What considerations should be taken for a Muslim patient with type 2 diabetes who is observing Ramadan and is prescribed Sema-O (semaglutide)?

Management of Oral Semaglutide (Sema-O) During Ramadan

Oral semaglutide should be continued during Ramadan at the same dose and timing with no adjustment needed, as GLP-1 receptor agonists carry minimal hypoglycemia risk and provide excellent glucose control during fasting periods. 1

Pre-Ramadan Assessment (6-8 Weeks Before)

Conduct a comprehensive risk stratification visit that includes: 1, 2

• Glycemic control evaluation (A1C, fasting glucose) 1
• Renal function testing to ensure medication safety 1
• Hepatic status assessment 1
• Complete biochemical profile 1

Patients on semaglutide monotherapy fall into the low-risk category for fasting complications, making them ideal candidates for safe Ramadan observance. 1

Semaglutide Dosing Strategy During Ramadan

The dose and timing of oral semaglutide remain completely unchanged during Ramadan, whether the patient takes 3 mg, 7 mg, or 14 mg daily. 1 This applies because:

• The glucose-dependent mechanism of GLP-1 receptor agonists minimizes hypoglycemia risk even during prolonged fasting 1
• GLP-1 agonists enhance insulin sensitivity and suppress hepatic glucose output without forcing insulin secretion when glucose levels are normal or low 1
• Do not reduce the semaglutide dose based on concern about hypoglycemia, as this could worsen glycemic control 1

Managing Combination Therapy

If Combined with Metformin:

• Adjust metformin timing to two-thirds of the total daily dose immediately before the sunset meal (Iftar) and one-third before the predawn meal (Suhur) 3, 1, 2

If Combined with Sulfonylureas:

• Reduce sulfonylurea dose by at least 50% or discontinue entirely to minimize hypoglycemia risk 1, 2
• Chlorpropamide is absolutely contraindicated during Ramadan due to high risk of prolonged, unpredictable hypoglycemia 3, 1
• Newer sulfonylureas (gliclazide MR or glimepiride) are safer options if continuation is necessary 3

Glucose Monitoring Protocol

Self-monitor blood glucose closely during the first 3-4 weeks of Ramadan, particularly during high-risk periods: 1, 2

• Check glucose in the first few hours after starting the fast each day 1
• Check again in the late afternoon before breaking fast 1
• Break the fast immediately if blood glucose drops below 70 mg/dL 2
• Break the fast if symptoms of dehydration or acute illness occur 1

Hydration and Nutritional Strategy

Maintain adequate hydration by drinking at least 1.5-2 L of water during non-fasting hours (between sunset and predawn). 1, 2

Distribute calories over two to three smaller meals during the non-fasting interval rather than one large meal at sunset to prevent postprandial hyperglycemia and maintain stable glucose levels. 1, 2

Break the fast with a small, balanced meal containing fiber, protein, and complex carbohydrates. 2

Critical Safety Considerations

Volume depletion remains a concern even with semaglutide, so adequate hydration during non-fasting periods is essential. 2 The GLP-1 mechanism makes semaglutide well-suited for Ramadan fasting because it does not force insulin secretion when glucose levels are already normal or low. 1

Common Pitfalls to Avoid

• Do not skip the pre-Ramadan assessment, as identifying patients on high-risk combination therapy is essential for preventing complications 1
• Do not allow patients to continue full-dose sulfonylureas when combined with semaglutide during Ramadan, as this combination creates unacceptable hypoglycemia risk 1
• Do not assume all oral antidiabetic agents require the same management approach—semaglutide's unique mechanism distinguishes it from sulfonylureas and insulin secretagogues 3, 4