Iftaar and Insulin: Managing Diabetes During Ramadan

Each year—during the ninth month of the Hijri (lunar) calendar—1.8 billion Muslims celebrate the Holy Month of Ramadan. For roughly 30 days, able-bodied Muslims are religiously required to abstain from food or drink from sunrise to sunset.¹ Individuals with type 1 diabetes (T1D) or type 2 diabetes (T2D) are exempt from this practice due to health risks; however, 42.8% and 78.7% of patients with T1D and T2D, respectively, continue to fast for at least 15 days.² 

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Managing Diabetes During Ramadan

Recommendations published in the Diabetes/Metabolism Research and Reviews provide primary care providers (PCPs) guidance on best practice for managing diabetes during Ramadan. The guidance is updated every 5 years, with the most recent update published in May 2025.

Monitoring technology is valuable to assess glycemic control and enable timely interventions in T1D patients. These technologies prevent the risk of both hypo- and hyperglycemic episodes, facilitating safer fasting. Examples of recommended technology include:

• Continuous glucose monitoring (CGM) devices,
• Integrated pump-sensor systems,
• Hybrid closed-loop systems, and
• AI-equipped CGM devices.

The guidelines recommend pharmacologic therapies with a low risk of hypoglycemia (as described in Table 1) to minimize total hypoglycemic episodes. Choice of a preferred agent, per the American Diabetes Association and the European Association for the Study of Diabetes, must take into consideration the presence or absence of atherosclerotic cardiovascular disease (or indicators of high risk), chronic kidney disease, and heart failure (HF).^1,3 Metformin remains first-line—alongside lifestyle and diabetes self-management education and support—for patients during Ramadan.^1,4

Carefully Consider GLP-1 Use During Ramadan

Tirzepatide, a glucagon-like peptide-1 (GLP-1)/glucose-dependent insulinotropic polypeptide (GIP) agonist, is now available for prescribing in patients with both T2D and obesity; however, no clinical trials have evaluated its use during Ramadan fasting.

Oral GLP-1 receptor agonists, like semaglutide, can be safely recommended for use during Ramadan. Oral semaglutide should be titrated to 7 mg before Ramadan (around 2 to 3 weeks) to ensure effectiveness and patient safety. Of note, dosing should be individualized at Iftaar (sunset meal) because food-drug interactions can impede its absorption.

Literature—particularly, an analysis of 20,000 United States adults—suggests a higher risk of cardiovascular disease mortality in those who restricted eating to less than 8 hours per day; additional studies are needed to confirm these findings.^1,5 In the meantime, physicians should advise patients wishing to fast to exercise caution regardless of the severity of cardiovascular risk factors. Patients with high risk should avoid Ramadan fasting.

Role of PCP Counseling for Observers

Fasting may present risks to post-metabolic and bariatric surgery (MBS) patients. Pre-Ramadan counseling (6 to 8 weeks before Ramadan) is imperative to assessing risks and ensuring patient safety. Additionally, providers should tailor dietary, hydration, and medication recommendations to post-MBS patients to reduce and prevent complications. Risk of nutrient deficiencies, for example, can be minimized by recommending appropriate supplementation (eg, calcium, vitamin D) to be taken at Iftaar. The guideline itself includes other specific examples.

PCPs play an important role in ensuring safety and counselling patients on safe fasting practices and possible risks. PCPs should begin counselling patients wishing to fast and/or modify or initiate treatments 6 to 8 weeks before Ramadan. Emphasis is placed on counseling patients with poorly controlled diabetes or post-MBS patients during this timeframe.

The recommendations provide PCPs guidance for managing patients with diabetes during Ramadan. From technology and pharmacologic choices to recommendations for specific patient populations, each measure is critical to ensure patient safety during an important, spiritual month.

REFERENCES

1. Ibrahim M, Ba-Essa EM, Ahmed A, et al. Recommendations for the Management of Diabetes During Ramadan Applying the Principles of the ADA/EASD Consensus: Update 2025. Diabetes Metab Res Rev. 2025;41(5):e70057. doi:10.1002/dmrr.70057

2. Salti I, Bénard 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. doi:10.2337/diacare.27.10.2306

3. American Diabetes Association Professional Practice Committee, “9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes—2025,”supplement.Diabetes Care 2025;48:S181–S206. https://doi.org/10.2337/dc25‐S009.

4. Ibrahim M, Davies MJ, Ahmad E, et al. Recommendations for management of diabetes during Ramadan: update 2020, applying the principles of the ADA/EASD consensus. BMJ Open Diabetes Res Care. 2020;8(1):e001248. doi:10.1136/bmjdrc-2020-001248

5. Chen M, Zhong VW. Abstract P192: Association Between Time-Restricted Eating and All-Cause and Cause-Specific Mortality. Circulation. 2024;149(Suppl_1): AP192-AP. doi:10.1161/circ.149.suppl_1.P192