It is Eid today and understanding what it is and means is a good way of showing you respect cultural practices and beliefs, even if they differ from your own. Ethnic, cultural or diversity issues happen to be one of the SCA case types.
An example could be a Muslim diabetic wanting advice for Ramadan.
A common and important consultation in primary care could be about how do we advise a Muslim diabetic patient who is on metformin and empagliflozin on how to approach Ramadan. This tests clinical knowledge, cultural sensitivity, and shared decision-making all at once. Here's how I'd approach it. My suggestion would be as follows:
Before diving into drug advice, explore what Ramadan means to this individual. Ask about their usual fasting practice, whether they've fasted before since their diagnosis, how it went, and what their intention is this year. Some patients will have already decided to fast and want practical help; others may be unsure and want your guidance on whether it's safe. Respect that fasting during Ramadan is deeply important — your role is to help them do it as safely as possible, not to discourage it unless there's a genuine clinical reason.
A patient on metformin and empagliflozin alone (no insulin, no sulphonylurea) is generally in a lower-risk category for fasting. The key risks are dehydration (empagliflozin is an SGLT2 inhibitor with a diuretic effect), hypoglycaemia (low risk with this combination, but not zero), and hyperglycaemia if medications are adjusted incorrectly or eating patterns change dramatically. Check their most recent HbA1c, renal function, and blood pressure. If they have significant renal impairment, recurrent UTIs, or a history of diabetic ketoacidosis, the risk profile changes substantially.
For metformin, the adjustment is relatively straightforward. If they're on twice-daily dosing, they can take one dose at Suhoor (the pre-dawn meal) and one at Iftar (the meal at sunset). If on a once-daily modified-release preparation, take it at Iftar. Metformin carries very low hypoglycaemia risk on its own, so it's generally safe to continue.
For empagliflozin, this is where it needs more thought. The main concern is dehydration and the associated risk of volume depletion, postural hypotension, and in rare cases euglycaemic diabetic ketoacidosis. During Ramadan, patients are not drinking water for roughly 16–17 hours (in the UK in spring).
The practical options are:
a) to continue empagliflozin but take it at Iftar so the peak diuretic effect coincides with the period when they can drink freely,
b) to reduce the dose if they're on 25mg (step down to 10mg for the month), or
c) in some cases to consider temporarily stopping it for Ramadan and restarting afterwards, particularly if they have borderline renal function, are elderly, or live in a hot environment.
This is a shared decision — discuss the risks and let the patient choose.
Hydration is critical. Encourage them to drink plenty of water between Iftar and Suhoor, and to avoid very salty or sugary foods at Iftar that will worsen thirst the following day. Suhoor should not be skipped — it's the equivalent of a slow-release fuel load for the day, so complex carbohydrates, protein, and adequate fluid are important.
Blood glucose monitoring should be increased during Ramadan. Advise them to check their glucose at least once or twice daily, particularly in the first week as they adjust. Reassure them that checking blood glucose with a finger-prick does not invalidate the fast — this is the established scholarly consensus, though some patients may not be aware of it.
Be explicit about this. They should break the fast immediately if their blood glucose drops below 3.9 mmol/L (or below 4.0 depending on your local guidance), if they feel unwell with symptoms of hypoglycaemia or dehydration (dizziness, confusion, palpitations, significant fatigue), or if their blood glucose goes above 16.7 mmol/L.
Emphasise that Islam permits breaking the fast for health reasons and that preserving health is a religious obligation — most Islamic scholars support this. If the patient is uncertain, suggest they speak to their local imam or consult resources from the Muslim Council of Britain or the Diabetes and Ramadan International Alliance.
Ideally this conversation happens 6–8 weeks before Ramadan to allow time for any medication adjustments to settle. Arrange a review during or shortly after Ramadan to check how it went, review glucose readings, assess hydration and renal function, and restart or re-titrate any medications that were adjusted.
A good GP consultation is often a balance: you're clinically thorough but also culturally respectful, you're giving clear practical advice but also involving the patient in decisions, and you're acknowledging that fasting is important to them rather than treating it as an inconvenience or a risk to be managed away. Phrases like "I want to help you fast safely" land much better than "I'd advise against fasting."
Author
A. Khan
You may be entitled to free access through study budget because annual subscription is included in the Clinitalk course.
Approved areas include the West Midlands.
12 month subscription + 1 day course is only £295
