Fasting Recommendations for Patients With

Insulin-Dependent Diabetes
Andrea G. Scott, PharmD, MPH
|February 15, 2017
Question
Can patients with insulin-dependent diabetes safely fast for medical or religious
reasons?

Response from Andrea G. Scott, PharmD, MPH 

Pharmacist, StoneSprings Hospital Center, Dulles, Virginia

Fasting is a challenge for all patients but can be particularly difficult for patients
with insulin-dependent diabetes. Patients may have to fast for laboratory tests,
surgery, diagnostic procedures (eg, colonoscopy), or religious reasons.

The duration of the fast is also important because it can affect how much insulin
a patient will need during that time.

Patients with insulin-dependent diabetes need to understand the management of

diabetes during fasting to prevent hypoglycemia (blood glucose < 70 mg/mL or
3.9 mmol/L).

Not eating for an extended period of time leads to decreased blood glucose in all
patients. In patients without diabetes, insulin levels decrease as glucagon
increases, and the act of glycogenolysis provides about 75% of glucose
requirements.[1] This mechanism allows blood glucose levels to remain within a
normal range. In patients with insulin-dependent diabetes, the glucagon
response is lost, and epinephrine becomes the main method to increase
gluconeogenesis in the liver. However, the epinephrine response also diminishes
over time; thus, patients with insulin-dependent diabetes are at risk for
hypoglycemia.[2] Symptoms of hypoglycemia include sweating, shaking, mood
changes, hunger, headache, tachycardia, and, in severe cases,
unconsciousness, seizures, and coma.[2] Healthcare professionals should discuss
the symptoms of hypoglycemia with patients who are planning to fast.

The duration of the fast and the type of insulin used can help guide insulin
treatment during the fasting period.

Some minor adjustments to insulin may be required if patients are fasting for
laboratory tests or surgery (eg, 8-12 hours). Short-acting insulin before meals
should be stopped until the patient has a meal. The basal insulin dose may need
to be reduced by one half or one third, particularly for morning dosage regimens.
Patients should be advised to eat a meal or snack and to resume their normal
insulin regimen following the laboratory tests or procedure.

If possible, laboratory tests, surgery, or diagnostic procedures should be

scheduled for the early morning because fasting until later in the day will cause
greater glucose level disruption.[3]

Colonoscopies require more planning for patients with insulin-dependent

diabetes because the fast includes specific dietary orders and bowel cleansing.
Colonoscopies should also be scheduled for early in the day to cause the least
disruption to blood glucose levels. On the day before the procedure, patients are
asked to follow a clear liquid diet. Blood glucose should be checked throughout
the day to monitor for hypoglycemia and hyperglycemia. Adequate hydration on
the preoperative day is important for cleansing the bowel and preventing
dehydration, which can lead to hyperglycemia and possibly ketoacidosis. On the
day of the colonoscopy, patients using intermediate- or long-acting insulin should
be advised to take one third to one half of their insulin dose. Mealtime insulin
should not be used until the patient eats. Fast-acting insulin can be used to
correct hyperglycemia.[4,5]

Fasting holidays present a unique challenge. Both Judaism and Islam exempt
people with medical conditions that contraindicate fasting. Patients with poorly
controlled diabetes or patients who are pregnant should be advised against
fasting. Blood glucose monitoring is absolutely essential when fasting; if
hypoglycemia develops, the fast should be broken and the low blood sugar
corrected.

Suggested adjustment to insulin regimens based on the duration of the fast is

outlined in the Table below.[3,6,7]

Table. Recommendations for Insulin Regimens During Fasting [3,6,7]

Duration of Fasting Type of Insulin Used Recommendation

Sunrise to sundown Long- or intermediate- Reduce evening dose
acting (glargine, by
detemir, 20%
regular) Reduce morning dose
by
one third to one half
Short-acting (lispro, Use with evening meal
aspart, glulisine ) prior to fast
Use to correct glucose
>250 mg/mL on fasting
day
 Sundown to sundown Long- or intermediate- Reduce evening dose
acting (glargine, by
detemir, one third to one half
regular) Reduce morning dose
by
one third to one half
Short-acting (lispro, Use with evening meal
aspart, glulisine) prior to fast
Use to correct glucose
>250 mg/mL on fasting
day
Prolonged fasting Long- or intermediate- Reduce dose by 15%-
sunrise to sundown acting (glargine, 30%; take at predawn
(eg, detemir, meal
Ramadan) NPH)
Twice-daily long- or Usual dose at predawn
intermediate-acting meal; reduce evening
(glargine, detemir, NPH) dose by 50%
Short-acting (lispro, Reduce evening dose
aspart, glulisine) by
50%; normal dose at
predawn meal
Use to correct glucose
>250 mg/mL on fasting
day
For patients who use insulin pumps, basal rates should be reduced to prevent
hypoglycemia; other aspects of the insulin regimen, such as correction boluses,
should remain the same. During a prolonged fast, such as Ramadan, a typical
adjustment includes reduction of the basal rate by 20%-40% in the last 3-4 hours
of fasting and then increasing the basal rate by 0%-30% after the sunset meal. [7]

In conclusion, patients with insulin-dependent diabetes can fast safely and

control blood glucose. Healthcare professionals should evaluate patients who are
planning to fast and ensure that they understand the importance of glucose
monitoring throughout the fast and how to prevent hypoglycemia.

References
1. Kerndt PR, Naughton JL, Driscoll CE, et al: Fasting: the history,
pathophysiology and complications (Medical Progress). West J Med.
1982;137:379-399.
2. Briscoe VJ, Davis SN. Hypoglycemia in type 1 and type 2 diabetes:
physiology, pathophysiology, and management. Clin Diabetes. 2006;
24:115-121.

3. Grajower MM. 24-hour fasting with diabetes: management of religious

observances and of the preoperative patient. Diabetes Metab Res Rev.
2011. Epub ahead of print. doi: 10.1002/dmrr.1169.

4. Southwest Gastroenterology Associates. Diabetic Medication Instructions

for Colonoscopy Preparation and Procedure.
2015. http://southwestgi.com/wp-content/uploads/2015/06/DiabeticMedicat
ionInstructionsforColonoscopyPrep.pdf Accessed December 11, 2016.

5. Concord Hospital. Diabetes medication instructions for colonoscopy

preparation and procedure. May 2015. Accessed December 11, 2016.

6. Grajower MM. Management of diabetes mellitus on Yom Kippur and other

Jewish fast days. Endocr Pract 2008;14:305-311.

7. International Diabetes Federation and Diabetes and Ramadan

International Alliance. Diabetes and Ramadan: Practical Guidelines. April
2016. http://www.daralliance.org/daralliance/wp-content/uploads/IDF-
DAR-Practical-Guidelines_15-April-2016_low.pdf Accessed December 11,
2016.