Recommendations for the Management of Diabetes During Ramadan Applying the Principles of the ADA/ EASD Consensus: Update 2025

Abstract

Ramadan fasting is a sacred ritual observed by approximately 1.8 billion Muslims each year, most of whom adhere to fasting due to its significance as a core pillar of Islam. Able-bodied Muslims who are capable of fasting are religiously required to do so. Ramadan is profoundly spiritual and of great importance in the Muslim community that occurs for roughly 30 days, in alignment with the lunar calendar. During Ramadan, Muslims abstain from food and drink for 11–16 h a day on average; however, this could be significantly shorter or longer depending on the season and the geographic location, ultimately breaking their fast during the sunset meal ‘Iftaar’. Before the great strides were taken in the management of diabetes, these patients were initially considered not able to observe this holy month, creating significant frustration and disconnect with their families and loved ones. As patient outcomes improved through the emergence of better pharmacotherapy and increasing use of technology, these restrictions have been reconsidered. This prompted us to create the 2005 first global statement regarding best practices in the management of diabetes during Ramadan as an official American Diabetes Association (ADA) report. Since then, we have received numerous requests and comments asking for updated versions that include the latest data, medications, and technology. We decided to issue an update every 5 years, including 2010, 2015 and 2020. Our updated recommendations collate some of the more directly implicative findings on patient care for Ramadan fasting and align closely with the ADA's consensus for diabetes management. We recommend the prioritisation of pharmacologic therapies with a low risk profile for hypoglycaemia. Technological advancements, including integrated pump-sensor systems, hybrid closed-loop systems, and artificial intelligence (AI)-equipped continuous glucose monitoring (CGM) devices, show great promise in the monitoring of blood glucose levels and can provide tangible reductions in hypoglycaemia episodes, suggesting possible utility in the facilitation of fasting in patients with type 1 diabetes mellitus (T1D). Our recommendations align with the ADA consensus for the use of CGM devices, in concordance with appropriate time in range (TIR) targets to reduce hypoglycaemia and glycaemic variability. The implications of Ramadan fasting on atherosclerotic cardiovascular disease (ASCVD) risk remain uncertain due to the sparsity of evidence, but the literature suggests an increased risk. Until more conclusive evidence is reported, we advise patients with a high ASCVD risk to avoid Ramadan fasting. We emphasise the pivotal role primary care providers (PCPs) have in counselling, managing, and following patients who intend to fast and advise counselling to begin ideally 6–8 weeks prior to Ramadan start, with particular recommendations to be given to patients post-bariatric surgery.