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Table 3—

Recommended changes to treatment regimen in patients with type 2 diabetes who fast during Ramadan

Before RamadanDuring Ramadan
Patients on diet and exercise control No change needed (modify time and intensity of exercise), ensure adequate fluid intake 
Patients on oral hypoglycemic agents Ensure adequate fluid intake 
Biguanide, metformin 500 mg three times a day, or sustained release metformin (glucophage R) Metformin, 1,000 mg at the sunset meal (Iftar), 500 mg at the predawn meal (Suhur) 
TZDs, pioglitazone or rosiglitazone once daily No change needed 
Sulfonylureas once a day, e.g., glimepiride 4 mg daily, gliclazide MR 60 mg daily Dose should be given before the sunset meal (Iftar); adjust the dose based on the glycemic control and the risk of hypoglycemia 
Sulfonylureas twice a day, e.g., glibenclamide 5 mg or gliclazide 80 mg, twice a day (morning and evening) Use half the usual morning dose at the predawn meal (Suhur) and the full dose at the sunset meal (Iftar), e.g., glibenclamide 2.5 mg or gliclazide 40 mg in the morning, glibenclamide 5 mg or gliclazide 80 mg in evening 
Patients on insulin Ensure adequate fluid intake 
70/30 premixed insulin twice daily, e.g., 30 units in morning and 20 units in evening Use the usual morning dose at the sunset meal (Iftar) and half the usual evening dose at predawn (Suhur), e.g., 70/30 premixed insulin, 30 units in evening and 10 units in morning; also consider changing to glargine or detemir plus lispro or aspart 
Before RamadanDuring Ramadan
Patients on diet and exercise control No change needed (modify time and intensity of exercise), ensure adequate fluid intake 
Patients on oral hypoglycemic agents Ensure adequate fluid intake 
Biguanide, metformin 500 mg three times a day, or sustained release metformin (glucophage R) Metformin, 1,000 mg at the sunset meal (Iftar), 500 mg at the predawn meal (Suhur) 
TZDs, pioglitazone or rosiglitazone once daily No change needed 
Sulfonylureas once a day, e.g., glimepiride 4 mg daily, gliclazide MR 60 mg daily Dose should be given before the sunset meal (Iftar); adjust the dose based on the glycemic control and the risk of hypoglycemia 
Sulfonylureas twice a day, e.g., glibenclamide 5 mg or gliclazide 80 mg, twice a day (morning and evening) Use half the usual morning dose at the predawn meal (Suhur) and the full dose at the sunset meal (Iftar), e.g., glibenclamide 2.5 mg or gliclazide 40 mg in the morning, glibenclamide 5 mg or gliclazide 80 mg in evening 
Patients on insulin Ensure adequate fluid intake 
70/30 premixed insulin twice daily, e.g., 30 units in morning and 20 units in evening Use the usual morning dose at the sunset meal (Iftar) and half the usual evening dose at predawn (Suhur), e.g., 70/30 premixed insulin, 30 units in evening and 10 units in morning; also consider changing to glargine or detemir plus lispro or aspart 

The recommendations given in this table are for illustrative purposes and are largely based on expert clinical opinion and not on scientific data derived from clinical studies. The recommendations must be adjusted for each specific patient. Adapted from Akbani et al. (30). TZD, thiazolidinedione.

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