Sodium glucose co transporter 2 inhibitors and Ramadan: Another string to the bow

Use of SGLT2 inhibitors during Ramadan: An expert panel statement

Fasting from dawn to sunset, during the holy month of Ramadan, constitutes one of the five main pillars in Islam and is observed by the majority of Muslims. Owing to important physiological changes, Ramadan fasting holds a crucial place in the context of diabetes management. Approximately one-fifth of the world's Muslim population resides in the Middle East and Africa (MEA) region. To discuss the challenges and management of diabetes during Ramadan fasting in the MEA region, a panel of 12 experts in the field of diabetes from across the MEA region attended two expert committee meetings held in Dubai. The key point of discussion was the safety and efficacy of the use of sodium-glucose co-transporter 2 inhibitors (SGLT2i) during Ramadan, based on outcomes of the recent clinical trials with SGLT2i. This is the first consensus recommendation on the management of diabetes with SGLT2i across the MEA region during Ramadan. The document summarizes expert views and opinions on the current management of diabetes with SGLT2i during Ramadan and aims to enhance the current knowledge and understanding on the issue of diabetes management during Ramadan. This will aid the physicians of the MEA region with appropriate decision-making for their patients during Ramadan.

Evolving physicians' perceptions and practices regarding use of SGLT2 inhibitors for type 2 diabetes during Ramadan fasting

OBJECTIVES

We followed up the evolving perceptions and practices regarding use of SGLT-2 inhibitors in Ramadan.

METHODS

We compared results of the three survey in 2015, 2017, 2019.

RESULTS

Senior doctors represented 43.5-66.4% and endocrinologists accounted for 38.1-60.2%. There was a steady reduction in the proportions of respondents who did not know SGLT2-Is at all, who have just heard about the class and those who are quite familiar with the class but have not yet used any. Whereas the proportions of those using the SGLT2-Is class occasionally only was stable. However those who use the SGLT2-Is regularly increased from 11.0% to 45.6% and 62.6%. The respondents' who SGLT2-Is are safe and may be used in all fasting diabetic patients increased from 15.5%, 14.7% to 23.1%. Whereas the view that SGLT2-Is should not be used decreased progressively. Majority of respondents in the three surveys suggested that specific advice is given if they allow the use of SGLT2-Is during Ramadan. More respondents advise taking the medication with the first evening meal than before the last pre-dawn meal and advised to attend to their hydration status. One third of respondents would resume SGLT2-Is immediately after the end of Ramadan; 15% after 1-2 weeks, or prefer to wait till the next medical or educator's clinic visit and others would re-evaluate patients' management plan.

CONCLUSIONS

The medical professions' knowledge and perceptions regarding the use of SGLT2-Is during Ramadan fasting have evolved over the last few years due to increasing research and experience.

Glycemic management during Jain fasts

This review describes the various fasts observed by adherents of the Jain religion. It attempts to classify them according to their suitability for people with diabetes and suggests appropriate regime and dose modification for those observing these fasts. The review is an endeavor to encourage rational and evidence-based management in this field of diabetology.

Safe and pragmatic use of sodium-glucose co-transporter 2 inhibitors in type 2 diabetes mellitus: South Asian Federation of Endocrine Societies consensus statement

Diabetes prevalence shows a continuous increasing trend in South Asia. Although well-established treatment modalities exist for type 2 diabetes mellitus (T2DM) management, they are limited by their side effect profile. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) with their novel insulin-independent renal action provide improved glycemic control, supplemented by reduction in weight and blood pressure, and cardiovascular safety. Based on the clinical outcomes with SGLT2i in patients with T2DM, treatment strategies that make a "good clinical sense" are desirable. Considering the peculiar lifestyle, body types, dietary patterns (long duration religious fasts), and the hot climate of the South Asian population, a unanimous decision was taken to design specific, customized guidelines for T2DM treatment strategies in these regions. The panel met for a discussion three times so as to get a consensus for the guidelines, and only unanimous consensus was included. After careful consideration of the quality and strength of the available evidence, the executive summary of this consensus statement was developed based on the American Association of Clinical Endocrinologists/American College of Endocrinology protocol.

Effectiveness and Safety of Newer Antidiabetic Medications for Ramadan Fasting Diabetic Patients

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.

Fasts, feasts and festivals in diabetes-1: Glycemic management during Hindu fasts

This communication is the first of a series on South Asian fasts, festivals, and diabetes, designed to spread awareness and stimulate research on this aspect of diabetes and metabolic care. It describes the various fasts observed as part of Hindu religion and offers a classification scheme for them, labeling them as infrequent and frequent. The infrequent fasts are further sub-classified as brief and prolonged, to facilitate a scientific approach to glycemic management during these fasts. Pre-fast counseling, non-pharmacological therapy, pharmacological modification, and post-fast debriefing are discussed in detail. All available drug classes and molecules are covered in this article, which provides guidance about necessary changes in dosage and timing of administration. While in no way exhaustive, the brief review offers a basic framework which diabetes care professionals can use to counsel and manage persons in their care who wish to observe various Hindu fasts.