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

• 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