https://diabetes.acponline.org/archives/2015/11/13/6.htm

Review: In patients with type 2 diabetes who fast, sitagliptin reduces hypoglycemia more than sulfonylurea

Patients who took sitagliptin were significantly less likely to have hypoglycemia during Ramadan, according to a systematic review.


Patients who took sitagliptin were significantly less likely to have hypoglycemia during Ramadan, according to a systematic review, which included 9 randomized controlled trials (RCTs) and 7 observational studies. The review generally concluded that dipeptidyl peptidase-4 inhibitors were associated with fewer hypoglycemic events than sulfonylureas, supporting their use during Ramadan, although the authors noted that liraglutide requires more study on this question, as it also appeared to provide benefits.

The review was published in the July Diabetes, Obesity and Metabolism. The following commentary by Gunjan Y. Gandhi, MD, MSc, was published in the ACP Journal Club section of the Oct. 20 Annals of Internal Medicine.

Blood glucose levels generally fall in persons with diabetes during Ramadan fasting, with increased risk for hypoglycemia. Diabetes should be treated with medications that do not further increase this risk.

Dipeptidyl peptidase (DPP)-4 inhibitors (such as sitagliptin) augment incretins, a group of metabolic hormones that stimulate a decrease in blood glucose levels by causing glucose-dependent insulin secretion and inhibiting glucagon release. Although the meta-analysis by Gray and colleagues is by no means conclusive in quality or quantity, its results show that DPP-4 inhibitors cause less hypoglycemia than sulfonylureas, which cause facultative pancreatic insulin secretion. This probably does not come at the cost of worsening glycemic control or weight gain. In Muslims who fast during Ramadan, adherence may be higher for this class of medications, although the cost of sitagliptin may be prohibitive for some patients. If metformin is not tolerated or is contraindicated, incretin-based therapy with DPP-4 inhibitors, as monotherapy or as an add-on to metformin, may be a reasonable alternative to sulfonylureas.

Another incretin-mimetic therapy, glucagon-like peptide-1 analogues, work similarly to DPP-4 inhibitors and could be further evaluated as a potential treatment option. Other noninsulin treatment agents, such as α-glucosidase inhibitors (which reduce glucose absorption), thiazolidinediones (which reduce insulin resistance), and sodium-glucose cotransporter-2 inhibitors (which induce glucosuria), could be considered. However, detailed evidence is inadequate to support widespread use in persons with diabetes who fast during Ramadan.

Care providers need to discuss modifying treatment regimens with their patients early before Ramadan. Individualized educational interventions for empowering patients and increasing self-care awareness seem to reduce risk for hypoglycemia while helping with weight control and improving glycemic control. This approach may need involvement from medical care teams, families, communities, and religious organizations. The importance of self-monitoring blood glucose levels should be reinforced. Such approaches as supplementing education by telemonitoring seem to increase safety during fasting.

We need RCTs that directly compare the effects of available medications on patient-important outcomes, such as seizures, falls, and death. Additional studies for special populations, such as the elderly, are also needed.