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Lee SWH, Chen WS, Sellappans R, Md Sharif SB, Metzendorf MI, Lai NM. Interventions for people with type 2 diabetes mellitus fasting during Ramadan. Cochrane Database Syst Rev 2023; 7:CD013178. [PMID: 37435938 PMCID: PMC10355254 DOI: 10.1002/14651858.cd013178.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
BACKGROUND Fasting during Ramadan is obligatory for adult Muslims, except those who have a medical illness. Many Muslims with type 2 diabetes (T2DM) choose to fast, which may increase their risks of hypoglycaemia and dehydration. OBJECTIVES To assess the effects of interventions for people with type 2 diabetes fasting during Ramadan. SEARCH METHODS We searched CENTRAL, MEDLINE, PsycINFO, CINAHL, WHO ICTRP and ClinicalTrials.gov (29 June 2022) without language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) conducted during Ramadan that evaluated all pharmacological or behavioural interventions in Muslims with T2DM. DATA COLLECTION AND ANALYSIS Two authors screened and selected records, assessed risk of bias and extracted data independently. Discrepancies were resolved by a third author. For meta-analyses we used a random-effects model, with risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes with their associated 95% confidence intervals (CIs). We assessed the certainty of evidence using the GRADE approach. MAIN RESULTS We included 17 RCTs with 5359 participants, with a four-week study duration and at least four weeks of follow-up. All studies had at least one high-risk domain in the risk of bias assessment. Four trials compared dipeptidyl-peptidase-4 (DPP-4) inhibitors with sulphonylurea. DPP-4 inhibitors may reduce hypoglycaemia compared to sulphonylureas (85/1237 versus 165/1258, RR 0.53, 95% CI 0.41 to 0.68; low-certainty evidence). Serious hypoglycaemia was similar between groups (no events were reported in two trials; 6/279 in the DPP-4 versus 4/278 in the sulphonylurea group was reported in one trial, RR 1.49, 95% CI 0.43 to 5.24; very low-certainty evidence). The evidence was very uncertain about the effects of DPP-4 inhibitors on adverse events other than hypoglycaemia (141/1207 versus 157/1219, RR 0.90, 95% CI 0.52 to 1.54) and HbA1c changes (MD -0.11%, 95% CI -0.57 to 0.36) (very low-certainty evidence for both outcomes). No deaths were reported (moderate-certainty evidence). Health-related quality of life (HRQoL) and treatment satisfaction were not evaluated. Two trials compared meglitinides with sulphonylurea. The evidence is very uncertain about the effect on hypoglycaemia (14/133 versus 21/140, RR 0.72, 95% CI 0.40 to 1.28) and HbA1c changes (MD 0.38%, 95% CI 0.35% to 0.41%) (very low-certainty evidence for both outcomes). Death, serious hypoglycaemic events, adverse events, treatment satisfaction and HRQoL were not evaluated. One trial compared sodium-glucose co-transporter-2 (SGLT-2) inhibitors with sulphonylurea. SGLT-2 may reduce hypoglycaemia compared to sulphonylurea (4/58 versus 13/52, RR 0.28, 95% CI 0.10 to 0.79; low-certainty evidence). The evidence was very uncertain for serious hypoglycaemia (one event reported in both groups, RR 0.90, 95% CI 0.06 to 13.97) and adverse events other than hypoglycaemia (20/58 versus 18/52, RR 1.00, 95% CI 0.60 to 1.67) (very low-certainty evidence for both outcomes). SGLT-2 inhibitors result in little or no difference in HbA1c (MD 0.27%, 95% CI -0.04 to 0.58; 1 trial, 110 participants; low-certainty evidence). Death, treatment satisfaction and HRQoL were not evaluated. Three trials compared glucagon-like peptide 1 (GLP-1) analogues with sulphonylurea. GLP-1 analogues may reduce hypoglycaemia compared to sulphonylurea (20/291 versus 48/305, RR 0.45, 95% CI 0.28 to 0.74; low-certainty evidence). The evidence was very uncertain for serious hypoglycaemia (0/91 versus 1/91, RR 0.33, 95% CI 0.01 to 7.99; very low-certainty evidence). The evidence suggests that GLP-1 analogues result in little to no difference in adverse events other than hypoglycaemia (78/244 versus 55/255, RR 1.50, 95% CI 0.86 to 2.61; very low-certainty evidence), treatment satisfaction (MD -0.18, 95% CI -3.18 to 2.82; very low-certainty evidence) or change in HbA1c (MD -0.04%, 95% CI -0.45% to 0.36%; 2 trials, 246 participants; low-certainty evidence). Death and HRQoL were not evaluated. Two trials compared insulin analogues with biphasic insulin. The evidence was very uncertain about the effects of insulin analogues on hypoglycaemia (47/256 versus 81/244, RR 0.43, 95% CI 0.13 to 1.40) and serious hypoglycaemia (4/131 versus 3/132, RR 1.34, 95% CI 0.31 to 5.89) (very low-certainty evidence for both outcomes). The evidence was very uncertain for the effect of insulin analogues on adverse effects other than hypoglycaemia (109/256 versus 114/244, RR 0.83, 95% CI 0.44 to 1.56; very low-certainty evidence), all-cause mortality (1/131 versus 0/132, RR 3.02, 95% CI 0.12 to 73.53; very low-certainty evidence) and HbA1c changes (MD 0.03%, 95% CI -0.17% to 0.23%; 1 trial, 245 participants; very low-certainty evidence). Treatment satisfaction and HRQoL were not evaluated. Two trials compared telemedicine with usual care. The evidence was very uncertain about the effect of telemedicine on hypoglycaemia compared with usual care (9/63 versus 23/58, RR 0.42, 95% CI 0.24 to 0.74; very low-certainty evidence), HRQoL (MD 0.06, 95% CI -0.03 to 0.15; very low-certainty evidence) and HbA1c change (MD -0.84%, 95% CI -1.51% to -0.17%; very low-certainty evidence). Death, serious hypoglycaemia, AEs other than hypoglycaemia and treatment satisfaction were not evaluated. Two trials compared Ramadan-focused patient education with usual care. The evidence was very uncertain about the effect of Ramadan-focused patient education on hypoglycaemia (49/213 versus 42/209, RR 1.17, 95% CI 0.82 to 1.66; very low-certainty evidence) and HbA1c change (MD -0.40%, 95% CI -0.73% to -0.06%; very low-certainty evidence). Death, serious hypoglycaemia, adverse events other than hypoglycaemia, treatment satisfaction and HRQoL were not evaluated. One trial compared drug dosage reduction with usual care. The evidence is very uncertain about the effect of drug dosage reduction on hypoglycaemia (19/452 versus 52/226, RR 0.18, 95% CI 0.11 to 0.30; very low-certainty evidence). No participants experienced adverse events other than hypoglycaemia during the study (very low-certainty evidence). Death, serious hypoglycaemia, treatment satisfaction, HbA1c change and HRQoL were not evaluated. AUTHORS' CONCLUSIONS There is no clear evidence of the benefits or harms of interventions for individuals with T2DM who fast during Ramadan. All results should be interpreted with caution due to concerns about risk of bias, imprecision and inconsistency between studies, which give rise to low- to very low-certainty evidence. Major outcomes, such as mortality, health-related quality of life and severe hypoglycaemia, were rarely evaluated. Sufficiently powered studies that examine the effects of various interventions on these outcomes are needed.
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Affiliation(s)
| | - Won Sun Chen
- Department of Statistics, Data Science and Epidemiology, Swinburne University of Technology, Hawthorn, Australia
- Curtin Medical School, Curtin University, Bentley WA 6102, Australia
| | - Renukha Sellappans
- School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya, Malaysia
| | | | - Maria-Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich-Heine University, Düsseldorf, Germany
| | - Nai Ming Lai
- School of Medicine, Taylor's University, Subang Jaya, Malaysia
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Ahmed M, Badi S, Elidrisi A, Husain NE, Zainudin SB, Mahmood A, Abubaker NE, Alghamdi AS, Ahmed MH. Safety and effectiveness of newer antidiabetic medications during Ramadan fasting and safety of Ramadan fasting after bariatric surgery. J Diabetes Metab Disord 2022; 21:1991-2004. [PMID: 36404821 PMCID: PMC9672258 DOI: 10.1007/s40200-022-01145-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/10/2022] [Indexed: 11/27/2022]
Abstract
Background Fasting during Ramadan is mandatory for all adult healthy Muslims. International studies found that most Muslims with diabetes mellitus fast during Ramadan. The main risk factors are hypoglycemia, Hyperglycemia, diabetic ketoacidosis, and dehydration during fasting. Therefore, stratification of the risks for severe acute diabetes complications needs to be considered for each individual and strategies personalized to advert these complications. The advent of new diabetes medications which are effective yet with a better safety profile and monitoring of blood glucose levels during the day are important to reduce the risk of untoward effects of hypoglycemia and hyperglycemia during Ramadan fasting. Here we review the safety and effectiveness of the newer diabetes medications for Ramadan fasting and whether it is safe to perform fasting after bariatric surgery. Methods An extensive literature search using PubMed and Google Scholar was done using different search terms. The eligible studies were 48 randomized controlled trials, prospective observational studies, and reviews from January 2008 to June 2022 which were conducted in individuals living with diabetes. Results and Conclusions The newer diabetes medications such as GLP-1 agonists, DPP-4 inhibitors, SGLT-2 inhibitors, and new Insulin therapy are thought to be safe and effective during fasting of Ramadan. These medications are associated with a reduction in HbA1c, body weight, systolic blood pressure and risk of hypoglycemia during Ramadan fasting. However, further studies with larger sample size are needed to confirm the efficacy and safety of these newer medications during Ramadan fasting. Individuals with Bariatric surgery should seek advice and approval to fast from the bariatric dietician, physician, and surgeon before the beginning of the month of Ramadan.
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Affiliation(s)
- Musaab Ahmed
- College of Medicine, Ajman University, Ajman, United Arab Emirates
- Center of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates
| | - Safaa Badi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Omdurman Islamic University, Khartoum, Sudan
| | - Ala Elidrisi
- Department of Pathology, Faculty of Medicine and Health Sciences, Omdurman Islamic University, Khartoum, Sudan
| | - Nazik Elmalaika Husain
- Department of Pathology, Faculty of Medicine and Health Sciences, Omdurman Islamic University, Khartoum, Sudan
| | | | - Arshad Mahmood
- Department of Colorectal Surgery, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes, Buckinghamshire UK
| | - Nuha Eljaili Abubaker
- Clinical Chemistry Department, College of Medical Laboratory Science, Sudan University of Science and Technology, Khartoum, Sudan
| | | | - Mohamed H. Ahmed
- Department of Medicine and HIV Metabolic Clinic, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes, Buckinghamshire UK
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Kacimi SEO, Sukaina M, Elgenidy A, Farahat RA, Cheema HA, Benmelouka AY, Awad DM, Belaouni HA, Abdelli MK, Tidjane A, Mesli NS, Shah J, Setti MO, Afifi AM, Ghozy S, the Ramadan Diabetes Research Group (RDRG) Collaborators. Hypoglycemic Events in Diabetic Patients under Non-insulin Regimens During Ramadan: A Frequentist Network Meta-Analysis.. [DOI: 10.1101/2022.05.28.22275730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
AbstractBackgroundDiabetic Muslims who choose to fast during Ramadan encounter major risks such as hyperglycemia, hypoglycemia, diabetic ketoacidosis, and dehydration. Recently, newer antidiabetic agents have been found to be less likely to cause hypoglycemic emergencies. This meta-analysis aimed to present collective and conclusive results from major randomized controlled trials (RCTs) to determine the risk of hypoglycemia among patients taking oral antidiabetics during Ramadan.MethodsWe searched PubMed, Web of Science, and Google Scholar for RCTs. We performed a frequentist network meta-analysis using the “netmeta” package of R software version 4.1.1 to investigate the risk of developing hypoglycemia after taking oral antidiabetic drugs during Ramadan.ResultsNine RCTs with a total of 3464 patients were included in the final analysis. In the comparison of all antidiabetic drug classes with sulfonylureas, SGLT-2 inhibitors were associated with the lowest hypoglycemic risk (RR, 0.18; 95% CI, 0.04-0.78; P-score, 0.909), followed by GLP-1 agonists (RR, 0.31; 95% CI, 0.17-0.56; P-score, 0.799), and DDP-4 inhibitors (RR, 0.57; 95% CI, 0.43-0.75; P-score, 0.483). When comparing individual drugs, dapagliflozin was associated with the lowest hypoglycemic risk (RR, 0.18; 95% CI, 0.04-0.78; P-score, 0.874), followed by lixisenatide (RR, 0.25; 95% CI, 0.09-0.71; P-score, 0.813), liraglutide (RR, 0.34; 95% CI, 0.17-0.69; P-score, 0.715), and sitagliptin (RR. 0.51; 95% CI, 0.37-0.71; P-score, 0.515).ConclusionSGLT-2 inhibitors are associated with the least documented hypoglycemic events and adverse outcomes compared with other oral hypoglycemic drugs. These findings could have considerable public health and clinical implications when extrapolated to the global Muslim population with a similar clinical background.Abstract Figure
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Shiju R, Akhil A, Thankachan S, Tuomilehto J, Al Arouj M, Bennakhi A. Safety Assessment of Glucose-Lowering Drugs and Importance of Structured Education during Ramadan: A Systematic Review and Meta-Analysis. J Diabetes Res 2022; 2022:3846253. [PMID: 35242880 PMCID: PMC8886741 DOI: 10.1155/2022/3846253] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/10/2022] [Accepted: 01/26/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Ramadan is the sacred month of the Islamic Hijri (lunar) calendar, and during this entire month, healthy adult Muslims abstain from eating and drinking from dawn to sunset. Muslims with Type 2 Diabetes Mellitus (T2DM) who choose to fast during Ramadan encounter major risks such as hypoglycemia, hyperglycemia, diabetic ketoacidosis, dehydration, and thrombosis. Although patients with poor glycemic control and on multiple insulin injections are at high risk and exempt from fasting, many still insist on it. Thus, healthcare professionals play a pivotal role in managing diabetes-related complications in patients who fast during Ramadan. However, there is a lack of standard guidelines to be followed in association with structured education and administration of drugs and dosage. Therefore, we performed a systematic review and meta-analysis of the literature to determine the safety and efficacy of different classes of drugs and the importance of structured education during Ramadan. METHODS In this review, an extensive PubMed search was performed to obtain literature on T2DM patients who fast during the month of Ramadan until the year 2020. Preference was given to fully downloadable articles. The articles were extracted based on the eligibility criteria. The extracted data were analyzed using Review Manager software version 5.3. RESULTS A total of 32 articles were included for the review and 7 studies for meta-analysis. Majority of the studies demonstrated the importance of structured education either as a group session or as a one-on-one session with the healthcare professionals in preventing diabetes-related risks during Ramadan. As far as glucose-lowering drugs are concerned, DPP-4 inhibitor combined with metformin remains the drug of choice for T2DM patients who fast during Ramadan. The newer class of glucose-lowering agents appear to lower the risk of hypoglycemia in comparison with sulphonylureas, while among sulphonylureas gliclazide is relatively safe. The meta-analysis indicates that DPP-4 inhibitors would significantly reduce the risk of hypoglycemia as compared to sulphonylurea (odds ratio = 0.38, 95% CI: 0.26 to 0.55, p < 0.00001). CONCLUSION The results of our systematic review show that structured education and counselling by healthcare professionals can be an effective tool in preventing complications associated with fasting during Ramadan in people with T2DM. Additionally, the safest class of oral glucose-lowering drugs preferred during Ramadan fasting in T2DM patients is DPP-4 inhibitors.
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Affiliation(s)
- Rashmi Shiju
- Office of Regulatory Affairs, Dasman Diabetes Institute, Kuwait
| | - Ayesha Akhil
- Office of Regulatory Affairs, Dasman Diabetes Institute, Kuwait
| | | | - Jaakko Tuomilehto
- Department of Public Health, University of Helsinki, Helsinki, Finland
- Public Health Prevention Unit, Finnish Institute for Health and Welfare, Finland
- Diabetes Research Group, King Abdulaziz University, Jeddah, Saudi Arabia
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Gad H, Hayat T, Al-Muhannadi H, Malik BR, Mussleman P, Malik RA. Efficacy and safety of the newer oral hypoglycemic agents in patients with T2DM during Ramadan: A systematic review and meta-analysis. Diabetes Res Clin Pract 2021; 172:108562. [PMID: 33271228 DOI: 10.1016/j.diabres.2020.108562] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Abstract
AIMS This systematic review and meta-analysis aims to evaluate the safety and efficacy of the newer glucose lowering treatments on glycemic control, weight, blood pressure and hypoglycemia in patients with T2DM during Ramadan. METHODS A literature search was done in PubMed, Embase, and the Cochrane Library. Quality assessment was done using the ROBINS-I and Cochrane tools for risk of bias and analyses were performed using RevMan version 5.3. RESULTS A total of 20 studies were included in the meta-analysis. Dipeptidyl peptidase-4 inhibitors (DPP-4i) led to a significant reduction in HbA1c (%) (SMD -0.25) and a non-significant decrease in weight (kg) (SMD -1.06) during Ramadan. Glucagon-like peptide (GLP-1) agonist therapy was associated with a significant decrease in HbA1c (%) (SMD -0.68) and a non-significant decrease in weight (kg) (SMD -2.57) and systolic blood pressure (SBP) (mmHg) (SMD -3.50) after Ramadan. Sodium-glucose co-transporter 2 inhibitor (SGLT-2i) therapy was associated with a significant decrease in HbA1c (%) (SMD -0.51) and a non-significant decrease in weight (kg) (SMD -1.41), SBP (SMD -1.10) and diastolic blood pressure (DBP) (mmHg) (SMD -2.08) after Ramadan. CONCLUSIONS This systematic review and meta-analysis shows clinical benefits with the newer glucose lowering medications in patients with T2DM who fast during Ramadan.
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Affiliation(s)
- Hoda Gad
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Tabraiz Hayat
- Family Medicine, Leabaib Health Center, Primary Health Care Corporation, Doha, Qatar
| | | | - Balal Rasheed Malik
- Mobile Healthcare Service, Ambulance Department, Hamad Medical Corporation, Doha, Qatar
| | - Paul Mussleman
- Library Services, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Rayaz A Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar; Institute of Cardiovascular Medicine, University of Manchester, Manchester, United Kingdom.
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Abdelrahim D, Faris ME, Hassanein M, Shakir AZ, Yusuf AM, Almeneessier AS, BaHammam AS. Impact of Ramadan Diurnal Intermittent Fasting on Hypoglycemic Events in Patients With Type 2 Diabetes: A Systematic Review of Randomized Controlled Trials and Observational Studies. Front Endocrinol (Lausanne) 2021; 12:624423. [PMID: 33763029 PMCID: PMC7984365 DOI: 10.3389/fendo.2021.624423] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/11/2021] [Indexed: 01/14/2023] Open
Abstract
Ramadan is the 9th month of the lunar calendar during which Muslims abstain from food and drink between dawn and sunset for 30 consecutive days. Ramadan fasting is observed by all healthy Muslim adults, as well many Muslims with type 2 diabetes (T2DM). Hypoglycemic events (HE) are a serious complication associated with diabetes management and are associated with increased cardiovascular disease risk. Conflicting results have been reported concerning the incidence of HE among people with T2DM observing Ramadan fasting. This review summarizes available scientific evidence on the occurrence of HE and the effects of different moderators on the incidence of HE among patients with T2DM during Ramadan. We conducted a systematic review of available observational studies and randomized controlled trials (RCTs) for patients with T2DM who fasted during Ramadan, with HE as the primary outcome. Ten databases were searched for relevant studies from inception until October 31, 2020. In total, 68 studies (35 RCTs and 33 observational studies) met the inclusion criteria. Non-sulfonylureas hypoglycemic medications showed superior effects in lowering the incidence of HE over sulfonylureas hypoglycemic medications. Variable moderators were associated with experiencing HE during Ramadan in both observational studies and RCTs, including sex, geographical location, body anthropometric indicators, season, dietary behaviors, fasting duration, time since diagnosis, and pre-fasting education. This comprehensive systematic review covered the largest number of observational and clinical studies investigating the impact of Ramadan on HE among patients with T2DM. The study highlights the significance of different moderators that influence the effect of Ramadan fasting on HE, including dietary behaviors, fasting time duration, sex, season, country, pre-fasting education, age, and time since diagnosis. The study also highlighted the impact of different hypoglycemic medications on HE and noted the superiority of non-sulfonylureas over sulfonylureas hypoglycemic medications in lowering the risk for hypoglycemia in people with T2DM during Ramadan fasting.
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Affiliation(s)
- Dana Abdelrahim
- Department of Nutrition and Food Technology, Faculty of Agriculture, The University of Jordan, Amman, Jordan
| | - MoezAlIslam E. Faris
- Department of Clinical Nutrition and Dietetics, College of Health Sciences/Research Institute for Medical and Health Sciences (RIMHS), University of Sharjah, Sharjah, United Arab Emirates
- *Correspondence: Ahmed S. BaHammam, ; MoezAlIslam E. Faris, ;
| | - Mohamed Hassanein
- Endocrine Department, Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Ayman Z. Shakir
- Department of Clinical Nutrition and Dietetics, College of Health Sciences/Research Institute for Medical and Health Sciences (RIMHS), University of Sharjah, Sharjah, United Arab Emirates
| | - Ayesha M. Yusuf
- Department of Clinical Nutrition and Dietetics, College of Health Sciences/Research Institute for Medical and Health Sciences (RIMHS), University of Sharjah, Sharjah, United Arab Emirates
| | | | - Ahmed S. BaHammam
- Department of Medicine, College of Medicine, The University Sleep Disorders Center, King Saud University, Riyadh, Saudi Arabia
- *Correspondence: Ahmed S. BaHammam, ; MoezAlIslam E. Faris, ;
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Ahmed SH, Chowdhury TA, Hussain S, Syed A, Karamat A, Helmy A, Waqar S, Ali S, Dabhad A, Seal ST, Hodgkinson A, Azmi S, Ghouri N. Ramadan and Diabetes: A Narrative Review and Practice Update. Diabetes Ther 2020; 11:2477-2520. [PMID: 32909192 PMCID: PMC7480213 DOI: 10.1007/s13300-020-00886-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Indexed: 02/06/2023] Open
Abstract
Fasting in the Islamic month of Ramadan is obligatory for all sane, healthy adult Muslims. The length of the day varies significantly in temperate regions-typically lasting ≥ 18 h during peak summer in the UK. The synodic nature of the Islamic calendar means that Ramadan migrates across all four seasons over an approximately 33-year cycle. Despite valid exemptions, there is an intense desire to fast during this month, even among those who are considered to be at high risk, including many individuals with diabetes mellitus. In this review we explore the current scientific and clinical evidence on fasting in patients with diabetes mellitus, focussing on type 2 diabetes mellitus and type 1 diabetes mellitus, with brief reviews on pregnancy, pancreatic diabetes, bariatric surgery, the elderly population and current practice guidelines. We also make recommendations on the management of diabetes patients during the month of Ramadan. Many patients admit to a do-it-yourself approach to diabetes mellitus management during Ramadan, largely due to an under-appreciation of the risks and implications of the rigors of fasting on their health. Part of the issue may also lie with a healthcare professional's perceived inability to grasp the religious sensitivities of Muslims in relation to disease management. Thus, the pre-Ramadan assessment is crucial to ensure a safe Ramadan experience. Diabetes patients can be risk-stratified from low, medium to high or very high risk during the pre-Ramadan assessment and counselled accordingly. Those who are assessed to be at high to very high risk are advised not to fast. The current COVID-19 pandemic upgrades those in the high-risk category to very high risk; hence a significant number of diabetes patients may fall under the penumbra of the 'not to fast' advisory. We recognize that fasting is a personal choice and if a person chooses to fast despite advice to the contrary, he/she should be adequately supported and monitored closely during Ramadan and for a brief period thereafter. Current advancements in insulin delivery and glucose monitoring technologies are useful adjuncts to strategies for supporting type 1 diabetes patients considered to be high risk as well as 'high-risk' type 2 patients manage their diabetes during Ramadan. Although there is a lack of formal trial data, there is sufficient evidence across the different classes of therapeutic hypoglycaemic agents in terms of safety and efficacy to enable informed decision-making and provide a breadth of therapeutic options for the patient and the healthcare professional, even if the professional advice is to abstain. Thus, Ramadan provides an excellent opportunity for patient engagement to discuss important aspects of management, to improve control in the short term during Ramadan and to help the observants understand that the metabolic gains achieved during Ramadan are also sustainable in the other months of the year by maintaining a dietary and behavioural discipline. The application of this understanding can potentially prevent long-term complications.
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Affiliation(s)
- Syed H Ahmed
- Department of Endocrinology and Metabolic Medicine, Countess of Chester Hospital NHS Foundation Trust, Chester, UK.
- School of Medicine, University of Liverpool, Liverpool, UK.
| | | | - Sufyan Hussain
- Department of Diabetes and Endocrinology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Department of Diabetes, School of Life Course Sciences, King's College London, London, UK
- Institute of Diabetes, Endocrinology and Obesity, King's Health Partners, London, UK
| | - Ateeq Syed
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ali Karamat
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ahmed Helmy
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Salman Waqar
- Nuffield Department of Primary Care Health Sciences, University Oxford, Oxford, UK
| | - Samina Ali
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | | | - Susan T Seal
- Department of Endocrinology and Metabolic Medicine, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Anna Hodgkinson
- Department of Diabetes and Endocrinology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- NHS South East London Clinical Commissioning Group, London, UK
| | - Shazli Azmi
- Institute of Cardiovascular Science, University of Manchester, Manchester, UK
- Manchester Diabetes Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Nazim Ghouri
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Diabetes and Endocrinology, Queen Elizabeth University Hospital, Glasgow, UK
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Aydin N, Kul S, Karadağ G, Tabur S, Araz M. Effect of Ramadan fasting on glycaemic parameters & body mass index in type II diabetic patients: A meta-analysis. Indian J Med Res 2020; 150:546-556. [PMID: 32048618 PMCID: PMC7038805 DOI: 10.4103/ijmr.ijmr_1380_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background & objectives: There has been an ongoing debate about the impact of Ramadan fasting (RF) on the health of these individuals who fast during Ramadan. The aim of this meta-analysis was to evaluate the relationship between RF and glycaemic parameters in type 2 diabetes mellitus (T2DM) patients. Methods: Search terms were decided and databases such as MEDLINE EBSCO, Google Scholar and EMBASE were searched for eligible studies. Standardized mean differences and 95 per cent confidence intervals (CIs) of post-prandial plasma glucose (PPG), fasting plasma glucose (FPG), glycated haemoglobin (HbA1c) (%) and fructosamine levels were calculated for different treatment regimens. Results: Of the 40 studies, 19 were found eligible for inclusion in the meta-analysis. Based on pooled results, significant reductions in FPG were found in single oral antidiabetics (OAD) [standardized weighted mean difference (SMD)=0.47, 95% CI=(0.20-0.74)], multi-OAD [SMD=0.36, 95% CI=(0.11-0.61)] and multitreatment subgroups [SMD=0.65, 95% CI=(0.03-1.27)] and overall [SMD=0.48, 95% CI=(0.27-0.70)]. Furthermore, HbA1c (%) [SMD=0.26, 95% CI=(0.03-0.49)] and body mass index (BMI) [SMD=0.18, 95% CI=(0.04-0.31)] were significantly decreased in the multi-OAD group. Interpretation & conclusions: The meta-analysis showed that RF was not associated with any significant negative effects on PPG and fructosamine levels. However, BMI and FPG and HbA1c (%) were positively affected by RF.
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Affiliation(s)
- Neriman Aydin
- Department of Public Health, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Seval Kul
- Department of Biostatistics, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Gülendam Karadağ
- Department of Public Health-Nursing School, Dokuz Eylül University, İzmir, Turkey
| | - Suzan Tabur
- Department of Internal Medicine, Division of Endocrinology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Mustafa Araz
- Department of Internal Medicine, Division of Endocrinology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
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9
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Madsen KS, Kähler P, Kähler LKA, Madsbad S, Gnesin F, Metzendorf M, Richter B, Hemmingsen B. Metformin and second- or third-generation sulphonylurea combination therapy for adults with type 2 diabetes mellitus. Cochrane Database Syst Rev 2019; 4:CD012368. [PMID: 30998259 PMCID: PMC6472662 DOI: 10.1002/14651858.cd012368.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The number of people with type 2 diabetes mellitus (T2DM) is increasing worldwide. The combination of metformin and sulphonylurea (M+S) is a widely used treatment. Whether M+S shows better or worse effects in comparison with other antidiabetic medications for people with T2DM is still controversial. OBJECTIVES To assess the effects of metformin and sulphonylurea (second- or third-generation) combination therapy for adults with type 2 diabetes mellitus. SEARCH METHODS We updated the search of a recent systematic review from the Agency for Healthcare Research and Quality (AHRQ). The updated search included CENTRAL, MEDLINE, Embase, ClinicalTrials.gov and WHO ICTRP. The date of the last search was March 2018. We searched manufacturers' websites and reference lists of included trials, systematic reviews, meta-analyses and health technology assessment reports. We asked investigators of the included trials for information about additional trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) randomising participants 18 years old or more with T2DM to M+S compared with metformin plus another glucose-lowering intervention or metformin monotherapy with a treatment duration of 52 weeks or more. DATA COLLECTION AND ANALYSIS Two review authors read all abstracts and full-text articles and records, assessed risk of bias and extracted outcome data independently. We used a random-effects model to perform meta-analysis, and calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the certainty of the evidence using the GRADE instrument. MAIN RESULTS We included 32 RCTs randomising 28,746 people. Treatment duration ranged between one to four years. We judged none of these trials as low risk of bias for all 'Risk of bias' domains. Most important events per person were all-cause and cardiovascular mortality, serious adverse events (SAE), non-fatal stroke (NFS), non-fatal myocardial infarction (MI) and microvascular complications. Most important comparisons were as follows:Five trials compared M+S (N = 1194) with metformin plus a glucagon-like peptide 1 analogue (N = 1675): all-cause mortality was 11/1057 (1%) versus 11/1537 (0.7%), risk ratio (RR) 1.15 (95% confidence interval (CI) 0.49 to 2.67); 3 trials; 2594 participants; low-certainty evidence; cardiovascular mortality 1/307 (0.3%) versus 1/302 (0.3%), low-certainty evidence; serious adverse events (SAE) 128/1057 (12.1%) versus 194/1537 (12.6%), RR 0.90 (95% CI 0.73 to 1.11); 3 trials; 2594 participants; very low-certainty evidence; non-fatal myocardial infarction (MI) 2/549 (0.4%) versus 6/1026 (0.6%), RR 0.57 (95% CI 0.12 to 2.82); 2 trials; 1575 participants; very low-certainty evidence.Nine trials compared M+S (N = 5414) with metformin plus a dipeptidyl-peptidase 4 inhibitor (N = 6346): all-cause mortality was 33/5387 (0.6%) versus 26/6307 (0.4%), RR 1.32 (95% CI 0.76 to 2.28); 9 trials; 11,694 participants; low-certainty evidence; cardiovascular mortality 11/2989 (0.4%) versus 9/3885 (0.2%), RR 1.54 (95% CI 0.63 to 3.79); 6 trials; 6874 participants; low-certainty evidence; SAE 735/5387 (13.6%) versus 779/6307 (12.4%), RR 1.07 (95% CI 0.97 to 1.18); 9 trials; 11,694 participants; very low-certainty evidence; NFS 14/2098 (0.7%) versus 8/2995 (0.3%), RR 2.21 (95% CI 0.74 to 6.58); 4 trials; 5093 participants; very low-certainty evidence; non-fatal MI 15/2989 (0.5%) versus 13/3885 (0.3%), RR 1.45 (95% CI 0.69 to 3.07); 6 trials; 6874 participants; very low-certainty evidence; one trial in 64 participants reported no microvascular complications were observed (very low-certainty evidence).Eleven trials compared M+S (N = 3626) with metformin plus a thiazolidinedione (N = 3685): all-cause mortality was 123/3300 (3.7%) versus 114/3354 (3.4%), RR 1.09 (95% CI 0.85 to 1.40); 6 trials; 6654 participants; low-certainty evidence; cardiovascular mortality 37/2946 (1.3%) versus 41/2994 (1.4%), RR 0.78 (95% CI 0.36 to 1.67); 4 trials; 5940 participants; low-certainty evidence; SAE 666/3300 (20.2%) versus 671/3354 (20%), RR 1.01 (95% CI 0.93 to 1.11); 6 trials; 6654 participants; very low-certainty evidence; NFS 20/1540 (1.3%) versus 16/1583 (1%), RR 1.29 (95% CI 0.67 to 2.47); P = 0.45; 2 trials; 3123 participants; very low-certainty evidence; non-fatal MI 25/1841 (1.4%) versus 21/1877 (1.1%), RR 1.21 (95% CI 0.68 to 2.14); P = 0.51; 3 trials; 3718 participants; very low-certainty evidence; three trials (3123 participants) reported no microvascular complications (very low-certainty evidence).Three trials compared M+S (N = 462) with metformin plus a glinide (N = 476): one person died in each intervention group (3 trials; 874 participants; low-certainty evidence); no cardiovascular mortality (2 trials; 446 participants; low-certainty evidence); SAE 34/424 (8%) versus 27/450 (6%), RR 1.68 (95% CI 0.54 to 5.21); P = 0.37; 3 trials; 874 participants; low-certainty evidence; no NFS (1 trial; 233 participants; very low-certainty evidence); non-fatal MI 2/215 (0.9%) participants in the M+S group; 2 trials; 446 participants; low-certainty evidence; no microvascular complications (1 trial; 233 participants; low-certainty evidence).Four trials compared M+S (N = 2109) with metformin plus a sodium-glucose co-transporter 2 inhibitor (N = 3032): all-cause mortality was 13/2107 (0.6%) versus 19/3027 (0.6%), RR 0.96 (95% CI 0.44 to 2.09); 4 trials; 5134 participants; very low-certainty evidence; cardiovascular mortality 4/1327 (0.3%) versus 6/2262 (0.3%), RR 1.22 (95% CI 0.33 to 4.41); 3 trials; 3589 participants; very low-certainty evidence; SAE 315/2107 (15.5%) versus 375/3027 (12.4%), RR 1.02 (95% CI 0.76 to 1.37); 4 trials; 5134 participants; very low-certainty evidence; NFS 3/919 (0.3%) versus 7/1856 (0.4%), RR 0.87 (95% CI 0.22 to 3.34); 2 trials; 2775 participants; very low-certainty evidence; non-fatal MI 7/890 (0.8%) versus 8/1374 (0.6%), RR 1.43 (95% CI 0.49 to 4.18; 2 trials); 2264 participants; very low-certainty evidence; amputation of lower extremity 1/437 (0.2%) versus 1/888 (0.1%); very low-certainty evidence.Trials reported more hypoglycaemic episodes with M+S combination compared to all other metformin-antidiabetic agent combinations. Results for M+S versus metformin monotherapy were inconclusive. There were no RCTs comparing M+S with metformin plus insulin. We identified nine ongoing trials and two trials are awaiting assessment. Together these trials will include approximately 16,631 participants. AUTHORS' CONCLUSIONS There is inconclusive evidence whether M+S combination therapy compared with metformin plus another glucose-lowering intervention results in benefit or harm for most patient-important outcomes (mortality, SAEs, macrovascular and microvascular complications) with the exception of hypoglycaemia (more harm for M+S combination). No RCT reported on health-related quality of life.
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Affiliation(s)
- Kasper S Madsen
- University of CopenhagenFaculty of Health and Medical SciencesBlegdamsvej 3BCopenhagen NDenmark2200
| | - Pernille Kähler
- Faculty of Health and Medical SciencesCopenhagen Medical UniversityBlegdamsvej 3CopenhagenDenmark2100Ø
| | | | - Sten Madsbad
- Hvidovre Hospital, University of CopenhagenDepartment of EndocrinologyHvidovreDenmark
| | - Filip Gnesin
- Department 7652, RigshospitaletDepartment of Endocrinology, Diabetes and MetabolismBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Maria‐Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | - Bernd Richter
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | - Bianca Hemmingsen
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
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10
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Rashid F, Abdelgadir E. A systematic review on efficacy and safety of the current hypoglycemic agents in patients with diabetes during Ramadan fasting. Diabetes Metab Syndr 2019; 13:1413-1429. [PMID: 31336501 DOI: 10.1016/j.dsx.2019.02.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 02/01/2019] [Indexed: 01/18/2023]
Abstract
The fasting in the holy month of Ramadan is passionately practised among the Muslims population around the world. Patients with diabetes are generally considered to have various risks with fasting. The recent pharmacologic and technical advances in the management of diabetes may have enabled these patients to practice safe fasting. The purpose of this review is to scientific evidence on the safety and efficacy of the current hypoglycemic agents during Ramadan. METHODS: An extensive Electronic search via PubMed and Google scholar was accomplished through using different search terms. The eligible studies were limited to only published Randomised controlled trial (RCT) and prospective observational studies from 2007 to 2018 on patients with all types of diabetes on any pharmacological management, who intended to fast in Ramadan. RESULTS AND CONCLUSIONS: The current era witnessed a gradual shift in the management of these patients with diabetes who elected to fast in Ramadan, despite the variable health-related risks with fasting. Results from available RCTs and observational studies in patients with type 2 diabetes showed lower risk of hypoglycemia, similar or better efficacy for glycemic and weight control with SGLT2 inhibitors, incretin mimetics and the newer insulin analogues compared to Sulfonylurea. Gliclazide is a relatively safer option among all sulfonylurea. Patients requiring insulin did better with insulin analogues, especially the newer premixed formulation at the time of breaking fast compared to the former insulin formulation. Current commonly used newer hypoglycemic agents are generally safe during Ramadan, however, their safety in the higher risk diabetes patients is highly needed.
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Affiliation(s)
- Fauzia Rashid
- Endocrine Department, Dubai Hospital, P.O.Box: 7272, Dubai, United Arab Emirates
| | - Elamin Abdelgadir
- Endocrine Department, Dubai Hospital, P.O.Box: 7272, Dubai, United Arab Emirates.
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11
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Kalra S, Bahendeka S, Sahay R, Ghosh S, Md F, Orabi A, Ramaiya K, Al Shammari S, Shrestha D, Shaikh K, Abhayaratna S, Shrestha PK, Mahalingam A, Askheta M, A. Rahim AA, Eliana F, Shrestha HK, Chaudhary S, Ngugi N, Mbanya JC, Aye TT, Latt TS, Akanov ZA, Syed AR, Tandon N, Unnikrishnan AG, Madhu SV, Jawa A, Chowdhury S, Bajaj S, Das AK. Consensus Recommendations on Sulfonylurea and Sulfonylurea Combinations in the Management of Type 2 Diabetes Mellitus - International Task Force. Indian J Endocrinol Metab 2018; 22:132-157. [PMID: 29535952 PMCID: PMC5838894 DOI: 10.4103/ijem.ijem_556_17] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
For decades, sulfonylureas (SUs) have been important drugs in the antidiabetic therapeutic armamentarium. They have been used as monotherapy as well as combination therapy. Focus on newer drugs and concerns about the risk of severe hypoglycemia and weight gain with some SUs have led to discussion on their safety and utility. It has to be borne in mind that the adverse events associated with SUs should not be ascribed to the whole class, as many modern SUs, such as glimepiride and gliclazide modified release, are associated with better safety profiles. Furthermore, individualization of treatment, using SUs in combination with other drugs, backed with careful monitoring and patient education, ensures maximum benefits with minimal side effects. The current guidelines, developed by experts from Africa, Asia, and the Middle East, promote the safe and smart use of SUs in combination with other glucose-lowering drugs.
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Affiliation(s)
- Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India
| | - Silver Bahendeka
- Department of Internal Medicine, Diabetes & Endocrinology, St. Francis Hospital, Nsambya, Kampala, Uganda
| | - Rakesh Sahay
- Department of Endocrinology, Osmania Medical College, Hyderabad, Telangana, India
| | - Sujoy Ghosh
- Department of Endocrinology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Fariduddin Md
- Department of Endocrinology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Abbas Orabi
- Department of Internal Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Kaushik Ramaiya
- Department of Internal Medicine, Hindu Mandal Hospital, Dar es Salaam, Tanzania
| | | | - Dina Shrestha
- Department of Endocrinology, Norvic International Hospital and Medical College, and Hospital for Advanced Medicine and Surgery, Maharajganj, Kathmandu, Nepal
| | - Khalid Shaikh
- Department of Diabetes, Faculty of Internal Medicine, Royal Oman Police Hospital, Muscat, Oman
| | - Sachitha Abhayaratna
- Department of Pharmacology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Pradeep K. Shrestha
- Department of Medicine, Tribhuvan University Teaching Hospital, Maharajganj, Kathmandu, Nepal
| | | | | | - Aly Ahmed A. Rahim
- Department of Internal Medicine, Diabetes & Metabolism Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Fatimah Eliana
- Department of Internal Medicine, Faculty of Medicine, YARSI University, Jakarta, Indonesia
| | - Hari K. Shrestha
- Department of Internal Medicine, Kathmandu University Hospital, Dhulikhel, Nepal
| | | | - Nancy Ngugi
- Department of Endocrinology, Kenyatta National Hospital, Nairobi, Kenya
| | - Jean Claude Mbanya
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé, Yaounde, Cameroon
| | - Than Than Aye
- Department of Endocrinology, University of Medicine 2, Yangon, Myanmar
| | - Tint Swe Latt
- Department of Medicine, University of Medicine 2, Yangon, Myanmar
| | - Zhanay A. Akanov
- Center of Diabetes, Clinic of Internal Diseases, Asfendiyarov Kazakh National Medical University, Almaty, Republic of Kazakhstan
| | - Abbas Raza Syed
- Department of Endocrinology, Shaukat Khanum Hospital and Research Center, Lahore, Pakistan
| | - Nikhil Tandon
- Department of Endocrinology, Metabolism and Diabetes, All India Institute of Medical Sciences, Pune, Maharashtra, India
| | - A. G. Unnikrishnan
- Department of Endocrinology and Diabetes, Chellaram Diabetes Institute, Pune, Maharashtra, India
| | - S. V. Madhu
- Department of Medicine, University of Delhi, New Delhi, India
| | - Ali Jawa
- Department of Endocrinology, Diabetes and Metabolism, Wilshire Cardiovascular and Endocrine Center of Excellence, Lahore, Pakistan
| | - Subhankar Chowdhury
- Department of Endocrinology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Sarita Bajaj
- Department of Medicine, MLN Medical College, Allahabad, Uttar Pradesh, India
| | - Ashok Kumar Das
- Department of General Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
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12
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Sadikot S, Jothydev K, Zargar AH, Ahmad J, Arvind SR, Saboo B. Clinical practice points for diabetes management during RAMADAN fast. Diabetes Metab Syndr 2017; 11 Suppl 2:S811-S819. [PMID: 28629656 DOI: 10.1016/j.dsx.2017.06.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 06/06/2017] [Indexed: 10/19/2022]
Abstract
Diabetes management during Ramadan is very crucial from the patient perspective as it can present significant risk of hypoglycemia and death when proper care is not taken. Moreover, managing diabetes in fasting Ramadan patients require different mechanisms than the routine diabetes management and pose significant challenge to the health care practitioners. Here we set forth to review the available literature of various clinical trials and studies on different antidiabetic agents in the context of Ramadan. On the basis of available evidence, we suggest that gliclazide is effective and it could be safely recommended in type 2 diabetic patients fasting during Ramadan.
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Affiliation(s)
- Shaukat Sadikot
- International Diabetes Federation, Executive Board Member - International Atherosclerosis Association, Consultant at Jaslok Hospital and Research, Centre, Mumbai, India.
| | - K Jothydev
- Department of Diabetology, Jyothydev's Diabetes and Research Centre (JDC), Trivandrum, India
| | - A H Zargar
- Endocrine Society of India, Member Institute Body - AIIMS, New Delhi, Chairman - Independent Ethics Committee - Fortis Hospital, India
| | - Jamal Ahmad
- Centre for Diabetes & Endocrinology, Faculty of Medicine, J. N. Medical College Hospital, A.M.U., Aligarh, India
| | - S R Arvind
- DIACON Jospital, Diabetes Care and Research Centre, Bengaluru, India
| | - Banshi Saboo
- Diabetes Care & Hormone Clinic, Ahmedabad, India
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Hassanein M, Al-Arouj M, Hamdy O, Bebakar WMW, Jabbar A, Al-Madani A, Hanif W, Lessan N, Basit A, Tayeb K, Omar M, Abdallah K, Al Twaim A, Buyukbese MA, El-Sayed AA, Ben-Nakhi A. Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract 2017; 126:303-316. [PMID: 28347497 DOI: 10.1016/j.diabres.2017.03.003] [Citation(s) in RCA: 195] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 03/06/2017] [Indexed: 12/24/2022]
Abstract
Ramadan fasting is one of the five pillars of Islam and is compulsory for all healthy Muslims from puberty onwards. Exemptions exist for people with serious medical conditions, including many with diabetes, but a large number will participate, often against medical advice. Ensuring the optimal care of these patients during Ramadan is crucial. The International Diabetes Federation (IDF) and Diabetes and Ramadan (DAR) International Alliance have come together to deliver comprehensive guidelines on this subject. The key areas covered include epidemiology, the physiology of fasting, risk stratification, nutrition advice and medication adjustment. The IDF-DAR Practical Guidelines should enhance knowledge surrounding the issue of diabetes and Ramadan fasting, thereby empowering healthcare professionals to give the most up-to-date advice and the best possible support to their patients during Ramadan.
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Affiliation(s)
- Mohamed Hassanein
- Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates.
| | | | | | - Wan Mohamad Wan Bebakar
- School of Medical Sciences, Universiti Sains Malaysia, Hospital Universiti Sains Malaysia, Kota Bharu, Malaysia
| | | | | | - Wasim Hanif
- University Hospital Birmingham, Birmingham, UK
| | - Nader Lessan
- Imperial College London Diabetes Centre, Abu Dhabi, United Arab Emirates
| | - Abdul Basit
- Baqai Institute of Diabetology & Endocrinology, Baqai Medical University, Karachi, Pakistan
| | - Khaled Tayeb
- Diabetes Center, Al-Noor Hospital, Makkah, Saudi Arabia
| | - Mak Omar
- Nelson R Mandela School of Medicine, University of KwaZulu Natal, Durban, South Africa
| | | | - Abdulaziz Al Twaim
- King Abdulaziz Medical City, National Guard Hospital, Western Region, Saudi Arabia
| | | | - Adel A El-Sayed
- Chair of Diabetes Unit, Department of Internal Medicine, Sohag Faculty of Medicine, Sohag University, Egypt
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14
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Khattab M, Mahmoud K, Shaltout I. Effect of Vildagliptin Versus Sulfonylurea in Muslim Patients with Type 2 Diabetes Fasting During Ramadan in Egypt: Results from VIRTUE Study. Diabetes Ther 2016; 7:551-60. [PMID: 27550549 PMCID: PMC5014796 DOI: 10.1007/s13300-016-0190-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Fasting in patients with type 2 diabetes mellitus (T2DM) is associated with high risk of hypoglycemia. The aim of this study was to compare the effectiveness and safety of vildagliptin in T2DM patients fasting during Ramadan in a real-life setting in Egypt. METHODS In this 16-week prospective and noninterventional study, data were collected up to 6 weeks before and after Ramadan fasting. Patients who had received vildagliptin or sulfonylurea (SU) either as dual therapy with metformin or as monotherapy were enrolled into the study. RESULTS Two hundred fifty four patients were enrolled in the study, out of which 246 [121 (97.6%) treated with vildagliptin and 125 (99.2%) with SU] were included in the safety analysis set. A significantly lower proportion of patients experienced ≥1 hypoglycemic event (HE) with vildagliptin as compared to those receiving SUs (1.7% vs. 19.2%, respectively; p < 0.001). No patient in either group reported a grade 2 HE. At week 16, mean change in HbA1c from baseline for vildagliptin and SU were -0.1% and +0.3%, respectively, with a between-treatment difference of -0.4% (p < 0.001). Mean change in body weight from baseline for vildagliptin and SU were -0.8 and -0.1 kg, with a between-treatment difference of -0.7 kg (p = 0.011). A higher proportion of SU-treated patients experienced adverse events compared to those treated with vildagliptin (23.2% vs. 5.8%, respectively), the primary reason being the high incidence of hypoglycemia in the SU group (n = 24, 19.2%). CONCLUSIONS Treatment with vildagliptin was associated with lower incidence of hypoglycemia compared with SU and showed good glycemic and weight control in patients with T2DM fasting during Ramadan in a real-life setting in Egypt. FUNDING Novartis Pharma AG.
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Affiliation(s)
- Mohamed Khattab
- Internal Medicine and Diabetes, Cairo University, Giza, Egypt.
| | - Khalifa Mahmoud
- Internal Medicine and Diabetes, Alexandria University, Alexandria, Egypt
| | - Inass Shaltout
- Internal Medicine and Diabetes, Cairo University, Giza, Egypt
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15
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Al Sifri S, Rizvi K. Filling the Knowledge Gap in Diabetes Management During Ramadan: the Evolving Role of Trial Evidence. Diabetes Ther 2016; 7:221-40. [PMID: 27091198 PMCID: PMC4900978 DOI: 10.1007/s13300-016-0168-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Indexed: 12/14/2022] Open
Abstract
UNLABELLED Muslim patients with type 2 diabetes (T2D) who fast during Ramadan face challenges in diabetes management due to substantial alterations in lifestyle and treatment that frequently accompany the decision to fast. International guidelines for treating T2D do not fully address the clinical issues unique to fasting, and other guidance documents lack the large and high-quality evidence base available for non-fasting conditions. We reviewed 10 randomized controlled trials and 20 observational studies in T2D during Ramadan to assess the quality of evidence and identify issues in trial design that should be addressed in future studies. Results indicated that heterogeneity in key aspects of trial design precluded meaningful comparisons across studies. These included patients' baseline treatment at entry; use of a cutoff for glycemic control [glycated hemoglobin (HbA1c)] for eligibility; exclusion of patients with a history of recurrent hypoglycemia or hypoglycemia unawareness, or with other serious systemic diseases; duration of treatment and follow-up, selection of safety versus efficacy as primary end point; and definition and measurement of those end points. Fructosamine was rarely used as an efficacy end point, despite the advantage of reflecting glycemic control over a period more closely aligned with the duration of Ramadan fasting than HbA1c. Adherence to treatment, definition and adherence to fasting, and changes in diet and exercise were reported inconsistently, and when reported, not in a fashion that would allow adequate control of confounding due to these variables. Despite a large body of evidence demonstrating their safety and efficacy in non-fasting populations, only two trials reported data for glucagon-like peptide-1 analogs, and neither involved a head-to-head comparison against dipeptidyl peptidase-4 inhibitors. More rigorous studies using trial designs suited to the unique conditions of a fasting population and capturing both standardized efficacy and safety end points are needed to provide better guidance to optimal treatment of T2D during Ramadan fasting. FUNDING Novo Nordisk AG.
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Affiliation(s)
- Saud Al Sifri
- Endocrinology Department, Alhada Military Hospital, Taif, Saudi Arabia.
| | - Kashif Rizvi
- Specialized British Medical Unit, Mazaya Clover Centre, Jabriya, Kuwait
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16
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Loh HH, Yee A, Loh HS, Sukor N, Kamaruddin NA. Comparative studies of dipeptidyl peptidase 4 inhibitor vs sulphonylurea among Muslim Type 2 diabetes patients who fast in the month of Ramadan: A systematic review and meta-analysis. Prim Care Diabetes 2016; 10:210-219. [PMID: 26392074 DOI: 10.1016/j.pcd.2015.09.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 09/02/2015] [Accepted: 09/03/2015] [Indexed: 12/21/2022]
Abstract
AIM To systematically review the literature to compare the use of DPP4 inhibitors vs sulphonylurea in type 2 diabetic Muslim patients who fast in Ramadan, with regards to its safety, tolerability, glycemic control, and body weight changes. METHODS All English-language medical literature published from inception till October 2014 which met the inclusion criteria were reviewed and analyzed. RESULTS A total of nine papers were included, reviewed and analyzed. The total sample size was 4276 patients. All studies used either of the two DPP4 inhibitors - Vildagliptin or Sitagliptin, vs sulphonylurea or meglitinides. Patients receiving DPP4 inhibitors were less likely to develop symptomatic hypoglycemia (risk ratio 0.46; 95% CI, 0.30-0.70), confirmed hypoglycemia (risk ratio 0.36; 95% CI, 0.21-0.64) and severe hypoglycemia (risk ratio 0.22; 95% CI, 0.10-0.53) compared with patients on sulphonylureas. There was no statistically significant difference in HbA1C changes comparing Vildagliptin and sulphonylurea. CONCLUSION DPP4 inhibitor is a safer alternative to sulphonylurea in Muslim patients with type 2 diabetes mellitus who fast during the month of Ramadan as it is associated with lower risk of symptomatic, confirmed and severe hypoglycemia, with efficacy comparable to sulphonylurea.
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Affiliation(s)
- Huai Heng Loh
- Faculty of Medicine and Health Sciences, University of Malaysia Sarawak, Jalan Datuk Mohd Musa, 94300 Kota Samarahan, Sarawak, Malaysia.
| | - Anne Yee
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Huai Seng Loh
- Clinical Academic Unit, Newcastle University Medicine Malaysia, No. 1, Jalan Sarjana 1, Kota Ilmu, Educity@Iskandar, 79200 Nusajaya, Johor, Malaysia
| | - Norlela Sukor
- Department of Medicine, Universiti Kebangsaan Malaysia Medical Center, Malaysia
| | - Nor Azmi Kamaruddin
- Department of Medicine, Universiti Kebangsaan Malaysia Medical Center, Malaysia
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Lee SWH, Lee JY, Tan CSS, Wong CP. Strategies to Make Ramadan Fasting Safer in Type 2 Diabetics: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials and Observational Studies. Medicine (Baltimore) 2016; 95:e2457. [PMID: 26765440 PMCID: PMC4718266 DOI: 10.1097/md.0000000000002457] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Ramadan is the holy month for Muslims whereby they fast from predawn to after sunset and is observed by all healthy Muslim adults as well as a large population of type 2 diabetic Muslims.To determine the comparative effectiveness of various strategies that have been used for type 2 diabetic Muslim who fast during Ramadan.A systematic review and network meta-analysis of randomized controlled studies (RCT) as well as observational studies for patients with type 2 diabetes who fasted during Ramadan was conducted. Eight databases were searched from January 1980 through October 2015 for relevant studies. Two reviewers independently screened and assessed study for eligibility, assessed the risk of bias, and extracted relevant data. A network meta-analysis for each outcome was fitted separately, combining direct and indirect evidence for each comparison.Twenty-nine studies, 16 RCTs and 13 observational studies each met the inclusion criteria. The most common strategy used was drug changes during the Ramadan period, which found that the use of DPP-4 (Dipeptidyl peptidase inhibitor -4) inhibitors were associated with a reduction in incidence of experiencing hypoglycemia during Ramadan in both RCTs (pooled relative risk: 0.56; 95% confidence interval: 0.44-0.72) as well as in observational studies (pooled relative risk: 0.27; 0.09-0.75). Ramadan-focused education was shown to be beneficial in reducing hypoglycemia in observational studies but not RCTs (0.25 versus 1.00). Network meta-analyses suggest that incretin mimetics can reduce the risk of hypoglycemia by nearly 1.5 times.The newer antidiabetic agents appear to lower the risk of hypoglycemia and improved glycemic control when compared with sulfonylureas. Ramadan-focused education shows to be a promising strategy but more rigorous examination from RCTs are required.
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Affiliation(s)
- Shaun Wen Huey Lee
- From the School of Pharmacy, Monash University Malaysia, Bandar Sunway (SWHL, JYL), School of Allied Health Sciences, SEGi University, Kota Damansara (CSST); and Jeffery Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia (CPW)
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Mudher Mikhael E. Effectiveness and Safety of Newer Antidiabetic Medications for Ramadan Fasting Diabetic Patients. J Diabetes Res 2016; 2016:6962574. [PMID: 27642611 PMCID: PMC5013205 DOI: 10.1155/2016/6962574] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 07/06/2016] [Accepted: 07/19/2016] [Indexed: 02/08/2023] Open
Abstract
Hypoglycemia is the most common side effects for most glucose-lowering therapies. It constitutes a serious risk that faces diabetic patients who fast during Ramadan (the 9th month in the Islamic calendar). New glucose-lowering classes like dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide 1 receptor agonist (GLP-1 RA), and sodium-glucose cotransporter-2 (SGLT-2) inhibitors are efficacious in controlling blood glucose level with less tendency to induce hypoglycemia and thus may constitute a good choice for diabetic patients during Ramadan. This study reviews the safety and efficacy of newer glucose-lowering therapies during Ramadan. This study was accomplished through a careful literature search about studies that assess the benefit and side effects of these new glucose-lowering therapies during Ramadan during September 2015. Vildagliptin, sitagliptin, liraglutide, exenatide, and dapagliflozin were the only studied glucose-lowering therapies. All of the studied newer glucose-lowering therapies except dapagliflozin were associated with reduced risk to induce hypoglycemia. Gastrointestinal upset was common with the usage of liraglutide while increased thirst sensation was common with dapagliflozin. In conclusion DPP-4 inhibitors such as vildagliptin and sitagliptin may form a suitable glucose-lowering therapy option for Ramadan fasting patients.
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Affiliation(s)
- Ehab Mudher Mikhael
- College of Pharmacy, Clinical Pharmacy Department, Baghdad University, Baghdad, Iraq
- *Ehab Mudher Mikhael:
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Gray LJ, Dales J, Brady EM, Khunti K, Hanif W, Davies MJ. Safety and effectiveness of non-insulin glucose-lowering agents in the treatment of people with type 2 diabetes who observe Ramadan: a systematic review and meta-analysis. Diabetes Obes Metab 2015; 17:639-48. [PMID: 25777247 DOI: 10.1111/dom.12462] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 03/04/2015] [Accepted: 03/12/2015] [Indexed: 01/07/2023]
Abstract
AIM To determine which non-insulin glucose-lowering treatment regimens are most appropriate in people with type 2 diabetes who choose to fast during Ramadan. METHODS Electronic databases were searched for randomized controlled trials (RCTs) and observational studies that compared non-insulin glucose-lowering agents in people with type 2 diabetes fasting during Ramadan. Those studies which reported hypoglycaemia, weight and glycated haemoglobin (HbA1c) change were included. Data were pooled using random effects models. RESULTS A total of 16 studies were included: 9 RCTs and 7 observational studies. There was evidence that dipeptidyl peptidase-4 (DPP-4) inhibitors led to fewer hypoglycaemic events compared with sulphonylureas. Sitagliptin significantly reduced the number of patients with ≥1 hypoglycaemic episodes during Ramadan [risk ratio (RR) 0.48, 95% confidence interval (CI) 0.36, 0.64; p > 0.0001]. This was not replicated in the RCTs of vildagliptin, but a significant reduction was found in the observational studies (RR 0.28, 95% CI 0.10, 0.75; p = 0.01) with high heterogeneity (I(2) = 86.7%). Significant reductions in HbA1c and weight were seen in the observational studies of vildagliptin versus sulphonylureas. The use of liraglutide led to significant weight loss (-1.81 kg, 95% CI -2.91, -0.71; p = 0.001) compared with sulphonylureas. Pioglitazone significantly increased weight compared with placebo (3.48 kg, 95% CI 2.82, 4.14; p < 0.0001). CONCLUSIONS The analysis supports the use of DPP-4 inhibitors during Ramadan rather than sulphonylureas for reduction in hypoglycaemia without a cost to diabetes control and weight. The glucagon-like peptide (GLP)-1 agonist liraglutide provides clinical benefits, but more studies are required. RCTs of DPP-4 inhibitors compared with GLP-1 agonists and novel therapies including the sodium-glucose co-transporter 2 and α-glucosidase inhibitors are needed to inform evidence-based guidelines.
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Affiliation(s)
- L J Gray
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - J Dales
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - E M Brady
- Leicester Diabetes Centre, University Hospitals of Leicester, Leicester, UK
| | - K Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Leicester Diabetes Centre, University Hospitals of Leicester, Leicester, UK
| | - W Hanif
- Department of Diabetes & Endocrinology, University Hospital Birmingham, NHS Trust, Birmingham, UK
| | - M J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Leicester Diabetes Centre, University Hospitals of Leicester, Leicester, UK
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Aziz KMA. Fasting during Ramadan: efficacy, safety, and patient acceptability of vildagliptin in diabetic patients. Diabetes Metab Syndr Obes 2015; 8:207-11. [PMID: 25931826 PMCID: PMC4404947 DOI: 10.2147/dmso.s54683] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Diabetes management during Ramadan fasting is challenging to the physician in terms of minimizing the risk of hypoglycemia. As compared to oral hypoglycemic agents (OHAs) and sulfonylureas (SUs), which carry a higher and significant risk of hypoglycemia, newer antidiabetic agents such as dipeptidyl peptidase-4 (DPP-4) inhibitors have demonstrated lower risk of hypoglycemia during Ramadan fasting, with better patient compliance. In addition to diabetes education and pre-Ramadan assessments, the physician should also consider use of DPP-4 inhibitors (such as vildagliptin) during Ramadan fasting to minimize the risk of hypoglycemia in type 2 diabetic subjects. Severe episodes of hypoglycemia have been demonstrated in recent research and clinical trials with OHAs/SUs. Conversely, these research observations have also demonstrated comparative safety and efficacy with lower risk of hypoglycemia associated with vildagliptin. Current research review has collected evidence-based clinical trials and observations for the drug vildagliptin to minimize the risk of hypoglycemia during Ramadan fasting, while at the same time focusing the role of diabetes self-management education (DSME), pre-Ramadan assessments, and patient care.
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Affiliation(s)
- Kamran MA Aziz
- Aseer Diabetes Center, Aseer Central Hospital, Ministry of Health, Abha, Saudi Arabia
- Correspondence: Kamran MA Aziz, Aseer Diabetes Center, Aseer Central Hospital, Ministry of Health, PO Box 34, Abha, Saudi Arabia, Tel +966 5 6836 1040, Email
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