Jardiance (Empagliflozin) Dose Adjustment During Ramadan
No dose reduction of Jardiance is necessary during Ramadan fasting, but the medication should be temporarily discontinued in specific high-risk situations to prevent serious complications, particularly diabetic ketoacidosis and dehydration. 1
Key Safety Considerations for SGLT2 Inhibitors During Ramadan
Primary Risks Requiring Medication Discontinuation
Jardiance increases the risk of diabetic ketoacidosis (DKA), which can occur even with blood glucose levels below 250 mg/dL, making it particularly dangerous during prolonged fasting when caloric intake is restricted 1
The FDA label specifically warns to temporarily discontinue Jardiance in clinical situations known to predispose to ketoacidosis, including prolonged fasting due to acute illness or surgery - Ramadan fasting clearly falls into this category 1
Jardiance causes intravascular volume contraction and should be temporarily discontinued in any setting of reduced oral intake or fluid losses, both of which occur during Ramadan fasting hours 1
Dehydration and Renal Function Concerns
SGLT2 inhibitors like Jardiance increase dehydration risk during Ramadan, which is already a major concern given the restriction of fluid intake from dawn to sunset 2
The medication can cause acute kidney injury, particularly in patients with hypovolemia, and requires monitoring for signs of volume depletion 1
For patients post-metabolic and bariatric surgery who wish to fast, guidelines specifically recommend avoiding SGLT2 inhibitors due to increased dehydration risk 2
Evidence-Based Recommendation Framework
When to Avoid Jardiance During Ramadan
Strongly advise against continuing Jardiance (or consider temporary discontinuation) if:
- Patient has history of diabetic ketoacidosis 1
- Patient has type 1 diabetes or pancreatic insulin deficiency 1
- Patient has eGFR below 45 mL/min/1.73 m² 1
- Patient lives in hot/humid climate with risk of excessive perspiration 2
- Patient performs intense physical labor during fasting hours 2
- Patient has history of recurrent dehydration 2
Alternative Medication Strategies
The most recent 2025 guidelines recommend GLP-1 receptor agonists as the preferred option for patients fasting during Ramadan, as they provide glucose control with minimal hypoglycemia risk and typically require no dose adjustment 3
DPP-4 inhibitors combined with metformin remain the safest oral medication choice during Ramadan fasting, with significantly lower hypoglycemia risk compared to sulfonylureas 4
If continuing Jardiance, patients must maintain adequate hydration (at least 1.5-2 L of water) during non-fasting hours between Iftar and Suhoor 2
Monitoring Requirements If Jardiance Is Continued
Close monitoring is essential if the decision is made to continue Jardiance:
Monitor for signs of ketoacidosis regardless of blood glucose levels - look for nausea, vomiting, abdominal pain, generalized malaise, and shortness of breath 1
Check blood glucose closely during the first 3-4 weeks of Ramadan, particularly in the first few hours after starting the fast and in the late afternoon before breaking fast 3
Break the fast immediately if blood glucose drops below 70 mg/dL or if any signs of dehydration or ketoacidosis develop 3
Monitor renal function more frequently, especially in patients with baseline eGFR below 60 mL/min/1.73 m² 1
Common Pitfalls to Avoid
Do not assume SGLT2 inhibitors are safe during Ramadan simply because they have low hypoglycemia risk - the primary concerns are ketoacidosis and dehydration, not hypoglycemia 1
Do not continue full-dose sulfonylureas if combining with any glucose-lowering agent during Ramadan - this substantially increases severe hypoglycemia risk 3
Do not wait for blood glucose above 250 mg/dL to suspect ketoacidosis - SGLT2 inhibitor-associated DKA often presents with euglycemia 1
Avoid caffeinated or sugary drinks during non-fasting hours as they increase dehydration risk 2
Pre-Ramadan Counseling Essential Points
Conduct pre-Ramadan assessment 6-8 weeks before Ramadan begins 2, 3
Discuss the specific risks of continuing Jardiance during prolonged fasting, including ketoacidosis and dehydration 1
Consider switching to GLP-1 receptor agonists or DPP-4 inhibitors before Ramadan begins if the patient insists on fasting 3, 4
Establish clear criteria for breaking the fast: blood glucose <70 mg/dL, signs of dehydration, or any symptoms of ketoacidosis 3
Ensure patient understands the importance of adequate hydration during non-fasting hours and has capacity to drink 1.5-2 L of water between Iftar and Suhoor 2