GLP-1 Receptor Agonists During Ramadan
GLP-1 receptor agonists (liraglutide, semaglutide) are safe and effective for Muslim patients with diabetes who fast during Ramadan and typically require no dose adjustment. 1
Risk Stratification and Patient Selection
Patients on GLP-1 agonists alone fall into the low-risk category for fasting complications during Ramadan. 1 This favorable risk profile stems from the glucose-dependent mechanism of action, which provides glycemic control with minimal hypoglycemia risk. 1, 2, 3
However, conduct pre-Ramadan assessment 6-8 weeks before Ramadan begins to evaluate: 1
- Glycemic control status and A1C levels
- Hydration capacity during non-fasting hours
- Presence of cardiovascular comorbidities
- Concurrent medications that may increase risk
Absolute contraindications to fasting (regardless of GLP-1 use) include: 1
- Type 1 diabetes (very high risk for severe hypoglycemia and DKA)
- History of severe hypoglycemia within 3 months
- Hypoglycemia unawareness
- Pregnancy or gestational diabetes
- Acute coronary syndrome or recent cardiac procedures
- Advanced heart failure or poorly controlled arrhythmias
Medication Management
GLP-1 Monotherapy
Continue GLP-1 receptor agonists at the same dose and timing with no adjustment needed. 1, 4 The pharmacokinetic profile of these agents—with their extended half-lives and glucose-dependent insulin secretion—makes them ideally suited for Ramadan fasting. 2, 3
Combination Therapy Adjustments
When GLP-1 agonists are combined with other agents, critical modifications are required:
Sulfonylureas: Reduce dose by at least 50% or discontinue entirely when combined with GLP-1 therapy. 1 This is non-negotiable—continuing full-dose sulfonylureas substantially increases severe hypoglycemia risk. 1 Among sulfonylureas, gliclazide is the relatively safer option if continuation is necessary. 3
Metformin: Adjust timing to two-thirds of total daily dose immediately before the sunset meal (Iftar) and one-third before the predawn meal (Suhur). 1 For example, if taking 1500 mg daily, give 1000 mg at Iftar and 500 mg at Suhur. 5
Insulin: If GLP-1 is combined with basal insulin, consider switching to long-acting analogs (glargine or detemir) with the usual morning dose given at Iftar and half the evening dose at Suhur. 5
Monitoring Protocol
Self-monitor blood glucose closely during the first 3-4 weeks of Ramadan, particularly: 1
- In the first few hours after starting the fast (highest hypoglycemia risk)
- Late afternoon before breaking fast (secondary risk period)
- Two hours after Iftar (to assess postprandial control)
Break the Fast Immediately If:
- Blood glucose drops below 70 mg/dL at any time 1
- Blood glucose is below 70 mg/dL in the first few hours after starting the fast, even if asymptomatic 5
- Blood glucose exceeds 300 mg/dL 5
- Any symptoms of hypoglycemia occur, regardless of glucose reading 5
The 70 mg/dL threshold is critical—do not wait to see if glucose stabilizes, as there is no guarantee against further decline. 5
Nutritional Strategy
Distribute calories over two to three smaller meals during the non-fasting interval rather than consuming one large meal at sunset. 1 This prevents excessive postprandial hyperglycemia that can occur when patients overindulge at Iftar. 5
Break the fast with a small, balanced meal containing: 1
- Fiber (vegetables, whole grains)
- Protein (lean meats, legumes)
- Complex carbohydrates (avoiding simple sugars)
Take the predawn meal (Suhur) as late as possible before the fast begins to minimize the duration of fasting. 5
Ensure adequate hydration by drinking at least 1.5-2 L of water during non-fasting hours. 6 Avoid caffeinated or sugary drinks that increase dehydration risk. 1
Physical Activity Modifications
Modify exercise intensity and timing to avoid hypoglycemia. 5 Schedule physical activity for 2 hours after the sunset meal rather than during fasting hours. 5 If performing Taraweeh prayers (multiple prayers after Iftar), consider this part of the daily exercise program. 5
Patients who perform intense physical labor during fasting hours should be counseled against fasting, as this substantially increases metabolic stress even with GLP-1 therapy. 5
Common Pitfalls to Avoid
Do not assume all diabetes medications are safe during Ramadan. 1 While GLP-1 agonists have an excellent safety profile, concurrent medications—particularly sulfonylureas—require dose reduction or discontinuation. 1
Do not continue full-dose sulfonylureas when combined with GLP-1 therapy, as this combination substantially increases severe hypoglycemia risk during prolonged fasting. 1
Do not advise patients to "do-it-yourself" medication adjustments. 7 Many patients admit to self-managing diabetes during Ramadan without medical guidance, largely due to under-appreciation of risks. 7 Pre-Ramadan structured education is essential. 8
Do not overlook dehydration risk. 1 While GLP-1 agonists themselves do not cause significant volume depletion (unlike SGLT2 inhibitors), inadequate fluid intake during non-fasting hours can increase thrombotic risk, particularly in elderly patients with hypertension and dyslipidemia. 5
Evidence Quality Considerations
The 2025 American Diabetes Association recommendations 1 represent the most current guidance and specifically address GLP-1 use during Ramadan—a significant advancement over the 2005 guidelines 5 which predate widespread GLP-1 availability. Recent systematic reviews 2, 3 and narrative reviews 7, 8 consistently demonstrate lower hypoglycemia rates with GLP-1 agonists compared to sulfonylureas during Ramadan fasting, supporting their preferential use in this population.