Cases/People with Long-term Conditions Including Cancer

Type 2 Diabetes Planning to Fast During Ramadan — Free SCA Practice Case

Man with type 2 diabetes planning to fast during Ramadan

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12:00

Golden Minute

Initial Introduction

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•Ask an open question — "How can I help you today?"

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•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Kamran Hashmi

Age

58 years

Consultation Type

Video

Age

Situation

Video Consultation. Routine appointment booked by the patient.

Reason for Encounter

"I want to ask about my diabetes tablets. There is something I would like to do this year."

Medical Records

●PMH: Type 2 diabetes for 6 years. Hypertension. Last review 3 months ago: HbA1c 62 mmol/mol, eGFR 78, urine ACR normal, BP 132/80, BMI 31.
●Medications: Metformin 1 g twice daily. Dapagliflozin 10 mg once daily (started 5 months ago). Ramipril 5 mg daily. Atorvastatin 20 mg at night.
●Allergies: NKDA.
●Social: Works on a building site. Non smoker.

Patient Script

For the friend playing the patient role

Character Overview: You are Kamran Hashmi, a 58 year old steel fixer for a construction contractor. You carry, cut and tie steel reinforcement bars and mesh on a large building site, ten hour days, mostly outdoors, and for part of most days you work up on a mobile platform fixing steel at height. You live with your wife Shabana, who works as a hospital ward housekeeper, and your son Zaid, 24, who is a trainee electrician. You have type 2 diabetes and you are a practising Muslim. Ramadan starts in about six weeks and you want to fast. You fasted fully last year, before your diabetes tablets were changed, and you have never discussed fasting with a doctor or nurse. You are polite, proud and a little guarded. You expect to be told you cannot fast and you have rehearsed your answer. You warm up quickly if the doctor takes your faith seriously and treats you as a man who can make his own decision. You go quiet and formal if you feel lectured or dismissed.

Opening Sentence: "Morning, doctor. I wanted to ask about my diabetes tablets. Ramadan starts in about six weeks and I would like to fast this year, and I wanted to know what I should do with the tablets. I've not asked anyone before."

History if Asked (Data Gathering Phase)

●The plan: "I want to fast every day, the whole month. From before dawn until sunset, around fifteen hours. It is important to me and to my family. We all fast together and break the fast at home."
●Last year: "I fasted about twenty five days. I was only on metformin then. I took one with the meal before dawn and one when we broke the fast. Mostly I was fine, but in the last week I felt washed out and dizzy at work, and one afternoon I had to sit down. I didn't tell anyone. I kept going."
●Medicines now: "Metformin one gram twice a day, with breakfast and with my evening meal. The dapagliflozin is one tablet every morning, I take it with the metformin. The doctor started it five months ago because my sugar was too high. Also ramipril in the morning and atorvastatin at night."
●Low sugars: "Never. No shaky spells, no sweats, nothing like that. I've never needed anybody to help me."
●High sugars, thirst and passing water: "Since the new tablet I pass a lot more water. Maybe six or seven times in the day at work. I'm thirsty by the afternoon but I put it down to the job. I had thrush once, three months ago, and it cleared with a cream."
●Being ill: "I have never been in hospital with my sugar. I have never been told I had ketones or acid in my blood. No vomiting or tummy trouble lately."
●Checking sugar: "I haven't got a meter. They didn't give me one because I'm not on insulin. I don't test ketones, and I don't know what that is."
●Complications: "Eyes and feet checked and fine. No chest pain, no breathlessness. My kidney test was fine, they told me."
●Other tablets: "Nothing else. No painkillers, nothing from the shop, no herbal medicines."
●Alcohol and smoking: "I don't drink and I've never smoked."

Ideas, Concerns, Expectations

Gating note: Kamran does not raise any of the following himself. Each part comes out only when the doctor asks what fasting means to him, what he thinks about fasting with his diabetes, what worries him, or what he was hoping for from the appointment.

●Ideas: He knows that people who are ill can be excused from fasting and that his imam has said so. He wants to try anyway, because he feels well and feels a month of fasting is a spiritual reset. He thinks his tablets are "mild" and cannot cause a low sugar. His friend Farooq, who also has diabetes, fasts every year without trouble. "My imam says the sick are excused, but I'm not sick. I feel well. I want to fast like everybody else in my house."
●Concerns: He is afraid the doctor will tell him he must not fast and make him feel he is being irresponsible or an excuse maker. He is privately worried by how weak he felt last year and by passing so much water at work. His wife is anxious and has asked him to find out what is safe. "I don't want to be lectured. Shabana is worried and I told her I'd ask. I felt rough last year, to be honest, but I don't know what to do about it."
●Expectations: He wants to be told which tablets to take at which time and how to keep going safely. He expects a flat no and would welcome help. "I just want to know when to take the tablets so I can get through the month."

If Asked: Daily Routine During Fasting and Diet

Gating note: Kamran answers each of these plainly when the doctor asks about it.

●The meal before dawn: "Last year it was dates, tea and a bit of bread, because I was half asleep. Shabana says I should eat properly."
●Breaking the fast: "Dates and water, then a big meal. Rice, curry, samosas and pakoras. Lots of sweet tea, and the sweet drinks at the mosque."
●Drinking: "I don't drink anything on site while fasting. Last year I drank a lot at night, probably two litres."
●Weight: "About 95 kilos. I know I should lose weight."

If Asked: Work

Gating note: Kamran answers these when the doctor asks about work or what could change.

●The job: Lifts and carries bars and mesh up to 25 kilograms, bending and tying steel, outdoors in most weather. He starts at 7 in the morning and finishes at 5 in the afternoon. There is a short midday break and he usually sits in the cabin.
●Working at height: If asked whether any of his work is at height, or where he was when he felt dizzy last year: for two to three hours of most days he is up on a mobile platform, about five metres off the ground, fixing mesh and tying steel with a guard rail round him. Last year's dizzy spell happened there, one afternoon in the last week of fasting. He gripped the rail until it passed, brought the platform down slowly and sat in the cabin. Nobody saw and he told no one. "I went light headed up on the platform. I held the rail till it passed. It frightened me a bit, to be honest." He has not thought of it as a fall risk until the doctor puts it to him.
●Telling work: His supervisor, Craig, and the other lads do not know he fasts, because "they'd make a fuss". He has never asked for lighter work. He could ask for prefabricating steel on the ground in the yard, instead of the platform, on fasting days, but has not wanted to look weak.
●Fit note: He does not want one. He is willing to talk to Craig if it is put to him as practical safety, not weakness.

If Asked: Associated Symptoms and History

Gating note: Kamran answers these only when asked. Every one is negative unless stated.

●If asked about nausea, vomiting, tummy pain, fast breathing, or a sweet or fruity smell on the breath: "No."
●If asked about dizziness when standing, dark urine, headaches, or cramps: "Dizzy and cramps in the last week of fasting last year. Not now. My urine is pale."
●If asked about diarrhoea, fever, chest infections or weight loss: "No."
●If asked about family history: "My father had diabetes and fasted for years. He died of a heart attack at 66."
●If asked about mood and sleep: "Fine."

If Asked: Home and Support

●Home and faith: Shabana cooks and will cook whatever the doctor suggests. Zaid fasts too. He is willing to talk to his imam, but trusts the doctor on the medicines.
●Appointments: He can come after 5, or take a phone call.

Responses to Management (The Negotiation Phase)

●
If the doctor says that fasting is not recommended, or that he should not fast:
- ●Reaction: Formal and flat. "I thought you'd say that. I've fasted for forty years." If the doctor then respects his choice and says it is his decision, and offers to help him do it as safely as possible, he softens: "Thank you. That is what I wanted. What do I do?" If the doctor does not move off the refusal: "Then I will do it anyway, doctor, and without advice."
●
If the doctor explains the tablets, their timing and why they matter:
- ●Reaction: Interested and practical. He asks which tablet goes with which meal. "So metformin with both meals, the same as last year? And the other one at night instead of the morning? Why?" If the doctor explains that the tablet makes him pass more water and can cause an acid problem in the blood, he is surprised: "That's why I've been passing so much." If it is suggested that he stops the dapagliflozin for the month, he asks: "Will my sugar go up?" and accepts a reasoned answer either way.
●
If the doctor raises dehydration, working at height and asking for ground level work:
- ●Reaction: Thoughtful. "I can't drink on site, I'm fasting." If told to drink plenty between sunset and dawn: "I can do that." If told that fasting and the tablet can leave him dizzy or faint, and that this is a danger up on the platform, he goes quiet and, if he has not yet mentioned it, admits where last year's dizzy spell happened: "That's what happened last year. I never thought of it as a fall risk." He asks "How would I know when I'm too dizzy to go up?" and accepts a clear rule, such as not going up if light headed and coming down at once if it starts. If told to tell Craig and ask for ground level work on fasting days: "I'd have to tell him I'm fasting." He agrees if it is framed as safety.
●
If the doctor explains when to break the fast and what to watch for:
- ●Reaction: Worried about religion. "Am I allowed to break it?" He says his imam has told him that a sick person breaking the fast is not a sin. He repeats back the warning signs when given specific ones. "Feeling sick, tummy pain, fast breathing, very dizzy, very thirsty or passing hardly any water. I break the fast and ring the surgery or 111." If given only vague advice, he asks: "How would I know?"
●
If the doctor offers monitoring, such as a glucose meter or tests:
- ●Reaction: Open. "Does checking my sugar break the fast?" He is relieved to be told that he can check, and says he will ask his imam. He asks how often to check and what number is too low or too high, and he asks about ketone strips if they are mentioned.
●
If the doctor offers follow up before and during Ramadan:
- ●Reaction: Agrees. "Yes, I can come after 5. Can Shabana come too, she'll want to hear it?" If asked to ring or be rung after the first week or two: "Yes, that's fine." If the doctor mentions sick day rules for the ramipril and metformin: "Nobody has told me about that before."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Kamran is a 58 year old steel fixer with type 2 diabetes, an HbA1c of 62 mmol/mol (about 7.8%), normal kidney function and no complications, who spends part of most working days at height on a mobile platform. He takes metformin, dapagliflozin, ramipril and atorvastatin and wants to fast for the whole of Ramadan, which starts in about six weeks. He has never asked a clinician before. The station tests whether the candidate can support a religious decision safely, rather than refusing it or waving it through.
●The model plan has seven parts. Take a history of last year's fast, his current routine, his work, including any work at height, and what fasting means to him. Treat his risk as real but manageable and treat the decision as his. Move metformin to the two meals either side of the fast. Make an explicit, reasoned decision about dapagliflozin. Prevent dehydration and falls at height. Give sick day rules, ketoacidosis warnings and clear criteria for breaking the fast. Arrange monitoring and review before, during and after the month.
●Acceptable alternatives: taking dapagliflozin with the sunset meal, pausing it on heavy work days, or pausing it for the month are all reasonable if the reason is given. A candidate who advises that not fasting is the safest option, but respects his choice and still gives the full safety plan, also earns the clinical rows. Offering a glucose meter, or a pre Ramadan nurse review in place of a doctor, are both fine. A flat refusal with no plan, or approval with no risk assessment, is not.

Fasting Guidance and Risk Assessment

●NICE Clinical Knowledge Summaries (CKS, Insulin therapy in type 2 diabetes, revised June 2026) say that fasting is generally not recommended in type 2 diabetes, especially with poor control, comorbidities or complications, and that prolonged fasting can cause hyperglycaemia, ketoacidosis, hypoglycaemia and dehydration. It also tells clinicians to advise pre fasting education when a person plans to fast, and to adjust therapy. The CKS Diabetes type 2 topic (revised July 2026) refers to this page for fasting advice.
●The Diabetes and Ramadan International Alliance (IDF-DAR) practical guidelines (2021) use a scored risk tool in which highly intense physical labour carries a heavy weighting alongside HbA1c, treatment and previous Ramadan experience. Highly intense labour scores 4 and an HbA1c of 7.5 to 9% scores 1, so Kamran scores at least 5. Counting his dizzy final week as a negative previous experience (1) and his lack of a glucose meter as monitoring indicated but not conducted (2) would take him above 6, the high risk threshold. The authors state that the tool rests on expert opinion (Grade D), and that people who insist on fasting must follow the relevant guidance whatever their category. No mark depends on the exact score or category.
●The point is that risk is individual and driven here by his job, not his glucose. His imam has said that people who are ill are excused. The candidate should acknowledge both routes, and leave the decision to Kamran, who can discuss it with his imam.

Tablet Timing

●Metformin does not cause hypoglycaemia on its own. The usual approach is to keep the same daily amount but give it with the sunset meal and the meal before dawn. He already takes it twice a day, so the change is the timing, not the amount. It should be taken with food to limit gastrointestinal effects.
●Dapagliflozin lowers glucose by making the kidneys pass glucose and water, so it can worsen dehydration. This matters more for someone who does heavy labour, works at height and cannot drink for fifteen hours. Taking it with the sunset meal, not before dawn, is the usual suggestion. For a man with this much physical work, pausing it on hard days or for the month is also reasonable, and glucose may rise a little. Either route is fine if explained. The IDF-DAR 2021 guidelines recommend taking SGLT2 inhibitors with the sunset meal, with extra fluids in the non fasting hours and no dose change, and starting them at least two weeks to a month before Ramadan, which Kamran has met. The dapagliflozin summary of product characteristics (SmPC) recommends temporary interruption for anyone who develops volume depletion, which supports pausing it. No mark depends on it.
●Ramipril can be taken with the meal before dawn. It matters mainly as a sick day rule drug because dehydration with an ACE inhibitor risks acute kidney injury. Atorvastatin at night is unchanged.

Ketoacidosis with Normal Glucose

●The MHRA Drug Safety Update (April 2016) and BNF warn of rare, serious ketoacidosis with SGLT2 inhibitors, including when glucose is only slightly raised. Risk factors named include restricted food intake and severe dehydration, which are exactly what fasting in a heavy job produces. Signs are nausea, vomiting, abdominal pain, fast breathing, marked tiredness or confusion, a sweet or metallic taste, or a different odour to urine or sweat. People should seek immediate medical advice, and treatment should be stopped if ketoacidosis is suspected.
●The key teaching is that a normal finger prick does not rule it out. A patient with these symptoms should break the fast, stop the tablet and be seen the same day. Blood ketone testing, where available, is preferred to urine.
●Kamran has already had a worrying sign: he passes urine six or seven times a day at work and is thirsty by the afternoon. His fast last year was before dapagliflozin was started. Fasting on it for the first time is the highest risk period.

Dehydration, Falls at Height and Work

●Heavy outdoor work, no drinks for most of the day and the extra urine output from dapagliflozin combine to give a real risk of volume depletion. The SmPC recommends temporary interruption of dapagliflozin if volume depletion occurs. Practical measures include drinking plenty between sunset and dawn, limiting sweet and caffeinated drinks, using shade and rest breaks, and breaking the fast if he develops cramps or passes little dark urine.
●Kamran has not told his supervisor. Candidates who help him frame it as safety, not weakness, and offer to write something if he wants it, do best. He does not want a fit note and does not need one.
●Part of most working days is spent on a mobile platform several metres off the ground, and last year's dizzy spell happened there. This is the hidden risk in the station. Dapagliflozin increases urine output and can modestly lower blood pressure, the SmPC advises caution where a fall in blood pressure could be a risk, and he also takes ramipril. Dehydration from a long fast adds to this. Dizziness or faintness is a recognised result of volume depletion: CKS gives postural dizziness as an example in people taking an SGLT2 inhibitor, and the BNF lists dizziness as a common side effect of dapagliflozin. On a platform it risks a fall. This is clinical reasoning from those effects, not a published rule for fasting at height.
●Practical advice follows from this. He should ask for ground level work, such as prefabricating steel in the yard, on fasting days. He should not go up on the platform if he is light headed or dehydrated, and should come down at once, sit and break the fast if dizziness starts. He should apply the sick day rules, including pausing dapagliflozin, if he becomes dehydrated.

Sick Day Rules and Breaking the Fast

●CKS directs clinicians to explain sick day rules to people fasting. If he is vomiting, has diarrhoea or is dehydrated, he should break the fast, temporarily stop metformin, dapagliflozin and ramipril and avoid anti inflammatory painkillers, restart once he is feeling better and has been eating and drinking normally for 24 to 48 hours (CKS Diabetes type 2, sick day rules), and seek advice if he is not recovering. Kamran was never told this.
●CKS advises breaking the fast immediately for symptomatic hypoglycaemia or glucose below 3.5 mmol/L, and avoiding fasting when unwell. The IDF-DAR 2021 guidelines use below 3.9 mmol/L (the usual hypoglycaemia threshold). Either figure is acceptable. Hypoglycaemia is unlikely on his tablets, but he should know what to do: break the fast with dates or juice. Very high readings with symptoms, or any of the ketoacidosis symptoms above, are also reasons to stop.
●His imam has told him that a sick person breaking the fast is not committing a sin. Acknowledging this respectfully removes the guilt that could make him keep going.

Monitoring, Diet and Follow Up

●He has no meter. Arranging one for the month is sensible, with checks mid afternoon, before the sunset meal and whenever he feels unwell. Ketone strips or a blood ketone meter are useful if available.
●A later meal before dawn with slow release carbohydrate, protein and vegetables helps. Breaking the fast with dates and water, a balanced sunset meal with less fried and sweet food, and avoiding sugary drinks improves control. Shabana cooks, so including her helps.
●Review before the fast starts, a contact in the first week or two, and a review after the month with HbA1c is the model. His HbA1c of 62 is above the usual target and can be addressed after Ramadan. Safety netting names whom to ring, when to use 111 and when to call 999.

Communication

●Kamran expects a flat refusal and has rehearsed his answer. Starting by asking what Ramadan means to him, and showing that he is trusted to decide, changes the consultation. He admits how rough he felt last year only when he feels safe.
●Explaining in everyday words, linking the risks to his own passing of urine at work and the dizzy spell on the platform, giving timings in simple steps, offering a written summary and inviting Shabana, make the plan usable. A teach back of the warning signs ensures he will act.

Common Mistakes in This Station

●Telling him he must not fast, with no safety plan, or telling him to fast with no risk assessment.
●Leaving dapagliflozin in the morning with no thought to dehydration or ketoacidosis.
●Missing the link between dehydration, dapagliflozin and a fall from the platform, or leaving out ramipril and the sick day rules.
●Giving no criteria for breaking the fast, or telling him to wait for a high glucose reading before worrying about ketoacidosis.
●Forgetting heavy work, work at height and fluids at work, or not offering a meter and a review.
●Using terms such as euglycaemic ketoacidosis without explanation, or lecturing.

Mapped to the RCGP curriculum topic: People with Long-term Conditions Including Cancer.

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