Table 1 Recommended changes to treatment regimen in patients with diabetes who fast during Ramadan in the context of covid-19 pandemic

From: Diabetes management during Ramadan amid Covid-19 pandemic

Diabetes medicationsGeneral considerations in Ramadan in the context of COVID-19 pandemic
Metformin• Patients on metformin may safely fast because of the low risk of severe hypoglycemia
• In the context of Covid-19, dehydration can lead to lactic acidosis
• In fasting patients on metformin, the risk of chronic kidney disease or acute kidney injury is high in the context of Covid-19
• Patients should immediately stop fasting and discontinue metformin on appearance of any symptom attributable to Covid-1
Sodium-glucose-co-transporter 2 inhibitors (canagliflozin, dapagliflozin, and empagliflozin, …)• Due to the low risk of hypoglycemia, they are generally considered safe in Ramadan
• There is increased risk of dehydration and diabetic ketoacidosis in Covid-19 complications
• Patients should immediately stop taking them if any associated symptom develops
• There is an increased risk for acute kidney injury in Covid-19 infection
Glucagon-like peptide-1 receptor agonists (albiglutide, dulaglutide, exenatide-extended release, liraglutide,
lixisenatide, and semaglutide,…)
• They may be safely used during Ramadan
• Dehydration caused by Covid-19 may lead to serious complications
• They should be stopped and adequate hydration needs to be immediately followed should any related symptom develop
Dipeptidyl peptidase-4 inhibitors (alogliptin, linagliptin, saxagliptin, and sitagliptin…)• The risk for development of hypoglycemia and other complications is relatively low in fasting
• They can be safely used during Ramadan
• These drugs are generally considered safe in Covid-19 infection
Sulfonylureas• They are unsuitable for use during fasting because of the high risk of hypoglycemia.
Insulin• Insulin therapy should be continued during fasting and Covid-19 infection
• Dose of insulin should be guided by regular self-monitoring of blood glucose levels every 2–4 h
• If severe complications of Covid-19 unfold, higher doses of insulin may be needed to achieve normoglycemia