Ramadan takes place during the ninth month of the Islamic calendar. It is the holiest month for Muslims and is marked by fasting from food and drink during daylight hours.1 While an estimated 93% of Muslims fast during Ramadan,1 those who experience difficulty fasting — including the elderly or people with chronic illnesses — may be exempt.2

One particular population of concern is Muslims with diabetes. Hypoglycemia risk is increased during Ramadan for those who fast.2 In particular, risk is increased where fasting and driving overlap, considering that patients with diabetes must meet certain glycemic parameters while driving for safety reasons.2

Nazim Ghouri, MBChB, MD, MRCP, of the Institute of Cardiovascular & Medical Sciences at the University of Glasgow, Scotland, and colleagues examined the interplay between fasting, driving, and diabetes in the Muslim community, presenting a novel review of secular and religious guidance that clinicians can reference when treating this patient population.2

“While there is no clear guidance or legal position on diabetes and driving for individuals who are fasting, Islamic law provides a logical framework to address this,” Dr Ghouri and colleagues noted. “Healthcare professionals need to raise and facilitate discussions on this often-overlooked topic with people with diabetes who are planning on fasting to minimize the potential for public harm.”

Published in Diabetes Research and Clinical Practice, the International Diabetes Federation and the Diabetes and Ramadan International Alliance released guidance focused on social and work-related aspects of Ramadan fasting in people with diabetes.3 The 2017 guidelines stratify patients into 1 of 3 categories to provide the best recommendations for patients with diabetes who wish to fast.

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Category 1: Very high risk. The first category encompasses patients with severe hypoglycemia, unexplained diabetic ketoacidosis, or hyperosmolar hyperglycemic coma within the 3 months prior to Ramadan; a history of hypoglycemia unawareness; pregnancy with preexisting diabetes; stage 4 or 5 chronic kidney disease; advanced macrovascular complications; and/or poorly controlled type 1 diabetes. These patients should listen to medical advice and must not fast. However, if patients in this category insist on fasting, they should receive structured education from a qualified diabetes team, regularly self-monitor blood glucose levels, follow recommendations for medication adjustments, and be prepared to break their fast in the event of hypoglycemia or hyperglycemia.