Use of sodium-glucose co-transporter 2 inhibitors during the fasting of ramadan: Is there cause for concern?
Authors: Beshyah Salem , Farooqi Muhammad , Suliman Sara , Benbarka Mahmoud 
Published: July 2017

Background: There is some anxiety among physicians about the safety of using sodium-glucose co-transporter 2 (SGLT2) inhibitors in Muslim type 2 diabetes mellitus (T2DM) patients who wish to observe the fast during Ramadan particularly during the summer in hot regions. There is a dearth of research data to help guide physicians and reassure patients.
Objectives: To try and extrapolate to the “Ramadan” scenario, we reviewed the pharmacology of SGLT2 inhibitors and those side effects that may be relevant to Ramadan fasting such as osmotic diuresis, dehydration, use in the elderly and concomitant use with diuretics as well as the potential risk of ketoacidosis. We also reviewed the perceptions among physicians along with the currently available expert opinions and recommendations. Approach: The following aspects are addressed 1. Characteristics and pharmacology of SGLT2 inhibition 2. Side effects having a potential relevance to Ramadan fasting 3. Studies of patient outcomes and physician perceptions and 4. Expert opinions and management recommendations.
Emerging concepts: 1. SGLT2 inhibitors are a new glucoselowering therapy for T2DM with documented benefits on blood glucose, hypertension, weight reduction and long term cardiovascular benefit. They have an inherent osmotic diuretic effect and lead to some volume loss and possible dehydration. 2. One study confirmed better glycemic control with less risk of hypoglycemia and no marked volume depletion when compared with sulphonylureas. The experiences with their use in the elderly and in combination with diuretics are reassuring for the safety of their use in Ramadan. 3. SGLT2 inhibitor-related diabetic ketoacidosis has not been reported during Ramadan fasting to date. 4. A survey of physicians' opinions revealed that the majority felt that SGLT2 inhibitors are generally safe in T2DM patients during Ramadan fasting but should be discontinued in certain high risk patients. Most respondents also indicated that they would advise taking the SGLT2 inhibitors with the sunset meal (Iftar) and recommend consuming extra clear fluids in the evening. 5. So far, only a few professional groups with interest in Ramadan fasting updated their guidelines and recommendations on management of diabetes to include the SGLT2 inhibitors. These opinions acknowledged the lack of trial data, recommended caution in high risk groups, advised regular monitoring and emphasized pre-Ramadan patients' education and awareness about possible complications. Conclusions: The current knowledge of SGLT2 inhibitors in clinical practice is reviewed with a focus on their use during Ramadan fasting. There are limited data however, extrapolating from their current use, it is likely that stable patients with no high risk of dehydration and with normal kidney functions may safely continue using the SGLT2 inhibitors therapy. It may be prudent that higher risk patients be observed carefully and any decision concerning SGLT2 inhibitors is taken on individual basis. Planned clinical trials, objective observational studies, clinical audits and patients' reports of their own clinical experience should provide ample opportunity to help answer many of the as yet unanswered questions. Results from studies conducted during the current Ramadan period are eagerly awaited.