Table 7.

Summary of therapeutic titration for injectable therapies^{[28,34,44,52]}

Glucose-lowering therapy	Recommendation during Ramadan Fasting	Recommendation during COVID-19
GLP-1RA	•  No dose modification required	•  Dose reduction needed when poor oral intake, GI problems, dehydration, AKI, active COVID -19
	•  Low risk of hypoglycaemia
Insulin	•  High risk of hypoglycemia	•  Dose reduction may be needed, depending on blood sugar levels
	Basal insulin: Preferred initial formulation.
	OD dose: Reduce dose by 15- 30 % and take at iftar.	•  Check blood glucose regularly
	BD dose: Normal morning dose at Iftar	•  Check ketones in Type 1
	And half the evening dose at Suhoor.	Diabetes regularly
	Short, Rapid-acting insulin, Pre-mixed insulin:	•  Follow “sick day rules”
	OD dose- Take at iftar.
	BD dose- Normal morning dose at Iftar and reduce night dose by 25-50 % and take it at Suhoor.
	TID dose- Omit afternoon dose, adjust Iftar and Suhoor doses according to BG every 3 days
	Insulin Pump: Basal rate reduce dose by 20-40% in the last 3-4 hours of fasting and increase dose by 0-30% after Iftar. Bolus rate is based on carbohydrate counting and insulin sensitivity factor.

GI: Gastrointestinal, AKI: Acute kidney injury, OD: Once daily, BD: Twice daily, TID: Thrice daily, GLP-1RA : Glucagon-like-peptide-1 receptor agonist, BG: Blood glucose Adapted from: ADA 2020, IDF 2016, IGDR 2015, IDF-DAR Practical Guidelines, South Asian Consensus Guidelines.