers. There are international and local clinical practice
guidelines on overall diabetes management available but practical guidelines on managing
diabetes particularly during Ramadan are limited.
In line with this, several endocrinologists from the Ministry of Health (MOH) and Ministry of
Education (MOE) have come together to form a working committee, dedicating their time
working together diligently to develop a practical guide to diabetes management during
Ramadan that will be relevant for Malaysian healthcare providers. I would like to acknowledge
the efforts taken by the working committee and to congratulate them on the development of
this practical guide which will assist healthcare providers particularly primary care physicians
in ensuring safe and optimal management of patients with diabetes during periods of fasting
particularly during Ramadan.
This practical guide is an addition to the collaborative milestones between MOH and the
Malaysian Endocrine & Metabolic Society (MEMS). With it in place, I believe our patients will
benefit from optimised treatment and management of their diabetes when they are fasting
during Ramadan. Hence I would like to urge all healthcare providers to fully utilise this practical
guide to further improve the quality of diabetes care in Malaysia during Ramadan period for the
lasting benefit of our patients.
PREFACE
In Malaysia, an estimated 61% of the population practice Islam as their religion. One of the five
pillars of Islam is to fulfill the annual fasting during the holy month of Ramadan. In those with
illness, fasting is exempted but the majority of Muslims with diabetes will eagerly fast during
Ramadan. Muslims may also practice the non-obligatory fast during the non-Ramadan period
and some non-Muslims may also practice fasting for either religious or health reasons.
There is a concern that fasting among those with diabetes may increase risk of acute diabetesrelated complications such as hypoglycaemia, hyperglycaemia and dehydration. It is generally
observed that there are higher rates of emergency department admissions and hospitalisation
for diabetes emergencies among those with diabetes who fast during Ramadan.
Therefore it is important for clinicians and health care providers to recognise and provide
appropriate advice to those with diabetes having high risks for complications during fasting.
With structured patient education and individualised adjustments of lifestyle and medications
performed well in advance, most Muslims with diabetes can achieve acceptable metabolic
control while fasting, having better confidence in self-management and thus, avoiding the known
serious complications previously described.
This practical guide has been developed to provide a clear and concise approach to all health care
providers regarding the management of diabetes during fasting, particularly in Ramadan. I hope
it will help to ensure that those with diabetes may practice fasting safely, free from adversity and
be able to experience the many potential health benefits of fasting in addition to the spiritual
fulfillment gained.
Finally, I would like to express my gratitude to everyone involved in the development of this
practical guide and especially to the members of the Working Committee for their support and
contribution.
Chairperson
Working Committee
ii
OBJECTIVES
The aim of the practical guide is to assist health care providers, particularly
primary care physicians in ensuring safe and optimal management of
patients with diabetes during periods of fasting as in Ramadan.
Clinical Questions
This practical guide aims to address the following clinical questions:
1. What are the benefits and risks of fasting?
2. Who are at risk to fast?
3. How to screen and educate patients with diabetes prior
to Ramadan?
4. What are the glycaemic targets during Ramadan?
5. How to monitor glycaemia in patients during Ramadan?
6. How to optimise lifestyle and anti-diabetic therapy?
Target Population
This practical guide is applicable to adults with diabetes intending to fast
as in Ramadan.
Target Group
This practical guide is meant for all health care professionals involved in
the management of patients with diabetes mellitus, both in primary care
and hospital care.
iii
WORKING COMMITTEE
CHAIRPERSON
ADVISOR
Dr. Zanariah Bt Hussein
Consultant Endocrinologist,
Hospital Putrajaya,
Putrajaya
Consultant Endocrinologist,.
Hospital Raja Permaisuri Bainun,
Perak
Consultant Endocrinologist,.
Hospital Pulau Pinang,.
Pulau Pinang
Consultant Endocrinologist,.
Hospital Sultanah Bahiyah,.
Alor Setar
Consultant Endocrinologist,.
Hospital Sultanah Aminah,.
Johor Bahru
Consultant Endocrinologist,
Hospital Raja Perempuan Zainab II,
Kelantan
Consultant Endocrinologist,
Hospital Putrajaya,.
Putrajaya
Consultant Endocrinologist,.
Pusat Perubatan Universiti
Kebangsaan Malaysia,.
Kuala Lumpur
iv
Consultant Endocrinologist,
Hospital Putrajaya,.
Putrajaya
Consultant Endocrinologist,
Hospital Universiti Sains Malaysia,
Kelantan
EXTERNAL REVIEWERS
Y. Bhg. Datin Dr. Rugayah Bakri
President,.
Malaysian Endocrine and Metabolic Society (MEMS),.
Senior Consultant Endocrinologist,.
Pusat Perubatan Universiti Kebangsaan Malaysia,.
Kuala Lumpur
Dr. G. R. Letchuman
Moderate risk
Low risk
Treatment adjustments
Changes to diabetes medication regimens:
Treatment choice
Timing and frequency of dosing
Dosage adjustments
Advised to abstain
from fasting
Section 1
BACKGROUND
SECTION 1 BACKGROUND
A few religions worldwide practice the fasting ritual. Ramadan fasting is observed by Muslims
worldwide as fasting from dawn until dusk daily for 29 30 days. Non-Ramadan fasting is
undertaken by Muslims and people of other faith as either a single day or a few consecutive days
of fasting. Due to Malaysias location near the Equator, annual Ramadan fasting in Malaysia is
between 12 14 hours daily.
Among the benefits of fasting apart from heeding the Creators order is to teach self-restraint and
discipline as well as resting and cleansing the alimentary tract. The call to fast during Ramadan
for a healthy Muslim is stated in the holy Quran, where there is also a clear guide on individuals
who are exempted from fasting which includes those with chronic diseases such as diabetes
mellitus. (Surah Al Baqarah Verse 184-185)
Fasting in certain individuals with diabetes may be associated with adverse outcomes; hence
they are not obliged to fast.1 However, many diabetic patients choose to fast as shown in the
Epidemiology of Diabetes and Ramadan (EPIDIAR) study.1 Managing a Muslim patient with
diabetes during Ramadan continues to be a challenge for healthcare professionals.2
The adverse outcomes during fasting include dehydration, hypoglycaemia and hyperglycaemia.2,3
In a Malaysian study, diabetic patients with tight glycaemic control as well as the elderly were
found to have a higher risk of developing hypoglycaemia.4
As a diabetic patient undertakes fasting, pre-fasting education and planning is of paramount
importance to lower the incidence of adverse outcomes associated with fasting.
References
1. Salti I, Bnard E, Detournay B, et al. A population-based study of diabetes and its characteristics during the fasting
month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study.
Diabetes Care. 2004; 27(10): 2306-2311.
2. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update
2010. Diabetes Care. 2010; 33(8): 1895-902.
3. Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010;
103(4): 139-147.
4. Loke SC, Rahim KF, Kanesvaran R, et al. A prospective cohort study on the effect of various risk factors on hypoglycaemia
in diabetics who fast during Ramadan. Med J Malaysia. 2010; 65(1): 3-6.
2
Section 2
GLUCOSE
LIVER
Glycogen stores
depletion excessive
breakdown
PERIPHERAL
TISSUES
(MUSCLE)
PANCREAS
Insulin secretion
decreased or absent
As the Ramadan fast only extends from dawn till dusk, there is ample opportunity to replenish
energy stores at pre-dawn and dusk meals. This provides a gradual transition from using glucose
to fat as the main source of energy, and prevents the breakdown of muscle for protein.1
After a few days of fast, circulating endorphin levels increase, resulting in improved alertness
and general well-being.2 Balanced food and fluid intake is important between fasts. The renal
homeostasis mechanism maintains the bodys water and salts, such as sodium and potassium. A
balanced diet with adequate quantities of nutrients, salts and water is vital.1
Type 1 diabetes1
In patients with Type 1 diabetes, glucose homeostasis is affected by underlying disease and
by insulin therapy. Glucagon secretion may fail to increase appropriately in response to
hypoglycaemia, and in patients with severe insulin deficiency, a prolonged fast in the absence of
adequate basal insulin can lead to excessive glycogen breakdown and increased gluconeogenesis
and ketogenesis leading to hyperglycaemia and eventual ketoacidosis.
Type 2 diabetes1
Patients with Type 2 diabetes may suffer similar consequences, however ketoacidosis.
is uncommon.
There can be varying changes in body weight among diabetics fasting in Ramadan. The
Epidemiology of Diabetes and Ramadan (EPIDIAR) study showed that majority of patients
had unchanged weight.3 Many patients show no significant change in their glycaemic control
although blood lipid levels have been shown to be reduced.4-7
References
1. Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010;
103(4): 139-147.
2. Lahdimawan A, Handono K, Indra MR et al. Effect of Ramadan Fasting on Endorphin and Endocannabinoid level in
Serum, PBMC and Macrophage. International Journal of Pharmaceutical Science Invention. 2013; 2(3): 46-54.
3. Salti I, Bnard E, Detournay B, et al. A population-based study of diabetes and its characteristics during the fasting
month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study.
Diabetes Care. 2004; 27(10): 2306-2311.
4. Akanji AO, Mojiminiyi OA, Abdella N. Beneficial changes in serum apo A-1 and its ratio to apo B and HDL in stable
hyperlipidaemic subjects after Ramadan fasting in Kuwait. Eur J Clin Nutr. 2000; 54(6): 508-513.
5. Mafauzy M, Mohammed WB, Anum MY, et al. A study of the fasting diabetic patients during the month of Ramadan.
Med J Malaysia. 1990; 45(1): 14-17.
6. Uysal AR, Erdoan MF, Sahin G, et al. Clinical and metabolic effects of fasting in 41 type 2 diabetic patients during
Ramadan. Diabetes Care. 1998; 21(11): 2033-2034.
7. Yarahmadi Sh, Larijani B, Bastanhagh MH, et al. Metabolic and clinical effects of Ramadan fasting in patients with type
II diabetes. J Coll Physicians Surg Pak. 2003; 13(6): 329-332.
Section 3
References
1. Mafauzy M, Mohammed WB, Anum MY, et al. A study of the fasting diabetic patients during the month of Ramadan.
Med J Malaysia. 1990; 45(1): 14-17.
2. Benaji B, Mounib N, Roky R, et al. Diabetes and Ramadan: review of the literature. Diabetes Res Clin Pract. 2006; 73(2):
117-125.
3. Chamakhi S, Ftouhi B, Rahmoune NB, et al. Influence of the fast of Ramadan on the balance glycemic to diabetics.
Medicographia. 1991; 13: 27-29.
4. Perk G, Ghanem J, Aamar S, et al. The effect of the fast of Ramadan on ambulatory blood pressure in treated
hypertensives. J Hum Hypertens. 2001; 15(10): 723-725.
5. Akturk IF, Biyik I, Kocas C, et al. PP-014 The effect of Ramadan fasting on blood pressure levels of hypertensive patients
with combination therapy. Int J Cardiol. 2012; 155(Suppl 1): S103.
6. Cheng CW, Adams GB, Perin L, et al. Prolonged fasting reduces IGF-1/PKA to promote hematopoietic-stem-cell-based
regeneration and reverse immunosuppression. Cell Stem Cell. 2014; 14(6): 810-823.
7. Ibrahim O, Kamaruddin N, Wahab N, et al. Ramadan fasting and cardiac biomarkers in patients with multiple
cardiovascular disease risk factors. The Internet Journal of Cardiovascular Research. 2010; 7(2).
8
Section 4
1. Hypoglycaemia
The effect of fasting during Ramadan on the rates of hypoglycaemia in patients with diabetes is
not known with certainty. However, the Epidemiology of Diabetes and Ramadan (EPIDIAR) study
showed a 4.7 fold increase in hospitalisation due to severe hypoglycaemia in Type 1 diabetes and
7.5 fold in Type 2 diabetes. Severe hypoglycaemia was also more frequent in patients who made
inappropriate changes to their medications dosages and lifestyle.1
A prospective study done locally showed that the rate of hypoglycaemia was 1.6 times higher
during fasting compared to non-fasting periods.2 Diabetics with HbA1c less than 8% and the
elderly have more than twice the risk of developing hypoglycaemia during the fasting month.
2. Hyperglycaemia / ketoacidosis
In EPIDIAR study, there was a five times increase in severe hyperglycaemia requiring hospitalisation
in Type 2 diabetes. In Type 1 diabetes, there were three times increase in the incidence of severe
hyperglycaemia, with or without ketosis.1
Hyperglycaemia may be due to excessive reduction of medication dosages to prevent
hypoglycaemia. Patients who reported an increase in their food and/or sugar intake during nonfasting hours also had significantly higher rates of severe hyperglycaemia.
Patients who are poorly controlled before Ramadan are at an increased risk of diabetic ketoacidosis
(DKA) when they fast. Excessive reduction of insulin dosage is also a contributing factor.
3. Dehydration
Dehydration happens as a result of limitation in fluid intake, especially if the fasting is prolonged
and in those who perform hard physical labour. Osmotic diuresis as a result of hyperglycaemia
further contributes to water and electrolyte depletion.
Orthostatic hypotension may occur leading to syncope, falls, injuries and fractures. Hypercoagulable states in diabetes might be exacerbated, enhancing the risk of thrombosis and stroke.
References
1. Salti I, Bnard E, Detournay B, et al A population-based study of diabetes and its characteristics during the fasting
month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study.
Diabetes Care. 2004; 27(10): 2306-2311.
2. Loke SC, Rahim KF, Kanesvaran R, et al. A prospective cohort study on the effect of various risk factors on hypoglycaemia
in diabetics who fast during Ramadan. Med J Malaysia. 2010; 65(1): 3-6.
10
Section 5
11
12
High risk
Moderate hyperglycaemia (HbA1c 7.59.0%)
Moderate renal failure
Advanced macrovascular complications
Living alone and treated with insulin or sulfonylureas
Patients with co morbid conditions that present additional risk factors
Old age with ill health
Treatment with drugs that may affect mentation
Moderate risk
Well-controlled diabetes treated with short-acting insulin secretagogues
Low risk
Well-controlled diabetes treated with lifestyle therapy, metformin, acarbose,
thiazolidinediones, and/or incretin-based therapies in otherwise healthy patients
Note: This classification is based largely on expert opinion and not on scientific data derived from clinical studies.
Those who fall in the very high and high risk group are advised to abstain from fasting.
This table is a modification of Table 2 from Recommendations for management of diabetes during Ramadan: update 2010 by Al-Arouj
et al. (2010).
13
References
1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update
2010. Diabetes Care. 2010; 33(8): 1895-902.
2. Azad K, Mohsin F, Zargar AH, et al. Fasting guidelines for diabetic children and adolescents. Indian J Endocrinol Metab.
2012; 16(4): 516-518.
3. Al Wakeel J, Mitwalli AH, Alsuwaida A, et al. Recommendations for fasting in Ramadan for patients on peritoneal
dialysis. Perit Dial Int. 2013; 33(1): 86-91.
4. Al Wakeel JS. Kidney function and metabolic profile of chronic kidney disease and hemodialysis patients during
Ramadan fasting. Iran J Kidney Dis. 2014; 8(4): 321-8.
5. Beshyah S, Benbarka M, Sherif I. Practical management of diabetes during Ramadan fast. Libyan J Med. 2007; 2(4):
185-189.
14
Section 6
PREPARATION PRIOR TO RAMADAN
15
16
b. Patient education
Structured patient education is important to impart the essential elements necessary to
render fasting safer so as to prevent and reduce risks and complications during fasting. The
Ramadan period presents a golden opportunity to empower people with diabetes for better
management of their diabetes, not only in Ramadan but also throughout the year.1,2,5
Educational sessions should be provided by healthcare professionals to people with diabetes
who are intending to fast for Ramadan, preferably several weeks before Ramadan to provide
adequate time for patients, their families and caregivers to prepare for the fasting month.1,2
Patients and care-givers / family members should receive education concerning self-care such
as the following:1,2,6
Risks of fasting
Hypoglycaemia symptoms and signs
Hyperglycaemia symptoms and signs
Dehydration
Blood glucose monitoring during fasting and non-fasting hours
When to stop the fast
Hydration
Meal planning and food choices
Physical activity timing and intensity
Medication administration timing and dosing
Management of Acute complications
Patient education programme may be delivered to people with diabetes either individually or
in a group session at diabetes resource centres and primary health care centres.
17
References
1. Bashir MI, Pathan MF, Raza SA, et al. Role of oral hypoglycemic agents in the management of type 2 diabetes mellitus
during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 503-507.
2. Benaji B, Mounib N, Roky R, et al. Diabetes and Ramadan: review of the literature. Diabetes Res Clin Pract. 2006; 73(2):
117-125.
3. Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010;
103(4): 139-147.
4. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update
2010. Diabetes Care. 2010; 33(8): 1895-902.
5. Hui E, Devendra D. Diabetes and fasting during Ramadan. Diabetes Metab Res Rev. 2010; 26(8): 606-610.
6. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type
2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.
18
Section 7
19
20
Mid-day
Pre-sahur
Premixed / bolus / basal insulin
Pre-iftar
Pre-sahur
Premixed or basal insulin
Pre-iftar
Premixed or bolus insulin
Pre-sahur
Pre-iftar / Pre-bed
Premixed or basal insulin
Pre-sahur
Premixed or bolus insulin
21
References
1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update
2010. Diabetes Care. 2010; 33(8): 1895-902.
2. Pathan MF, Sahay RK, Zargar AH, South Asian Consensus Guideline: Use of insulin in diabetes during Ramadan. Indian
J Endocrinol Metab. 2012; 16(4): 499-502.
3. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type
2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.
4. Ibrahim MA. Managing diabetes during Ramadan. Diabetes voice. 2007; 52(2): 19-22.
5. Hui E, Bravis V, Hassanein M, et al. Management of people with diabetes wanting to fast during Ramadan. BMJ. 2010;
340:c3053.
22
Section 8
23
24
Figure 2. An illustration of a good buka puasa meal A vs. one that intake should be limited
during buka puasa B .
Physical Activity
Appropriate modification in intensity and timing of physical activity is important to maintain
optimal glycaemic control and optimal weight.
Physical activities and exercise needs to be adjusted during Ramadan. The following are
recommended:2,3
Light and moderate intensity exercise on a regular basis.
Avoid rigorous exercise during fasting time because of risk of hypoglycaemia.
The timing of exercise is preferably 1-2 hours after the break of fast.
Performance of Tarawih night prayers helps to maintain physical activity.
25
References
1. Persatuan Dietitian Malaysia. Medical nutrition therapy guidelines for type 2 diabetes mellitus. 2013. Second Edition.
2. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type
2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.
3. Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010;
103(4): 139-147.
26
Section 9
27
28
Table 3. Adjustments of oral anti-diabetic agents in patients with Type 2 diabetes who are fasting
during Ramadan.6
Regimen
-glucosidase inhibitors
No changes
No changes
Twice daily
No changes
No changes
Thrice daily
Extendedrelease
Full dose
None
Dipeptidyl peptidase-4
inhibitors
No changes
No changes
Meglitinides
No changes
No changes
Biguanides
(Metformin)
Immediaterelease
Reduce/omit
Switch dosing to sunset meal
No changes
Thiazolidinediones
No changes
None
Modified from Pharmacological approaches to the management of type 2 diabetes in fasting adults during
Ramadan by AlMaatouq (2012).
MR: Modified-release
*Based on expert opinion.
29
References
1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update
2010; Diabetes Care. 2010; 33(8): 1895-902.
2. Mafauzy M. Repaglinide versus glibenclamide treatment of Type 2 diabetes during Ramadan fasting. Diabetes Res Clin
Pract. 2002; 58(1): 45-53.
3. Glimepiride in Ramadan (GLIRA) Study Group. The efficacy and safety of glimepiride in the management of type 2
diabetes in Muslim patients during Ramadan. Diabetes Care. 2005; 28(2): 421-422.
4. Al-Arouj M, Hassoun AA, Medlej R, et al. The effect of vildagliptin relative to sulphonylureas in Muslim patients with
type 2 diabetes fasting during Ramadan: the VIRTUE study. Int J Clin Pract. 2013; 67(10): 957-963.
5. Al Sifri S, Basiounny A, Echtay A, et al. The incidence of hypoglycaemia in Muslim patients with type 2 diabetes treated
with sitagliptin or a sulphonylurea during Ramadan: a randomised trial. Int J Clin Pract. 2011; 65(11): 1132-1140.
6. Almaatouq MA. Pharmacological approaches to the management of type 2 diabetes in fasting adults during Ramadan.
Diabetes Metab Syndr Obes. 2012; 5: 109-119.
30
Section 10
INSULIN THERAPY DURING Ramadan
31
Basal insulin
only
Not applicable.
32
Insulin regimen
Basal bolus
insulin
Basal insulin
Taken at bedtime or any time after iftar meals. May require dose
reduction if there is day time hypoglycaemia.
Bolus/Prandial
insulin
Insulin pump
33
References
1. Salti I, Bnard E, Detournay B, et al A population-based study of diabetes and its characteristics during the fasting
month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study.
Diabetes Care. 2004; 27(10): 2306-2311.
2. Kobeissy A, Zantout MS, Azar ST. Suggested insulin regimens for patients with type 1 diabetes mellitus who wish to
fast during the month of Ramadan. Clin Ther. 2008; 30(8): 1408-1415.
3. Kassem HS, Zantout MS, Azar ST. Insulin therapy during Ramadan fast for Type 1 diabetes patients. J Endocrinol Invest.
2005; 28(9): 802-805.
4. Kadiri A, Al-Nakhi A, El-Ghazali S, et al. Treatment of type 1 diabetes with insulin lispro during Ramadan. Diabetes
Metab. 2001; 27(4 Pt 1): 482-486.
5. Reiter J, Wexler ID, Shehadeh N, et al. Type 1 diabetes and prolonged fasting. Diabet Med. 2007; 24(4): 436-439.
6. Mucha GT, Merkel S, Thomas W, et al. Fasting and insulin glargine in individuals with type 1 diabetes. Diabetes Care.
2004; 27(5): 1209-1210.
7. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update
2010. Diabetes Care. 2010; 33(8): 1895-902.
8. Ministry of Health Malaysia. Practical guide to insulin therapy in type 2 diabetes mellitus. 2010.
9. Pathan MF, Sahay RK, Zargar AH, South Asian Consensus Guideline: Use of insulin in diabetes during Ramadan. Indian
J Endocrinol Metab. 2012; 16(4): 499-502.
10. Hui E, Devendra D. Diabetes and fasting during Ramadan. Diabetes Metab Res Rev. 2010; 26(8): 606-610.
11. Bin-Abbas BS. Insulin pump therapy during Ramadan fasting in type 1 diabetic adolescents. Ann Saudi Med. 2008;
28(4): 305-306.
12. Hawli YM, Zantout MS, Azar ST. Adjusting the basal insulin regimen of patients with type 1 diabetes mellitus receiving
insulin pump therapy during the Ramadan fast: A case series in adolescents and adults. Curr Ther Res Clin Exp. 2009;
70(1): 29-34.
13. Benbarka MM, Khalil AB, Beshyah SA, et al. Insulin pump therapy in Moslem patients with type 1 diabetes during
Ramadan fasting: an observational report. Diabetes Technol Ther. 2010; 12(4): 287-290.
14. H
ui E, Bravis V, Salih S, et al. Comparison of Humalog Mix 50 with human insulin Mix 30 in type 2 diabetes patients
during Ramadan. Int J Clin Pract. 2010; 64(8): 10951099.
34
GLOSSARY OF TERMS
BMI
DKA
Diabetic ketoacidosis
EPIDIAR
HDL
hs-CRP
ICR
IGF-1
OAD
Oral anti-diabetic
MR
Modified-release
PAI-1
SMBG
ACKNOWLEDGEMENTS
The members of the working committee of this guide would like to express their gratitude and
appreciation to the following for their contributions:
Panel of external reviewers who reviewed the draft.
All those who have contributed directly or indirectly to the development of this guide.
SOURCES OF FUNDING
The development of this guide was supported by an educational grant from:
35