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other-diabetes-topics

Real-world evidence of treatment intensification in people with T2D inadequately controlled on GLP-1 RAs

Insights from Prof. Timothy Baily on new Real-world evidence in deliver G study and the implications of adding Toujeo®&nbsp;to people with T2D inadequately controlled on GLP-RAs.

OTHER-DIABETES-TOPICS

DIABETES

<h2>Insulin dose adjustments for Type 1 Diabetes</h2>

<table border="1" cellpadding="1" cellspacing="1" style="width:100%;">
 <tbody>
 <tr>
 <td>Premixed (analogue or conventional)&nbsp;&nbsp; &nbsp;</td>
 <td>
 <ul>
 <li>Move usual morning dose to Iftar</li>
 <li>Take 50% of pre-Ramadan evening dose at Suhoor</li>
 </ul></td>
 </tr>
 <tr>
 <td>CSII/Insulin pump</td>
 <td>
 Basal rate adjustment
 <ul>
 <li>Decrease 20–40% for last 3–4 hours of fast</li>
 <li>Increase 10–30% for first few hours after iftar</li>
 </ul>
 Bolus doses
 <ul>
 <li>Apply same principles as before Ramadan</li>
 </ul></td>
 </tr>
 <tr>
 <td>MDI (basal bolus) with conventional insulin</td>
 <td>
 NPH insulin
 <ul>
 <li>Take usual morning dose in the evening during Ramadan</li>
 <li>Take 50% of pre-Ramadan dose at Suhoor</li>
 </ul>
 Regular insulin
 <ul>
 <li>Evening meal dose remains unchanged - Take 50% of pre-Ramadan evening dose at Suhoor</li>
 <li>Skip afternoon dose</li>
 </ul></td>
 </tr>
 <tr>
 <td>MDI (basal bolus) with analogue insulin</td>
 <td>
 Basal insulin
 <ul>
 <li>Reduce dose by 30–40%</li>
 <li>Take at Iftar</li>
 </ul>
 Rapid analogue insulin
 <ul>
 <li>Reduce Suhoor dose by 30–50%</li>
 <li>Skip pre-lunch dose</li>
 <li>Adjust Iftar dose based on 2-hour post-Iftar glucose reading</li>
 </ul></td>
 </tr>
 </tbody>
</table>
CSII, continuous subcutaneous insulin infusion; MDI, multiple-dose injections; NPH, natural protamine Hagedorn Diabetes and Ramadan:&nbsp;Practical Guidelines International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance. January 2021. Available at: <a href="http://www.idf.org/news/idf-dar-diabetes-in-ramadan%20guidelines" target="_blank">www.idf.org/news/idf-dar-diabetes-in-ramadan guidelines</a>

<h2>Insulin dose adjustments for Type 2 Diabetes</h2>

<table border="1" cellpadding="1" cellspacing="1" style="width:100%;">
 <tbody>
 <tr>
 <td>Long/intermediate-acting (basal) insulin</td>
 <td>
 NPH/detemir/glargine/glargine 300/ degludec, once daily
 <ul>
 <li>Reduce dose by 15–30%</li>
 <li>Take at Iftar</li>
 </ul>
 NPH/detemir/glargine, twice daily
 <ul>
 <li>Take usual morning dose at Iftar</li>
 <li>Take 50% of evening dose at Suhoor</li>
 </ul></td>
 </tr>
 <tr>
 <td>Short-acting insulin</td>
 <td>
 <ul>
 <li>Normal dose at Iftar</li>
 <li>No lunch-time dose</li>
 <li>Reduce Suhoor dose by 25–50%</li>
 </ul></td>
 </tr>
 <tr>
 <td>Premixed insulin dosing</td>
 <td>
 Once daily
 <ul>
 <li>Normal dose at Iftar</li>
 </ul>
 Twice daily
 <ul>
 <li>Take normal dose at Iftar</li>
 <li>Reduce Suhoor dose by 20–50%</li>
 </ul>
 Three times daily
 <ul>
 <li>No afternoon dose</li>
 <li>Adjust Iftar and Suhoor doses</li>
 <li>Dose-titration every 3 days</li>
 </ul></td>
 </tr>
 <tr>
 <td>Insulin pump dosing</td>
 <td>
 Basal rate
 <ul>
 <li>Reduce dose by 20–40% in last 3–4 hours of fasting</li>
 <li>Increase dose by up to 20% early after Iftar</li>
 </ul>
 Bolus rate
 <ul>
 <li>Normal carbohydrate counting and insulin sensitivity principles apply</li>
 </ul></td>
 </tr>
 </tbody>
</table>
For unit-specific titration recommendations as determined by individual blood glucose readings, see Chapter 10 of the IDF-DAR guidelines. 
 degludec, insulin degludec; detemir, insulin detemir; glargine, insulin glargine; NPH, neutral protamine Hagedorn&nbsp; Diabetes and Ramadan:&nbsp;Practical Guidelines International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance. January 2021. Available at: <a href="http://www.idf.org/news/idf-dar-diabetes-in-ramadan%20guidelines" target="_blank">www.idf.org/news/idf-dar-diabetes-in-ramadan guidelines</a>

<h2>Oral Anti-Diabetic drugs (OADs) recommended dose adjustments</h2>

<table border="1" cellpadding="1" cellspacing="1" style="width:100%;">
 <tbody>
 <tr>
 <td style="background-color: rgb(244, 242, 246);">
 Metformin</td>
 <td style="background-color: rgb(244, 242, 246);">
 Sulphonylureas</td>
 <td style="background-color: rgb(244, 242, 246);">
 Arcarbose</td>
 </tr>
 <tr>
 <td colspan="1" rowspan="4">
 Once daily
 <ul>
 <li>No adjustment usually required</li>
 <li>Take at Iftar</li>
 </ul>
 Twice daily
 <ul>
 <li>No adjustment usually required</li>
 <li>Take at Iftar</li>
 </ul>
 Three times daily
 <ul>
 <li>Take morning dose before Suhoor</li>
 <li>Combine afternoon dose with Iftar dose</li>
 </ul>
 Prolonged-release
 <ul>
 <li>No adjustment usually required</li>
 <li>Take at Iftar</li>
 </ul></td>
 <td colspan="1" rowspan="4">
 Once daily
 <ul>
 <li>Reduce dose for those well-controlled blood glucose</li>
 <li>Take at Iftar</li>
 </ul>
 Twice daily
 <ul>
 <li>No adjustment at Iftar</li>
 <li>Reduce Suhoor dose for those with well-controlled blood glucose</li>
 </ul>
 Older drugs e.g. glibenclamide
 <ul>
 <li>Should be avoided</li>
 </ul>
 Second generation sulphonylureas e.g. glicazide, glimepiride
 <ul>
 <li>Should be used in preference</li>
 </ul></td>
 <td>
 <ul>
 <li>No adjustment required</li>
 <li>Take at Iftar</li>
 </ul></td>
 </tr>
 <tr>
 <td>
 Thiazolidinediones
 <ul>
 <li>No adjustment</li>
 <li>Take with Iftar rather than Suhoor</li>
 </ul></td>
 </tr>
 <tr>
 <td>
 Short-acting insulin secretagogue 
 Three-meal dosing may be reduced/ redistributed to two doses</td>
 </tr>
 <tr>
 <td>
 SGLT-2 inhibitors
 <ul>
 <li>No adjustment</li>
 <li>Taken with Iftar</li>
 </ul></td>
 </tr>
 </tbody>
</table>

<table border="1" cellpadding="1" cellspacing="1" style="width:100%;">
 <tbody>
 <tr>
 <td colspan="2" style="background-color: rgb(244, 242, 246);">
 Incretin-based therapies</td>
 </tr>
 <tr>
 <td>
 DPP-4 inhibitors</td>
 <td>
 GLP-1 RAs</td>
 </tr>
 <tr>
 <td>
 No adjustment required</td>
 <td>
 No adjustment if appropiate dose titration prior to Ramadan (&gt;2–4 weeks before) has occured</td>
 </tr>
 </tbody>
</table>
Adapted from IDF-DAR Guidelines (2021)
For patients on multiple types of medication, please see Chapter 10 of the IDF-DAR guidelines
DPP-4, dipeptidyl peptidase-4; GLP-1 RAs, glucagon-like peptide-1 receptor agonists; SGLT-2, sodium-glucose co-transporter-2

Other Diabetes Topics

Latest Articles

Real-world evidence of treatment intensification in people with T2D inadequately controlled on GLP-1 RAs

Latest Resources

Insulin and Other Medications Dose Adjustments for Type 1 and 2 Diabetes in Ramadan