Ramadan Month for Type 2 Diabetes

Mellitus: Understanding the

Difference

A. Makbul Aman M
Division of Endocrine and Metabolism Department of Internal
Medicine
Faculty of Medinine Hasanuddin University Makassar 2021

Exp. Date: 3rd Feb

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FR+aa-/ st41am inagddaunrinMgudbaayratkime in the
is - a n o b
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l ig
s h ia
a t
r le
o
s a ma
ry d u ty al Healthy adult
0 h ra . i

month of Ramadan
Tidak Makan
Muslims
- Tidak minu

َُّ ‫ب تِكُ اونُ َماءَ نَيذِلَّا اهَ َي‬

- Tidak mem
‫أي‬ ِ
َ َ ْ ُ ُ ’‫ُمايَص‬
‫ع‬ ‫ل‬
َ ‫ي‬ ‫ك‬ ‫م‬ ‫ال‬
‫ك‬ ِ ‫ت‬ ‫ب‬ ‫ع‬ ‫ل‬ ‫ى‬ ‫ا‬ ‫ل‬ ِ ‫يذ‬ ‫ن‬ ِ
‫نم‬ ‫ق‬ ‫ب‬ِ ‫ل‬ ‫ك‬ ‫م‬
ُ َ َ َ َّ َ َ ْ ُ ْ َ‫كل‬
‫ل‬
َ ‫ع‬
َّ ُ ‫ْم‬
َ‫ام ك‬ َ
“Wahai orang-orang yang beriman!‫ت‬ َّ‫نَ و ُقت‬
َ Kamu
diwajibkan berpuasa sebagaimana
diwajibkan atas orang-orang yang dahulu
daripada kamu,
supaya kamu
bertaqwa. ”.
• Fasting in Ramadan is a means
learning
of self-
control
From sunrise to sunset:
No food
No drinking
No smoking
And no oral medications
Who Cannot
Fast
1. Phys i c a l y sْ iِ c k ( Q ur an:ِ 2
2. Traveler ‫َ ُكَ م‬
‫َا‬ ُ ‫ُك او ِبَ َلِع َمِ ال‬
‫ ا م‬a‫يص‬journey
‫ن‬ ‫ق‬ ‫ب‬ّ ‫ل‬ ‫ك‬ ‫م‬ ‫ل‬ ّ‫َ َ ِ َ وقتَت مكلع‬
on َ ’ ُ َ (above) ُ
ْ َ gm
ََ َ ‫ك‬ ‫ت‬ ‫ب‬ ‫لع‬ ‫ا‬ ‫ُنيذ‬
3.
5 Women
8 1 -4 ‫م‬
8‫ن‬
d َ u
1 rin) َ
َّ‫ل‬4.ِ‫ ?يذ‬Pregnant
َ ‫ن م اء ن‬ ‫ ا اهيَُّأي‬lactating
ُ and َ
ْeُnwomen
ْstruatiَon
5. pre pubertal children

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Can a diabetic patient fast
during Ramadan?
Ramadan affects patients with
diabetes
Change in frequency of meals
• Two meals per day:
• Sehri (before dawn)
•Iftari (at sunset)
Change in dietary
patterns
• Increase in intake of:
• Sugary drinks
• Fried foods

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• C arbohydrate-rich
meals

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• Sweets 5
Fasting during Ramadan is one of the five pillars of Islam and
commemorates the time when the Holy Quran was revealed
to Muhammad.1

Diabetes hinders individuals to conveniently

fasting during Ramadhan, why?
Many Muslims with The risks facing patie
Diabetes have an intense nts with diabetes are
desire to participate in heightened during
fasting during Ramadan. Ramadan.

Ensuring the optimal The type of diabetes

care of Muslim patients medication influences
with diabetes who fast the potential risks
during Ramadan is during Ramadhan.

Exp. Date: 3 Feb 20

crucial.

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1. International Diabetes Federation and the DAR International Alliance. 2016. Diabetes and
Ramadan: Practical Guidelines. Brussels, Belgium: International Diabetes Federation.

2
6
Overview of Type 2 Diabetes
Melitus during non-Ramadan
Period

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7
 Global Muslim with diabetes
prevalence1

Estimates suggest that there are 148

million Muslims with diabetes
worldwide1

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1. International Diabetes Federation and the DAR International Alliance. 2016. Diabetes and Ramadan: Practical
Guidelines. Brussels, Belgium: International Diabetes Federation.
8
 Global Muslim with diabetes prevalence1,2

The majority of Muslims with Percentage of patients with T2DM

T2DM fasted every day during fasting for specific periods during
Ramadan (CREED study)1 Ramadan

32.4
%

94.2% of Muslims with 5.9

%
67.6
%

diabetes fasted for at least half of

the month during Ramadan in 94.2
≥15
%
2010, and two- thirds fasted every days
day (<ever
y day)

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Every

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<15 ≥15 day
days days

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1. International Diabetes Federation and the DAR International Alliance. 2016. Diabetes and Ramadan: Practical
Guidelines. Brussels, Belgium: International Diabetes Federation.
2. Jabbar A, et al.2017. Diabetes Res Clin Pract. Oct;132:19-26. 9
Diabetes and
Ramadan Facts in
Indonesia
The World’s Total Muslim Population
(1.57 billion people; 23% of the
world population)
Indonesia (has the largest Muslim population
of any country on earth
Currently, no exact statistic defined Indonesian
Muslim with Diabetes fasting during Ramadan,
but the facts showed;
88% of total Indonesian population are Muslim 1
3 Muslim-majority countries
(Indonesia, Bangladesh,

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Egypt)

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being in the top 10 of countries with
the highest
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Key risk associated with

diabetes patients during
Ramadhan

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1
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Pathophysiological perspectives of diabetic patients

during Ramadhan:
what is the different between healthy
individuals and diabetic patients?

Healthy Diabetic Patients

individuals VS during Ramad
during Ramadhan . han

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1. International Diabetes Federation and the DAR International Alliance. 2016. Diabetes
and Ramadan: Practical Guidelines. Brussels, Belgium: International Diabetes
Federation. 1
2
 Pathophysiology of fasting in Pathophysiology of fasting in
healthy individuals Diabetes
Meal

Glucose

Insulin
sec retion
stimulates Inhibits

Pa nc rea
s
Gluconeogenesis G lyc ogen stores
depleted

Glucose

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Live Musc l
r e

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1 13
Adapted from Diabetes and Ramadan:Practical Guidelines. International Diabetes Federation (IDF), in
collaboration 3
There are risks associated with fasting in patients with
diabetes
1 Hypoglycaemia:
2
due to decreased or irregular food
intake together with the use of anti-
Hyperglycaemia:
due to excessive glycogen breakdown,
increased gluconeogenesis and
diabetic medication; 1–3 this has a reduced doses of antidiabetic
negative impact on patient morbidity, medication1,2

mortality & QoL3–9

3 Dehydration: 4

caused by limited fluid intake, Ketoacidosis:

as well as osmotic diuresis
produced by due to
hyperglycaemia1 increased
ketogenesis1,2
1Al-Arouj M et al. Diabetes Care 2010;33:1895–902;2Salti I et al. Diabetes Care 2004;27:2306–11; 3Amiel SA et al. Diabet Med 2007;25:245–54;
4Whitmer RA et al. JAMA 2009;301:1565–72; 5Bonds DE et al. BMJ 2010;340:b4909; 6Barnett AH. Curr Med Res Opin 2010;26:1333–42; 7Foley
JE et al. Vasc Health Risk Manag 2010;6:541–8; 8Begg IS et al. Can J Diabetes 2003;27:128–40; 9McEwan P et al. Diabetes Obes Metab 14
2010;12:431– 6
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EPIDIAR study: fasting during Ramadan increases the risk of
severe hypoglycaemia and hyperglycaemia in patients with
T2DM
EPIDIAR = EPIdemiology of DIAbetes and Ramadan; T2DM = type 2 diabetes mellitus
Higher risk of severe Higher risk of severe
hypoglycaemic events† in overall hyperglycaemic events† in overall
population during Ramadan‡1,2 population during Ramadan‡1,2

(events/100 patients/month)
P<0.000 P<0.0001
7.5-fold 1
increase* 5-fold increase
†Events requiring hospitalization in
overall population with T2DM;
patients/month)

‡c ompared with previous months

* There was a 7.5 fold difference of
(events/100

hypoglycaemia in overall population

Incidence
fasting during Ramadan. For patients
Incidence

who fasted for > 15 days difference

was, 6.7 fold

During
Pre-Ramadan
Ramadan

Therefore, Without suitable management, patients with diabetes are more likely
to experience severe Hypoglycaemia during Ramadan than in non-fasting

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periods.3

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1. Salti I, et al. Diabetes Care 2004;27:2306–11

2022
2. Al-Arouj M , et al. Diabetes C are 2010;33:1895–902
3.International Diabetes Federation and the DAR International Alliance. 2016. Diabetes
and Ramadan: Practical Guidelines. Brussels, Belgium: International Diabetes 1
Federation. 5
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The type of medication the patient is taking for diabetes

management influences the potential risks that fasting
may cause and needs careful attention within the treatment plan.1

In the pre-Ramadan assessment, the HCP may adjust the dose, timing
or the type of medication to minimise the risk to the patient.1

only of the whole population changed

their treatment dose (approximately

<50
one- fourth of patients treated with
oral antidiabetic drugs [OADs] and
one- third of patients using insulin).2

Exp. Date: 3rd Feb

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1. International Diabetes Federation and the DAR International Alliance. 2016. Diabetes and Ramadan:
Practical Guidelines. Brussels, Belgium: International Diabetes Federation.
2. Salti et al. 2004. Diabetes Care. Oct;27(10):2306-11. doi: 10.2337/diacare.27.10.2306. 1
6
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Therefore, Ramadan has a major

impact on the management of
diabetes in the Muslim population
and with so many Muslims with
diabetes deciding to fast,
the importance of practical
diabetes and Ramadan guidance
becomes evident.

Ensuring the optimal c are for

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T2DM patients during Ramadan

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is Crucial
 Key components of
a Ramadan-focused
educational Risk
quantifica
program
Studies have demonstrated a
-tion

clear benefit of Ramadan-focused education

program 1,2 When Blood
to glucose
• in terms of glycemic control, weight loss break lowerin
and Key
the fast g
components
a reduced risk of hypoglycemic events. 1,2 of a
• The positive outcomes of Ramadan- Ramadan-
focused focused
educational
education extend may also Medicati programe Fluids
beyond the month of fasting. 1,2 on and
increase awareness of the issues of diabetes adjustm dietar
Although multiple
management approaches
during Ramadan,may education
be ent y
advice
taken
is
fundamental to for the provision of optimal care
fasting.
when Patients should have a clear understanding of Exercise
advice
how, by changing their behaviours, they can minimise

Exp. Date: 3rd Feb

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potential risks.

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1. International Diabetes Federation and the DAR International Alliance. 2016. Diabetes and Ramadan: Practical Guidelines. Brussels, Belgium: International Diabetes
Federation. 1
8
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The Importance of Risk Stratification

of Individuals with Diabetes before
Ramadan

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9
 Factors for risk
quantification

Type of Patient Individual Presence of Individual Previous

diabetes medications hypoglycaemic complications social and Ramadan
risk and/or work experience
comorbidities circumstances

This assessment exercise must be carried out on an individual basis for each patient looking to
fast during Ramadan, and the care given must be personalised according to the patient’s
specific circumstances

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1. International Diabetes Federation and the DAR International Alliance. 2016 Diabetes and Ramadan: Practical Guidelines. 2
Brussels, Belgium: International Diabetes Federation, 2016. www.idf.org/guidelines/diabetes-in-ramadan and 0
The Importance of Risk Stratification of Individuals with Diabetes before
Ramadan
Category 1: very high-risk group
severe hypoglycaemia within the last 3 months
prior to Ramadan
Patients with a history of recurrent hypoglycaemia
Patients with lack of hypoglycaemia awareness
Patients with sustained poor glycaemic control
Ketoacidosis within the last 3 months
prior to Ramadan
Type 1 diabetes
Acute illness
Hyperosmolar hyperglycaemic coma within
the previous 3 months
Patients who perform intense physical labour
Pregnancy
Patients on chronic dialysis
Category 2: high-risk group
Patients with moderate hyperglycaemia
blood glucose levels of 10.0–16.5 mmol/L
(180–300 mg/dL) or high HbA1C (> 10%)
Patients with renal insufficiency
Patients with advanced
macrovascular complications
People living alone who are treated with
insulin or sulphonylureas
Patients living alone with comorbid
conditions that present additional risk
factors
old age with ill healt
Drugs that may affect cognitive state
Category 3: moderate risk
Well-controlled patients treated with
short- acting insulin secretagogues such
as repaglinide or nateglinide
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Category 4: low risk
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Well-controlled patients treated with diet
alone, metformin, or a thiazolidinedione, who 2
are otherwise healthy 1
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How to Help Patients Fast Safely

• Patient Education Program.
• Select more safe drugs.
• Adjust dose if needed
• Ensure good non – sugar fluid intake.
• Avoid heavy physical exercise at
afternoon.
• Ensure good calorie

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distribution.

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2
2
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Management of Type 2
Diabetes Melitus during
Ramadan Period

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3
 DIABETES AND RAMADAN
PRACTICAL GUIDANCE (1/2); 1,2

Two or four months before

Ramadan1
Based on PERKENI, 2015; Medication adjustment during Ramadan is
rec ommended to be assessed 2-4 months before Ramadan

Based on IDF DAR guideline 2016; All patients with diabetes wishing to fast
should have a pre-Ramadan assessment with a healthcare professional
(HC P), ideally 6–8 weeks before the start of Ramadan

Ramadhan focused education 1,2

Medical Assessment 1,2

• Individualized approach Education of patients and carers on the effects of fasting
• Review of overall glycemic control, blood pressure, on diabetes, including:
and lipids, renal function • Meal planning and dietary advice with dietitian
• Body weight and body max index • Appropriate levels of exercise
• Change to diabetes medication regimens: treatment • Blood glucose monitoring
choice, timing, and dosage adjusment • How to recognize and manage acute complication, eg
hypoglycemia, hyperglycemia, dehydration, and when
to breakfast

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00082
1. PERKENI. 2015. Panduan Penatalaksanaan DM Tipe 2 pada Individu Dewasa di Bulan
Ramadan. 2. Hui E et al. 2010. BMJ 2010;340:c3053.
3. International Diabetes Federation and the DAR International Alliance. 2016. Diabetes and Ramadan:
2
Practical Guidelines. Brussels, Belgium: International Diabetes Federation. 4
 DIABETES AND RAMADAN
PRACTICAL GUIDANCE (2/2); 1,2

Diet controlled patients Treatment with injectables

• Split daily calories over 2 or 3 smaller •
Insulin
In general, use an overnight
Oral glycaemic agents
meals during the non fasting intermediate acting insulin, plus a
• Choice of treatment should
interval rapid acting insulin before meals
be individualized
• Eat complex carbohydrates (eg • Adjustment to treatment necessary –
• Dipeptidyl peptidase-4
oatmeal, bran, brown rice) at suhur eg reduce insulin glargine dose by
rapid acting insulin secretagogues,
inhibitors,
(pre dawn meal) and simple 20% and use Mix 50 in the evening
and thiazolidinediones may be used
carbohydrates at iftar (sunset meal) Instead of Mix 30 to avoid
at meal times without dose
• Avoid foot high in fat and sugar postprandial hyperglycemia
adjustment
• Ensure adequate fluid intake during • Glucagon-like peptide-1 mimetics
• Ensure adequate fluid intake
non-fasting interval • No treatment adjustment required

Oral Insulin Metformin Sulfonylureas

Modify timing of doses: DPP4 (Sitagliptin)i:
Sec retagogue C onsider dose adjustment, eg
• Two thirds of daily dose • No dose adjustment
s Eg • Reduction in suhur dose if
at is needed.
•repaglinide
Short a cting taking twic e daily dose
iftar • The c ombination with
• Take twic e (eg c hange a twic e daily Thiazolidinedione
• One thirs of daily dose metformin (Janumet) in s No treatment
daily at dose of 80 mg glyc azide
at suhur Ramadan fasting adjustment
suhur and to 80 mg at iftar and 40
• If taking modified patients c arries a lower required
iftar mg at suhur)
release metformin onc e risk of hypoglyc emia

Exp. Date: 3rd Feb

•C onsider timing
If taking oncadjustment,
e daily dose,

Doc. No: ID-DIA-

daily, take dose at iftar
rather that at suhur
than the c ombination of
eg switch it to iftar (eg take
metformin with SU
a onc e daily 4mg
glimepiride dose at iftar)

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1. PERKENI. 2015. Panduan Penatalaksanaan DM Tipe 2 pada
Individu Dewasa di Bulan Ramadan. 2
2. Hui E et al. 2010. BMJ 2010;340:c 3053. 5
 There is a recommendation to change treatment during fasting
Before Ramadan During Ramadan
Patients on diet and exercise control Consider modifying the time and intensity of physical activity: ensure
adequate fluid intake
Patients on oral hyperglycemic agents Ensure adequate fluid intake
Biguanide. Metformin 500mg, three times Metformin, 1000mg at the sunset meal, 500mg at the predawn meal
daily
Thiazolidinediones, a-glucosidase inhibitors No change needed
Increatin based therapies as DPP4-inhibitors No change needed

Sulfonylureas once daily Dose should be given before the sunset meal; adjust the dose based on
glycemic control and the risk of hypoglycemia
Sulfonylureas twice daily Use half the usual morning dose at the predawn meal and the usual dose
at sunset meal
Patients on onsulin Ensure adequate fluid intake
2
2

Premixed or intermediate-acting insulin twice Consider changing to long acting or intermediate insulin in the evening
0008
2
2 0
-

daily and short or rapid acting insulin with meals; take usual dose at sunset eb
AF
DIr

meal and half usual dose at predawn meal d

-
3
D
I
e
:
N
Adopted from: Table 3- Recommended changes to treatment regimen in patients with type 2 diabetes who fast during Ramadan . Al-arouj M et al. Diabetes 26 o:
a
D
Care. 2010; 33(8):1895-1902. .
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The role of DPP4 Inhibitors forType

2 Diabetes Mellitus Patients during
Ramadan Period

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7
Management of patients with type 2 diabetes during
Ramadan

Incretin-based
therapies

GLP-1 receptor
agonists DPP-4 inhibitors

• Glucose dependent
• Low risk of hypoglycaemia
• Suitable for use during Ramadan?
Devendra et al. Int J Clin Pract 2009;63:1446–50; Beshyah et al. Libyan J Med 2007;2:16–20; Barnett. Clin Endocrinol
2009;70:343–53; To fast or not to fast? Leicestershirediabetes. Available at
http://www.leicestershirediabetes.org.uk//display/templatedisplay1.asp?
sectionid=244 (accessed May 2010)
GLP-1, glucagon-like peptide-1; DPP-4, dipeptidyl peptidase-4
 Incretin based therapy, DPP-4
inhibitors.
Dipeptidylpeptidase-4inhibitors (DPP-4 inhibitors) such as Sitagliptin is effective
in reducing HbA1c 0.5-0.8% and does not increase body weight.1,2,3

DPP4-I (Sitagliptin) has a low risk of hypoglycemia, and is suitable for use during
Ramadan.1,2,3

DPP4-I (Sitagliptin) use in the month of Ramadan does not require

dosage adjustments 1,2

DPP4-I considered the best substitute for sulfonylureas in patients who are not
controlled with metformin monotherapy and plan to fast in Ramadan.1,2,3

The combination Sitagliptin+metformin in Ramadan fasting patients also carries

a lower risk of hypoglycemia than the combination of metformin+Sulfonylurea.
1,2,3

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1. PERKENI. 2015. Panduan Penatalaksanaan DM Tipe 2 pada Individu Dewasa di Bulan Ramadan.
2. International Diabetes Federation and the DAR International Alliance. 2016. Diabetes and Ramadan: Practical Guidelines. Brussels, Belgium: International Diabetes
2
Federation. 9
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Sitagliptin vs Sulfonylurea in
Muslim Patients With Type 2
Diabetes Treated During
Ramadan

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0
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Pharmacological perspective of
Sulfonylurea and Sitagliptin for T2DM patients during Ramadhan
• Sulfonylurea (glucose independent process)
SUs stimulate insulin secretion from pancreatic β cells in a glucose-
independent process. Because of this, SUs are associated with a
higher risk of hypoglycaemia compared with other OADs, which
has raised some concerns about their use during Ramadan. 1,2
• Sitagliptin (glucose dependent process)
DPP-4 is an enzyme that rapidly metabolises glucagon-like
peptide-
1 (GLP-1), thereby regulating the activity of the hormone. By
blocking this action, DPP-4 inhibitors effectively increase the
circulating levels of GLP-1, which in turn stimulates insulin secretion
in a glucose-dependent manner. Therefore, incretin-based
therapy such Sitagliptin as DPP4-inhibitors has low risk of
hypoglycemia.1,2

Exp. Date: 3rd Feb

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1. PERKENI. 2015. Panduan Penatalaksanaan DM Tipe 2 pada Individu Dewasa di Bulan Ramadan.
2. International Diabetes Federation and the DAR International Alliance. 2016. Diabetes and
Ramadan: Practical Guidelines. Brussels, Belgium: International Diabetes Federation. 3
1
 The incidence of Hypoglycaemia in Muslim Type 2
Diabetics treated with Sitagliptin or a Sulphoylurea
during Ramadan.
1. Pilot Study
2. Ramadhan Study

“Fast and you

shall
become
healthy”
-Prophet Muhammad
(peace and
blessings
of Allah be
upon him)

Current Medical Research & Opinion Vol. 27, No. 6, 2011, 1237-1242
 Pilot Study: Hypoglycemia in Sulfonylurea-Treated Patients With Type
2 Diabetes During Ramadan Fasting: Study Design and Primary End Point1
• Objective
– To determine the incidence of symptomatic hypoglycemia in Muslim patients
with T2DM treated with SUs during Ramadan in 2009
• Design
– Prospective, observational study
– 1378 adult Muslim patients with T2DM who were treated with SUs
(± metformin) during Ramadan in 2009
– Patients with insulin-treated T2DM or T1DM were excluded from
the study
– Data collected via electronic data collection system
– All patients were treated according to their physician’s normal
practice
• Primary End Point
SU=sulfonylur T1DM=type
al. Curr Med
mellitus; T2DM=type 2 diabetes
mellitus. 2011;27(6):1237–1242.
 Pilot Study: Nearly 20% of SU-Treated Muslim Patients With Type 2
Diabetes Experienced Symptomatic Hypoglycemia During Ramadan
Fasting1
Incidence of Symptomatic Hypoglycemia During Ramadan in 2009
by Treatment Group

30 27,
25, 6
25 6
19, Glimepiride
20 7
Patients, %
16, Gliclazide
8 14,
15 Glibenclamid
0
e Glipizide
10 Overall
5
n=428 n=386 n=535 n=29 n=1378
0

• 1095 occurred among the 271 patients who recorded ≥1 symptomatic hypoglycemic
event
• Most common symptoms reported were: headache (14.5%), sweating (10.2%), tremor
(8.5%), and palpitations (7.0%)
Mean daily doses of SUs were: 2.8 mg for glimepiride, 129.3 mg for gliclazide, 10.7 mg for glibenclamide (glyburide), and 6.6 mg for glipizide.
SU=sulfonylurea.
1. Aravind SR et al. Curr Med Res Opin. 2011;27(6):1237–1242.
Ramadan Study

The incidence of hypoglycaemia in Muslim

patients with type 2 diabetes treated with
sitagliptin or a sulphonylurea during Ramadan:
a randomized trial
 Background
• 78.8% of patients with type 2 diabetes fast during Ramadan, with a 7.5-fold increase in
the incidence of severe hypoglycaemia.
• There is no consensus about the most appropriate oral antihyperglycaemic agent(s)
for patients with type 2 diabetes to use during Ramadan.
• SU is typically recommended in combination with metformin because of broad clinical
experience and lower cost. The ADA recommends caution when using SU during
Ramadan because they are associated with an increased risk of hypoglycaemia.
• Sitagliptin when added to ongoing metformin monotherapy was shown to reduce the
incidence of symptomatic hypoglycaemia 3- to 6-fold compared with the addition of a
SU in patients with type 2 diabetes.
• Given the low risk of hypoglycaemia demonstrated in previous sitagliptin trials in non-
fasting patients with type 2 diabetes, it was of interest to evaluate the incidence of
hypoglycaemia with sitagliptin during Ramadan fasting.
Aim
To compare the incidence of symptomatic hypoglycaemia in fasting Muslim
patients with type 2 diabetes treated with sitagliptin or a SU during Ramadan.
Salti I, Benard E, Detournay B et al. A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care 2004; 27: 2306-11.
Inzucchi SE. Oral antihyperglycemic therapy for type 2 diabetes: scientific review. JAMA 2002; 287: 360-72.
Malik S, Lopez V, Chen R, Wu W, Wong ND. Undertreatment of cardiovascular risk factors among persons with diabetes in the United States. Diabetes Res Clin Pract 2007; 77: 126-33.
Nauck MA, Meininger G, Sheng D, Terranella L, Stein PP. Efficacy and safety of the dipeptidyl peptidase-4 inhibitor, sitagliptin, compared with the sulfonylurea, glipizide, in patients with type 2 diabetes inadequately controlled on metformin alone: a randomized, double-blind, non-inferiority trial. Diabetes
Obes Metab 2007; 9: 194-205.
Arechavaleta R, Seck T, Chen Y et al. Efficacy and safety of treatment with sitagliptin or glimepiride in patients with type 2 diabetes inadequately controlled on metformin monotherapy: a randomized, double-blind, non-inferiority trial. Diabetes Obes Metab 2011; 13: 160-8. Data
on file, MSD
 Switching to Sitagliptin Treatment Was Associated With a
significantly Lower Incidence of Symptomatic Hypoglycemia
Compared With Remaining on Sulfonylurea Treatment1
Primary End Point (APaT Population):
Incidence of Symptomatic Hypoglycemia (Proportion of Patients With ≥1 Events)
RRR (95% CI) = 0.51 (0.34, 0.75); P < 0.001

1 13,
4 2

1
2
Patients,

18 6,
06 7
%

0
• 195 symptomatic hypoglycemic events were reported by 68 patients in the SU group compared with
128 events in 34 patients for the sitagliptin group
• Most common symptoms were headache, sweating, dizziness, hunger, and tremor

Mean doses of SUs were: 3.5 mg in the morning and 3.1 mg in the evening for glimepiride; 71.9 mg and 89.0 mg for gliclazide; and 6.1 mg and 5.9 mg for
glibenclamide (glyburide).
APaT=all patients as treated; CI=confidence interval; qd=once daily; RRR=relative risk ratio; SU=sulfonylurea.
1. Data on file, MSD.
 Results
• overall incidence of symptomatic hypoglycaemia recorded during Ramadan
was 4.8% in the sitagliptin group and 14.3% in the SU group.
• The proportion of patients with hypoglycaemic events (symptomatic or
asymptomatic) was 8.5% in the sitagliptin group and 17.9% in the SU group
• The risk of hypoglycaemia (symptomatic or asymptomatic) was significantly
decreased with sitagliptin relative to SU treatment.
• The risk of symptomatic hypoglycaemia was decreased by 67% with
sitagliptin relative to SU treatment.

Conclusion
 In Muslim patients with type 2 diabetes who observed the fast
during Ramadan, switching to a sitagliptin-based regimen
decreased the incidence of hypoglycaemia compared to
remaining on a SU-based regimen.
 #STOPHYP
O
Summary
(1)• Incretin Enhancers, such as Sitagliptin, increase
active incretin levels, thus improving glucose
homeostasis
• Favourable efficacy and safety profile maintained
into triple therapy and insulin regimens
• Sitagliptin is effective, safe and well tolerated in
patients with CKD
• Sitagliptin provide a favourable alternative to SU
based
therapy in Type 2 patients fasting during Ramadan
• Modulating the Incretin Axis may well become a
mainstay in Type 2 Diabetes Treatment and is well

Exp. Date: 3rd Feb

suited for the Asian Type 2 Diabetes phenotype

Doc. No: ID-DIA-

00082

2022
3
9
Summary
(2)• The components of JANUMET™ (sitagliptin/metformin
HCl) have complementary MOAs and
comprehensively address
3 core pathophysiologic defects of type 2 diabetes.
• Coadministration of sitagliptin and metformin results
in:
• Significant reductions in A1C, FPG, and PPG compared with
metformin alone
• Weight loss comparable to metformin alone
• Low incidence of hypoglycemia comparable to metformin
alone
• Similar overall incidence of side effects to metformin alone

Exp. Date: 3rd Feb

- In Muslim patients with type 2 diabetes who observed the

Doc. No: ID-DIA-

fast during Ramadan, switching to a sitagliptin-based

00082

2022
remainingdecreased
regimen on a SU-based
the incidence of hypoglyca emia 4
0
 Nyaman Puasa
dengan

“The blessings of Ramadan should belong to everyone, including the one with
Diabetes”

Exp. Date: 3rd Feb

Doc. No: ID-DIA-
00082

2022
#STOPHYP
O
Alhamdulillah your patients ready to fasting

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