Outcomes of People with Type 2 Diabetes using Sulfonylureas versus Other Non-Insulin Antidiabetic Agents during Ramadan: The Diabetes and Ramadan (DaR) Global Surveys

Abstract There is an increasing need to investigate fasting outcomes for Muslims with type 2 diabetes (T2D) who choose to fast during Ramadan. Although sulfonylureas (SUs) are widely used in T2D, concerns persist regarding their risk of hypoglycemia during prolonged fasting. Modern second-generation agents, particularly Gliclazide modified release (MR), have demonstrated improved pharmacokinetic stability and a lower risk of hypoglycemia compared with older sulfonylureas, such as glibenclamide. This study seeks to understand the reported fasting outcomes of patients using second-generation sulfonylureas during Ramadan. The Diabetes and Ramadan (DaR) global survey was conducted in 14 countries and investigated patients with T2D who fasted during Ramadan in 2020 and 2022. The survey was administered by health care practitioners after Ramadan and compared those who used second-generation sulfonylureas with those deemed to be in the low-risk group (LRG). After excluding individuals with cardiovascular, renal, or foot complications, as well as those treated with insulin, 5,294 individuals were included in the analysis (mean age ≈53 years). Participants on sulfonylureas and those in the LRG showed similar fasting adherence, with over 90% completing the Ramadan fast. Among sulfonylurea users, Gliclazide MR had the highest proportion of fasting for the full month (77%) and the lowest reported incidence of hypoglycemia (10.3%), comparable to the LRG (7.9%, p = 0.2). Fasting outcomes among participants using second-generation sulfonylureas were comparable to those on lower-risk oral agents during the Ramadan fasting period. Gliclazide MR demonstrated the most favorable profile, with the highest fasting blood glucose control rate and the lowest frequency of hypoglycemia among the sulfonylurea group. These findings support the safe use of modern sulfonylureas during Ramadan, provided it is under appropriate medical supervision. Further prospective and randomized studies are warranted to confirm the comparative safety and optimize treatment selection for individuals with T2D who fast.