no food or drinks are to be taken from dawn to sunset . according to some interpretations , taking of oral medicine is also forbidden during these hours . in the evening , the fast is broken with sweet drinks and snacks . if a muslim misses a day of fasting , ( s)he has to make up for it on a later day and often pay a penalty , which is used to feed the poor . certain people are excluded from this religious obligation to fast , including children under 12 , the sick , the traveling and women who are pregnant / breastfeeding young babies/ having their menstrual period . although sick persons are exempted from fasting , many still wish to keep the fast and force the doctor to allow them to do so . for people who are eligible / allowed not to fast in islam , some individual still feel the obligation to pay compensation may play a role in the economically weak patient wanting to keep the fast , as also in orthodox areas , negative reactions from other people may do the same . in these situations adrenal insufficiency can result from structural or functional lesions of the adrenal cortex ( primary adrenal insufficiency or addison 's disease ) or from structural or functional lesions of the anterior pituitary or hypothalamus ( secondary adrenal insufficiency ) . in developed countries , primary adrenal insufficiency is most frequently secondary to autoimmune adrenal disease , whereas tuberculous adrenalitis is the most frequent etiology in underdeveloped countries . other causes include adrenalectomy , bilateral adrenal haemorrhage , neoplastic infiltration of the adrenal glands , acquired immunodeficiency syndrome , inherited disorders of the steroidogenic enzymes , and x - linked adrenoleukodystrophy . secondary adrenal insufficiency resulting from pituitary or hypothalamic dysfunction generally presents in a more insidious manner than does the primary disorder , probably because mineralocorticoid biosynthesis is preserved . acute adrenal insufficiency disease is characterized by gastrointestinal symptoms ( nausea , vomiting , and abdominal pain ) , dehydration , hyponatremia , hyperkalemia , weakness , lethargy , and hypotension . it is usually associated with disorders of the adrenal rather than the pituitary or hypothalamus , and sometimes it follows abrupt withdrawal of glucocorticoids used at high doses or for prolonged periods . in the month of ramadan , a person keeping a fast refrains from eating and drinking during daylight hours , which is approximately 15 hours . during ramadan , the dietary pattern is also changed and in comparison to other days , people consume more oily and spicy items and sugar preparations at iftar . also at iftar parties , the chances of food and water contamination are higher , due to mass production of food and usually an unhygienic practice while serving . thus , a person suffering from adrenal insufficiency , in order to avoid adrenal crisis , should be advised regarding food habits , drug compliance , and warning signs properly . we recommend the following guidelines for patients suffering from adrenal insufficiency , who wish to keep the fast . the preferred drug for adrenal insufficiency is hydrocortisone , but as we know , the biological half - life of hydrocortisone is short ( half - life < 12 hours ) and the fasting hours are longer ( about 15 hours ) , therefore , longer acting glucocorticoids like prednisolone or dexamethasone may be considered as per patient compliance during the month of ramadan . also a combination of prednisolone in the morning and hydrocortisone in the evening may be considered to match the cortisol day curve . if possible , this drug replacement may be started a few weeks before ramadan and the patient should be monitored as per clinical symptoms ( e.g. , energy level , fatigue ) and signs like blood pressure , for proper dose adjustment . the timing of corticosteroid intake during iftar and sahar should be adjusted in such a manner that the interval between the two doses matches the cortisol day curve as much as possible . measurements of plasma adrenocorticotropic hormone ( acth ) and / or serum cortisol are not routinely necessary . in secondary adrenal insufficiency , mineralocorticoid replacement is not required , while in primary adrenal insufficiency the mineralocorticoid dose should be adjusted according to the corticosteroid preparation , as hydrocortisone has both glucocorticoid and mineralocorticoid activity , but the mineralocorticoid activity of prednisolone is lesser than hydrocortisone and that of dexamethasone is zero . the anti - inflammatory action of cortisol is 1 and that of prednisolone is 3 , while that of dexamethasone is 26 . monitoring for dose adjustment may be done with serum na , k , and blood pressure control.[26 ] due to consumption of oily foods and steroids , the patients should take proton - pump inhibitors , in order to prevent gastritis , if and when required . patient education is an important part of management ; they should be clear about warning symptoms of adrenal insufficiency , like fatigue , nausea and / or vomiting . it is also wise to share this information with the family , friends , and any caregivers , so that they can also identify signs of trouble and be prepared to act in case of adrenal crisis . the patients should be advised to carry their emergency medical information card that lists the doses of their daily medications and the names of their physician and family member(s ) , to call in case of an emergency . as a safety measurement , the patients should always carry a syringe and a vial of hydrocortisone or dexamethasone with them , and also safely store these at home . the patient should be able to take extra dosage of steroid if / when signs / symptoms of adrenal insufficiency appear but in addition family member or friend should know how to give give the steroid injection into a muscle ( usually the thigh ) during an episode of adrenal crisis especially if the person is found unconscious . following this the patients should be instructed to adjust the dosage ( double or triple their daily dose ) of corticosteroid during symptoms of stressful medical condition such as cold , flu , diarrhea or vomiting . as soon as illness is over and the symptoms have subsided they can return to taking their usual amount of medication . these patients should try their best to have proper meals and to avoid sugars , processed starches , caffeine , stimulant drugs , and as much as nicotine as possible . as a majority ( 75% ) of primary adrenal insufficiency patients are  salt - wasters , they should be advised to avoid exertional activity and to not spend more time in a hot climate during fasting hours . during non - fasting hours they should be sure to drink enough non - sugar - laden liquids and supplement them with enough salt to alleviate a dangerous situation . the patients should look for ankle edema , which may be due to insufficient salt , but usually disappears in about two to three days after taking adequate salt . they should avoid or reduce excessive heat , cold , overwork , lack of sleep , and arguments . they should try to take rest for longer periods during fasting hours , with proper sleep at night , in order to reduce stress . if deemed medically necessary , patients should be advised not to keep a fast . but patients who refuse to follow instructions ( against medical advice ) , must be advised regarding the suitable drugs for that particular period , the warning signs , sick - day management , physical activity , and dietary limits . they should also be advised to treat themselves appropriately whenever a warning sign is present .
adrenal insufficiency is a life - threatening event , so it is recommended for patients with known adrenal insufficiency to be properly educated regarding sick - day management . in the month of ramadan , 
 people refrain from eating and drinking during daylight hours . 
 it is very important for patients with adrenal insufficiency , who wish to keep a fast , to be well aware of the disease , the suitable drug to be used for that particular period , warning signs , sick - day management , physical activity , and dietary limits . 
 this article describes guidelines for the sick - day management of patients with adrenal insufficiency , in the month of ramadan .