T2 Diabetes and RamadanRamadan and chronic conditions This is a summarised version of IDF & DAR - Diabetes and Ramadan - Practical Guidelines 2021 - T2D chapter Medication adjustment recommendations also sourced from SAHF: Managing People with Diabetes Fasting for Ramadan During the COVID‐19 Pandemic All individuals seeking to fast should attend a pre-Ramadan visit 6-8 weeks before Ramadan ↓ ASSESSMENT ↓ Structured education for all individuals to include: Risk quantification The role of SMBG When to break the fast When to exercise Fluids and meal planning Medication adjustments during fasting To stratify risk and develop an individualised management plan Detailed medical history Aspects of diabetes and ability to self-manage Presence of comorbidities The individual’s prior experience in managing diabetes during Ramadan fasting The individual’s ability to self-manage diabetes Other aspects increasing the risk of fasting RISK STRATIFICATION: LOW, MODERATE and HIGH↓↓ Frequency of SMBG needs to be guided by risk stratification and individualised ALL INDIVIDUALS SHOULD BREAK THEIR FAST IF: Blood glucose < 70 mg/dL (3.9 mmol/L) Re-check within 1 hour if blood glucose 70–90 mg/dL (3.9–5.0 mmol/L) Blood glucose levels >300 mg/dL* (16.6 mmol/L) Symptoms of hypoglycaemia or acute illness occur * This applies for those with sudden rise in blood glucose level, individualisation of care is advisable Risk score and risk categories: ELEMENTS FOR RISK CALCULATION AND SUGGESTED RISK SCORE ←click to view table Risk score and risk categoriesLOW RISKMODERATE RISKHIGH RISK↓ Those at the low-risk level should be able to fast These individuals are at a lower risk of in terms of complications arising when fasting during Ramadan. However, circumstances can change leading to a change in the risk scoring. Therefore, risk stratification should be conducted annually to review the level of risk in advance of Ramadan. Those at the moderate-risk level are advised not to fast Many of these patients may choose to fast despite the advice not to fast. This important personal decision should be made after consideration of the associated risks in consultation with HCPs. They also need to be aware of the techniques or strategies to decrease this risk. If individuals choose to fast, then they would need to be cautious and discontinue fasting if any problems arise. Individuals who are in the high-risk category should not fastThese individuals are of high-very high risk of developing complications when fasting during Ramadan. We recommend that these individuals do not fast. If they do still insist on fasting the utmost care and monitoring should be provided alongside the strategies and recommendations mentioned in the full guidance: DIABETES AND RAMADAN PRACTICAL GUIDELINES 2021. MEDICATION ADJUSTMENTSMulti-select (Ctrl + click) the appropriate medicationMetformin Once-daily dosingMetformin Twice-daily dosingMetformin Three times daily dosingProlonged-release metforminSU Once-daily dosingSU Twice-daily dosingOlder drugs in SU classPIOGLITAZONEDPP4 inhibitorsSGLT2 inhibitorsGLP-1 RAsShort-acting insulin secretagoguesDose adjustments for long or short-acting insulinsDose adjustments for premixed insulinDose adjustments for insulin pump therapy METFORMIN Once-daily dosing No dose modification usually required + Take at Iftar METFORMIN Twice-daily dosing No dose modification usually required + Take at Iftar and Suhoor METFORMIN Three times daily dosing Morning dose to be taken before Suhoor + Combine afternoon dose with dose taken at Iftar Prolonged-release METFORMIN No dose modification usually required + Take at Iftar SAHF: Algorithm for managing diabetes in Ramadan ←Click to view SAHF: GUIDELINES FOR MANAGING DIABETES DURING RAMADAN: 2020 UPDATE SAHF 2020: Recommendations for glucose‐lowering therapies during Ramadan in the COVID‐19 pandemic Metformin Recommendation during Ramadan First‐line glucose‐lowering therapy Low risk of hypoglycaemia No dose modification required Additional recommendations during COVID‐19 pandemic Ensure adequate fluid intake Regular monitoring of blood glucose If severe COVID‐19 symptoms, stop metformin SULPHONYLUREAS Once daily dosing Take at Iftar + In individuals with well-controlled BG levels, the dose may be reduced SULPHONYLUREAS Twice-daily dosing Iftar dose remains the same + In individuals with well-controlled BG levels, the Suhoor dose should be reduced SULPHONYLUREAS - Older drugs in SU class Older drugs (e.g. glibenclamide) carry a higher riskof hypoglycaemia and should be avoided ↓ 2nd generation SUs such as glicazide, glicazide MR, glimepiride should be used instead SAHF: Algorithm for managing diabetes in Ramadan ←Click to view SAHF: GUIDELINES FOR MANAGING DIABETES DURING RAMADAN: 2020 UPDATE SAHF 2020: Recommendations for glucose‐lowering therapies during Ramadan in the COVID‐19 pandemic Sulphonylureas Recommendation during Ramadan Avoid glibenclamide due to high risk of hypoglycaemia Second‐generation sulphonylureas (glimepiride, glicazide) can be used Once‐daily dosing: Take at iftar Twice‐daily dosing: iftar dose remains the same, in those with adequate glucose levels, the suhoor dose should be reduced Additional recommendations during COVID‐19 pandemic Ensure adequate fluid intake Regular monitoring of blood glucose Pioglitazone Due to the low risk of hypoglycaemia with pioglitazone, NO DOSE MODIFICATION is required during Ramadan, but dose should be taken with Iftar. SAHF: Algorithm for managing diabetes in Ramadan ←Click to view SAHF: GUIDELINES FOR MANAGING DIABETES DURING RAMADAN: 2020 UPDATE SAHF 2020: Recommendations for glucose‐lowering therapies during Ramadan in the COVID‐19 pandemic Thiazolidinediones Recommendation during Ramadan Low risk of hypoglycaemia No dose modification required Additional recommendations during COVID‐19 pandemic Ensure adequate fluid intake Regular monitoring of blood glucose Dipeptidyl peptidase-4 (DPP-4) inhibitors DPP4-I do NOT REQUIRE TREATMENT MODIFICATIONS during Ramadan. SAHF: Algorithm for managing diabetes in Ramadan ←Click to view SAHF: GUIDELINES FOR MANAGING DIABETES DURING RAMADAN: 2020 UPDATE SAHF 2020: Recommendations for glucose‐lowering therapies during Ramadan in the COVID‐19 pandemic DPP‐4 inhibitors Recommendation during Ramadan Low risk of hypoglycaemia No dose modification required Additional recommendations during COVID‐19 pandemic Ensure adequate fluid intake Regular monitoring of blood glucose Sodium-glucose co-transporter-2 (SGLT2) inhibitors SGLT2 inhibitors have a low risk of hypoglycaemia. NO DOSE ADJUSTMENTs are required during Ramadan. SAHF: Algorithm for managing diabetes in Ramadan ←Click to view SAHF: GUIDELINES FOR MANAGING DIABETES DURING RAMADAN: 2020 UPDATE SAHF 2020: Recommendations for glucose‐lowering therapies during Ramadan in the COVID‐19 pandemic SGLT‐2 inhibitors Recommendation during Ramadan Emerged as a vital therapeutic option to delay or prevent cardiovascular and renal complications in people with Type 2 diabetes Low risk of hypoglycaemia No dose modification required People with diabetes should either be switched to or established on a stable dose well in advance of Ramadan (4 weeks) Additional recommendations during COVID‐19 pandemic Ensure adequate fluid intake Regular monitoring of blood glucose If unwell (even if blood glucose normal) or blood glucose >16.6mmol/L, check ketones; if elevated, stop medication seek medical advice Concerns and practical tips on the use of SGLT2 inhibitors during Ramadan fasting in people with Type 2 diabetes, in the COVID‐19 pandemic Concerns Volume depletion (due to osmotic diuresis) Dehydration (due to abstinence from fluid intake) Hypotension Euglycaemic diabetic ketoacidosis Mycotic fungal genital infections Practical tips Appropriate patient selection Review the need and decide on continuation/resumption/discontinuation Ensure absence of contraindications like severe renal impairment, end‐stage renal disease, or dialysis Consider temporary discontinuation in settings of reduced oral intake or fluid losses in people with & at risk of acute kidney injury and impairment in renal function Monitor for hydration status (volume and colour of urine) and maintain adequate fluid intake Monitor for hypotension, particularly in people on loop diuretics, older people, or those with impaired renal function (eGFR <60 mL/min/1.73m2) Assess people who present with signs and symptoms of metabolic acidosis for ketoacidosis Evaluate people for signs and symptoms of urinary tract infections and treat promptly, if indicated Consider lowering the dose of insulin secretagogue or insulin to reduce the risk of hypoglycaemia Avoid commencement of SGLT‐2i less than one month before the start of Ramadan Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) As long as liraglutide, lixesenatide, exenatide have been appropriately DOSE-TITRATED prior to Ramadan (at least 2–4 weeks), NO FURTHER TREATMENT MODIFICATIONS are required. SAHF: Algorithm for managing diabetes in Ramadan ←Click to view SAHF: GUIDELINES FOR MANAGING DIABETES DURING RAMADAN: 2020 UPDATE SAHF 2020: Recommendations for glucose‐lowering therapies during Ramadan in the COVID‐19 pandemic GLP‐1 receptor agonists Recommendation during Ramadan Emerged as a vital injectable therapy to delay or prevent cardiovascular and renal complications in people with Type 2 diabetes Low risk of hypoglycaemia No dose modification required Additional recommendations during COVID‐19 pandemic Ensure adequate fluid intake Regular monitoring of blood glucose If severe COVID‐19 symptoms with AKI or GI symptoms, stop GLP‐1RA Short-acting insulin secretagogues (repaglinide and nateglinide) The daily dose of short-acting insulin secretagogues (based on a three-meal dosing) may be REDUCED or REDISTRIBUTED to two doses during Ramadan according to meal sizes. SAHF: Algorithm for managing diabetes in Ramadan ←Click to view SAHF: GUIDELINES FOR MANAGING DIABETES DURING RAMADAN: 2020 UPDATE SAHF 2020: Recommendations for glucose‐lowering therapies during Ramadan in the COVID‐19 pandemic Insulin Recommendation during Ramadan High risk of hypoglycaemia Basal (long‐acting) insulin: Preferred initial formulation Dose reduction by 20% and take at iftar Rapid‐acting insulin: Omit lunch dose, take twice daily with meals at suhoor and iftar Mixed insulin: In those taking a higher dose of insulin in the morning and lower dose in the evening, dosing should be switched during fasting so that the lower dose is taken at suhoor and the higher dose at iftar (may be reduced in some cases) Additional recommendations during COVID‐19 pandemic Ensure adequate fluid intake Check blood glucose and ketones regularly Follow “sick day rules” This is a web app of a streamlined version of BIMA Ramadan Compendium 2021Please view the full guidance for further details Risk stratify the patient based on the categories below. Give special consideration to the patient's age, frailty, previous experience of fasting, and if they have more than one comobidity where risk may be compounded. Chronic condition - SelectCardiovascular diseaseRespiratory diseaseChronic Kidney DiseaseGastrointestinal diseaseNeurological diseaseDiabetesAdrenal diseaseBenign haematological diseaseHaematological malignanciesRheumatological diseaseObesityPregnancyOrgan transplantsSolid tumoursMental health Advise MUST NOT fast <div class="redbox"> <p><b><u>Advise must not fast</u></b></p> <ul> <li>If still choosing to fast, advise extreme caution and encourage them to seek the opinion of a trusted religious authority to discuss exemption from fasting.</li> </ul> </div> ↓ Advise should NOT fast <div class="orangebox"> <p><b><u>Advise should not fast</u></b></p> <ul> <li>If still choosing to fast, advise caution in fasting.</li> <li>Explore previous experience of fasting and if this has led to exacerbations of illness.</li> <li>Review medication and lifestyle advice.</li> </ul> <p></p> </div> ↓ Advise fasting is likely safe <div class="greenbox"> <p><b><u>Advise fasting is likely safe</u> if medical advice regarding medication and lifestyle is followed</b></p> <ul> <li>Ensure review of medication and adequate advice regarding hydration and sleep</li> </ul> </div> ↓ VERY HIGH RISK Those experiencing an acute exacerbation of their chronic lung disease Asthma/COPD sufferers at high risk of exacerbation and preventative inhaler timings cannot be altered to a fasting compatible regime VERY HIGH RISK Advanced heart failure (optimal medical therapy, Left Ventricular Ejection Fraction <35%, with class III-IV NYHA symptoms, ≥1 hospitalisation in the last 6 month due to decompensated heart failure and severely impaired functional capacity (e.g. 6 min walk distance <300m) Severe pulmonary hypertension (defined as WHO/NYHA III-IV classification, right ventricular dysfunction and objective markers on right heart catheterisation e.g. SvO2 <60%) VERY HIGH RISK CKD patients in stage 4-5 with eGFR<30 ml/min* Patients on all forms of hemodialysis and peritoneal dialysis Pregnant CKD patients CKD stage 3-5 patients with history of pre-existing cardiovascular disease CKD patients on tolvaptan * although HD and PD patients would be considered very high risk, a select group may be able to fast following risk stratification and counselling, factors to consider would include – residual renal function, fluid balance, potassium >6.0 mmol/L, motivation, compliance with medical advice, consider alternatives to fasting and winter fasting. VERY HIGH RISK Patients with established cirrhosis especially Child-Pugh B and C Patients who are < 6months post Liver transplant Patients with symptomatic active inflammatory bowel disease Patients with significant acute or chronic diarrhoea Patients with high output ileostomy VERY HIGH RISK Any condition predisposing to respiratory complications e.g. bulbar weakness, neuromuscular disorders* Myasthenia Gravis on regular pyridostigmine more than 3 times per day MND Poorly controlled epilepsy, on multiple antiepileptic medications, history of status epilepticus Parkinson’s disease requiring regular levo-dopa Neurodegenerative disorders with cognitive impairment * Expert-recommended upgrading of risk due to COVID-19. Recommendations subject to review if relevant evidence suggests re-grading VERY HIGH RISK One or more of the following: Severe hypoglycaemia within the 3 months prior to Ramadan*> DKA within the 3 months prior to Ramadan Hyperosmolar hyperglycaemic coma within the 3 months prior to Ramadan History of recurrent hypoglycaemia History of hypoglycaemia unawareness Poorly controlled T1DM Acute illness Pregnancy in pre-existing diabetes or GDM treated with insulin Chronic dialysis or CKD stage 4 & 5 Advanced macrovascular complications Old age with ill health Type 2 diabetes requiring insulin (MDI or mixed insulin) with no prior experience of safe fasting * Hypoglycaemia that is not due to accidental error in insulin dose. VERY HIGH RISK Any of the following: Multi-morbidity Diabetes mellitus requiring insulin therapy Co-existent pituitary (diabetes) insipidus Adrenal crises in the last 12 months Untreated mineralocorticoid deficiency Untreated TSH deficiency VERY HIGH RISK Sickle cell disease including HbSS, HbSC, HbS/Beta-Thal, HbSO, HbSD and those prone to sickle cell crisis Cold Haemagglutinin Disease with ongoing haemolysis Amyloidosis with renal impairment Antiphospholipid Syndrome with history of blood clots Paroxysmal Nocturnal Haemoglobinuria with active haemolysis or history of recurrent thrombosis Thrombophilias with history of recurrent thrombosis despite being on anticoagulation VERY HIGH RISK Patients requiring inpatient treatment for cancer or complications of cancer e.g. acute leukemias, high grade lymphomas, aggressive/refractory myeloma Patients requiring inpatient treatment undergoing autologous or allogeneic stem cell transplantation or its complications Patients requiring inpatient treatment for complications of cancer treatment e.g. neutropenic sepsis, severe vomiting, diarrhoea, pain and other symptoms Newly diagnosed myeloma patients who are at risk of kidney injury VERY HIGH RISK Active SLE with renal involvement Active vasculitis with renal involvement Low eGFR secondary to connective tissue diseases/vasculitis Scleroderma leading to pulmonary hypertension VERY HIGH RISK BMI > 40kg/m2 with any of the following: Established end-organ cardiovascular disease (e.g. previous myocardial injury, cardiac failure, previous CVA/TIA) Advanced CKD (stage 4-5) Advanced chronic pulmonary diseases Severe obstructive sleep apnoea VERY HIGH RISK Pregnancy with severe underlying maternal health conditions Complicated pregnancy VERY HIGH RISK SOT recipients who underwent a transplant in the last 12 months Patients on twice daily formulations of immunosuppression Pregnant transplant patients Transplant patients diagnosed with Post Transplant Diabetes Mellitus requiring twice daily oral hypoglycaemics or insulin treatment Kidney transplant recipients with reduced kidney function (eGFR < 30 ml/min) Patients with unstable graft function, recent rejection episodes and opportunistic Infections Liver transplant recipients with unstable graft function, decompensated liver disease or evidence of cirrhosis on biopsy VERY HIGH RISK Patients on clinical trials: drug trials often have specific requirements for patients to be fed or fasted when taking the experimental drug. These instructions must be fully adhered to, making fasting unsafe in this context. Patients requiring inpatient treatment for their cancer (or complications of it) cannot fast safely, and should be advised not to do so. Patients undergoing radical radiotherapy (especially for head and neck and upper GI malignancies) can experience serious side effects that severely limit oral intake with high risk of malnutrition; fasting would be unsafe. Patients receiving immunotherapy: immune mediated toxicities of treatment (including endocrine dysfunction) can be unpredictable and sudden in onset, making fasting potentially dangerous. VERY HIGH RISK Anorexia/bulimia nervosa with purging by vomiting; severe laxative abuse Severe substance dependence disorder where stopping regime may cause harm Medication dosing i nterval shorter than fasting hours, and necessary to prevent relapse/harm Poorly controlled SMI disorders (including clozapine use) Risk of electrolyte imbalance (e.g. lithium or metformin) or medication out of range HIGH RISK Poorly controlled lung disease with frequent exacerbations/hospital admissions Poorly controlled symptoms requiring frequent rescue inhaler and/or nebuliser use throughout the day Those receiving immunosuppressants for active lung disease Those receiving anti-fibrotic therapy HIGH RISK Poorly controlled hypertension (as defined by your specialist) Recent Acute Coronary Syndrome / myocardial infarction (<6 weeks) Hypertrophic Obstructive Cardiomyopathy (HOCM) with significant left ventricular outflow tract gradient (e.g. peak gradient ≥50mmHg) Severe valvular disease (defined by echocardiographic criteria) Severe heart failure without advanced features Poorly controlled arrhythmias (as defined by your specialist) High risk of fatal arrhythmias (e.g. inherited arrhythmic syndromes, arrhythmogenic cardiomyopathy) Implantable cardioverter defibrillator +/- cardiac resynchronisation therapy HIGH RISK CKD patients in stage 1-3 with unstable kidney function* CKD patients with known electrolyte abnormalities Patients at risk of dehydration due to fluid restriction requirements or need for diuretics Patients on ACE-I/ARB, SGLT2 inhibitors and mineralocorticoid receptor antagonists * unstable patients would include those with rapidly declining GFR, history of fluid overload and frailty. HIGH RISK Liver transplant patients taking Tacrolimus are at high risk of renal toxicity if they become dehydrated. They are also at risk of rejection if adherence to immunosuppression medication is not maintained due to fasting. Patients on prednisolone at doses > 20mg per day HIGH RISK Epilepsy requiring a medication regime incompatible with fasting which cannot be modified safely in time for Ramadan 2020 Myasthenia gravis on pyridostigmine 3 times daily or less Parkinson’s disease with low requirement for levo-dopa in younger patients HIGH RISK One or more of the following: T2DM with sustained poor glycaemic control* Well-controlled T1DM Well-controlled T2DM on MDI or mixed insulin Pregnant T2DM or GDM controlled by diet only or metformin CKD stage 3 Stable macrovascular complications Patients with comorbid conditions that present additional risk factors People with diabetes performing intense physical labour Treatment with drugs that may affect cognitive function Type 2 diabetes on SGLT-2 inhibitors (consider alternatives/stopping)** * The level of glycaemic control is to be agreed upon between doctor and patient according to a multitude of factors. Consider HbA1c >75mmol/mol for over 12 months ** risk upgraded in light of covid-19 pandemic HIGH RISK Recent diagnosis of steroid dependence within the last 12 months Pregnancy HIGH RISK Warm Auto-Immune Haemolytic Anaemia with active haemolysis Other Haemolytic Anaemias with active haemolysis Clotting disorders like the thrombophilias with history of thrombosis Aplastic anaemia on immunosuppression Thrombophilia with a history of thrombosis within the last three months and are on anticoagulation HIGH RISK Patients taking tacrolimus or ciclosporin where risk of kidney injury is increased by dehydration Patients newly commenced on induction chemotherapy for hematological malignancies such as myeloma, lymphoma, chronic leukemias or experiencing significant side effects Patients receiving oral chemotherapy or targeted therapy, that: require twice daily dosing must be taken with food are experiencing significant side effects Patients receiving a course of radiotherapy Patients who have undergone autologous or allogeneic transplantation within the last 6 months Patients receiving treatment for post-transplant complications such as GVHD. HIGH RISK Uncontrolled Gout Higher dose of steroids > 20mg/day* * Expert-recommended upgrading of risk due to COVID-19. Recommendations subject to review if relevant evidence suggests re-grading HIGH RISK BMI > 40kg/m2 with complicated metabolic syndrome and related complications e.g. those associated with high risk conditions (diabetes, hypertension, dyslipidemia, PCOS, hypothyroidism) HIGH RISK Uncomplicated pregnancy in an otherwise healthy woman in first trimester Pregnancy with moderately severe underlying maternal health conditions HIGH RISK Kidney transplant recipients with reduced kidney function (eGFR 30-60 ml/min) Heart, lung, liver, small bowel, pancreas and multi-organ transplant recipients with reduced graft function Patients at risk of dehydration due to fluid restriction requirements, need for diuretics or if they would be unable to meet their daily fluid intake requirement set by their transplant team HIGH RISK Patients receiving intravenous chemotherapy who have newly commenced their treatment regime, or are experiencing significant side effects Patients receiving oral chemotherapy or targeted therapy that require twice daily dosing or must be taken with food, or are experiencing significant side effects Patients receiving a course of radiotherapy (with or without chemotherapy) Patients immediately following cancer surgery HIGH RISK Stable bipolar/psychosis with medication regime compatible with fasting hours, >6m since relapse. Monitor during Ramadan LOW/MODERATE RISK Well controlled asthma/COPD requiring intermittent reliever inhaler use only Stable disease with infrequent exacerbations Those receiving immunosuppressants for stable disease (in remission) LOW/MODERATE RISK Stable hypertension Stable angina (episodes of angina are not occurring at rest or increasing significantly in frequency or severity) Mild heart failure with reduced ejection fraction (HFrEF) (Left Ventricular Ejection Fraction or LVEF ≥ 45%), Moderate HFrEF (LVEF 35 - 45%) or Heart Failure with preserved ejection fraction (HFpEF) (diagnosed by a combination of symptoms, LVEF ≥ 45-50%, Heart Failure Association score, natriuretic peptide levels +/- imaging - refer to specialist confirmation) Implantable loop recorder Permanent pacemaker (single or dual chamber) Mild/mild-moderate valvular disease (as defined by echocardiographic criteria) Supraventricular tachycardias/Atrial Fibrillation/Non sustained ventricular tachycardia Mild/moderate Pulmonary Hypertension (Pulmonary Artery Systolic Pressure >25mmHg without severe echocardiographic or right heart catheterisation features) LOW/MODERATE RISK CKD patients in stages 1-3 with stable kidney function CKD patients prone to urinary tract infections or stone formation LOW/MODERATE RISK Patients with Child A cirrhosis Patients with stable chronic liver disease without cirrhosis Patients with stable chronic inflammatory bowel disease in remission, including those on immunosuppressants Patients with peptic ulcer disease, reflux oesophagitis and irritable bowel syndrome LOW/MODERATE RISK History of cerebrovascular disease, dependent on level of disability History of MS, dependent on level of disability. See ABN guidance for management of immunosuppression during the COVID-19 pandemic Well controlled epilepsy with medication regime compatible with length of fast Myasthenia gravis not requiring pyridostigmine or purely ocular Migraine LOW/MODERATE RISK Well controlled type 2 diabetes (on one or more of the following therapies): Lifestyle therapy Metformin Acarbose Thiazolidinediones Second-generation SUs (moderate risk, regular SMBG advised) Incretin-based therapy (DPP-4 inhibitors or GLP-1 RAs) SGLT-2 inhibitors Basal Insulin (moderate risk, regular SMBG advised) LOW/MODERATE RISK Stable and well-controlled AI No significant comorbidities Treated mineralocorticoid deficiency (moderate risk) LOW/MODERATE RISK Thalassaemia carriers and sickle cell carriers who are not prone to crises Aplastic Anaemia not on active treatment White cell disorders with low count Inherited Bleeding disorders Immune Thrombocytopenias in remission Thrombophilia with history of thrombosis on Anticoagulation LOW/MODERATE RISK Patients receiving oral chemotherapy or targeted therapy, if: on a once daily dosing regime drug pharmacokinetics allow fasting well established (>3 cycles) on treatment not experiencing significant side effects Patients receiving outpatient parenteral chemotherapy beyond induction phase (except on drug administration days) if: well established on treatment no/few manageable side effects Patients on parenteral maintenance Immunotherapies with no/few manageable side effects e.g. Rituximab, Obinutuzumab Outpatients with haematological cancers who are not receiving any active treatment and are on active surveillance only e.g. MGUS, chronic leukemias, low grade lymphomas Patients with previously treated cancers who are currently in remission and on active surveillance LOW/MODERATE RISK Rheumatological conditions in remission e.g. rheumatoid arthritis, polymyalgia rheumatica, connective tissue diseases and vasculitis. Osteoarthritis Osteoporosis Sjogren's syndrome Well controlled gout LOW/MODERATE RISK BMI > 40kg/m2 with stable non-metabolic comorbidities (e.g. osteoarthritis, fibromyalgia) Simple obesity without any comorbidities LOW/MODERATE RISK Uncomplicated pregnancy in an otherwise healthy woman beyond first trimester Pregnancy with mild/well controlled underlying maternal health conditions LOW/MODERATE RISK Transplant patients not in the above categories. We would advise patients to discuss the suitability of fasting and monitoring necessary with their relevant transplant teams LOW/MODERATE RISK Patients receiving oral chemotherapy or targeted therapy, if: They are on a once-daily dosing regime The drug pharmacokinetics allow it to be taken whilst fasted They are well established on treatment They are not experiencing any side effects Patients receiving intravenous chemotherapy may be able to fast (except on drug administration days) if: They are well established on their treatment regime They have no/few manageable side effects Patients on intravenous biological therapies (eg trastuzumab, bevacizumab) who are not experiencing significant side effects may be able to fast on non-treatment days Patients on endocrine therapy or androgen deprivation therapies with no/few manageable side effects Patients on endocrine therapy or androgen deprivation therapies who are not experiencing significant side effects, may be able to fast Patients receiving palliative (single fraction) radiotherapy may be able to fast if their general fitness allows it Patients under cancer surveillance, who are more than 3 months beyond completion of cancer therapies (including surgery) and have recovered sufficiently, may be able to fast LOW/MODERATE RISK Mild mental health i llness not affecting functioning Well controlled mental illness (no relapses in previous 12m) with previous history of safe fasting Patients in High or Very High risk categories who still wish to fast Click to view If patients in these category wish to fast, is fasting shorter fasts in the winter a safe alternative? If not an option, or patients not willing to defer fasts and still wishing to fast, then they should be supported and should: Receive structured education (where appropriate) Be followed by an appropriate specialist/primary care contact whilst fasting Monitor their health regularly Adjust medication dose, frequency and timing as per recommendations Be prepared to break the fast/abstain from fasting in case of adverse events Patients with Grown-up Congenital Heart disease (GUCH) and/or Heart Transplant must consult their specialist for an individual risk assessment. For breastfeeding please refer to the MCB Ramadan Health Factsheet Issues relating to capacity are discussed in the General Principles section of the full review CKD, Chronic Kidney Disease; ACE-I, Angiotensin Converting Enzyme inhibitor; ARB, Angiotensin Receptor Blocker; eGFR, estimated Glomerular Filtration Rate; SGLT2, sodium-glucose Cotransporter-2 If patients wish to fast, they should be supported and should: Receive structured education Be followed by a qualified diabetes team Check their blood glucose regularly (SMBG) Adjust medication dose as per recommendations Be prepared to break the fast in case of hypo-or hyperglycaemia Be prepared to stop the fast in case of frequent hypo-or hyperglycaemia or worsening of other related medical conditions Abbreviations: CKD – chronic kidney disease; DKA – diabetic ketoacidosis; DPP-4 – dipeptidyl peptidase-4-; GDM – gestational diabetes mellitus; GLP-1 RA – glucagon-like peptide-1 receptor agonist; MDI – multiple dose insulin; SGLT-2 – sodium-glucose co-transporter 2; SMBG – self-monitoring of blood glucose; SU – sulfonylurea; T1DM – Type 1 diabetes mellitus; T2DM – Type 2 diabetes mellitus. Note: In all categories, people with diabetes should be advised to follow medical opinion due to probability of harm. The decision to fast is a personal decision for the person with diabetes, who should be supported by the healthcare professional (HCP) to achieve best possible outcomes. In all situations, patients should be aware that advancing age, frailty, obesity and comorbidity are associated with worse outcomes with COVID-19 illness. Consider upgrading risk based on clinical discretion and/or where multiple comorbidities exist. Also, discuss deferring fasts until shorter winter months for patients where medication regimes may not be suitably altered / severe dehydration risk. Continuing to fast with a COVID-19 illness may be detrimental to health and be of significant risk to life. This is not an exhaustive list and is to be used for informative and shared decision making by healthcare professionals with patients. It does not form a directive. In all categories, patients should be advised to follow medical opinion due to probability of harm. Where appropriate, expert individualised medical advice must be sought before any decisions around fasting in Ramadan are made. If a patient’s condition is not on this table and they have uncertainty or concerns about fasting, then they should seek medical advice before doing so. If this s not possible and they decide to fast, the advice given regarding terminating the fast should be followed. The decision to fast is a personal decision for the individual concerned, who should be supported to achieve the best possible outcomes. Consider upgrading risk if unable to seek timely medical attention and make necessary changes to the medication regime, arrange baseline blood tests, or other preparation that usually precedes fasting, due to the effect of COVID-19 on health services. Frailty is recognised by NICE as a predictor of worse outcomes with COVID-19. Use the Rockwood clinical frailty score (CFS) to assist with making assessments on risks of fasting in frail patients. Also, take caution with obesity (noting lower cut-off for S.Asian patients) risk in COVID-19. Ensure adequate hydration and nutrition; social distancing, isolation and shielding may be beneficial in this respect. In the context of the COVID-19 pandemic, episodes of illness should be taken seriously and strong consideration should be given to breaking the fast, as the onset of illness can be rapid. Recovery from COVID-19 may also be prolonged. Islamic jurists advise that any missed fasts should be made up in the future. However, if one’s health takes a permanent decline such that even fasting during the winter period becomes unsafe or impossible, the fidyah would have to be paid. Patients should speak to a trusted religious authority before doing so.