Muslims are obliged to participate in an intermittent fasting and refrain from eating from dawn to sunset for a month, unless they are advised not to fast. In Qatar, fasting duration ranges between 9 and 15 hours. The first meal in the day is just before the dawn (Suhoor), while the second meal is immediately after the sunset (Iftar). Fasting Muslims are expected to take their medication between Iftar and Suhoor. Healthcare Providers (HCPs) should be aware about the effect of the drug modification on the disease management.
Physiological and pharmacokinetic changes:
Gastro - intestinal tract: During fasting, the gastric pH significantly decreases up to 1, resulting in an increased gastro-intestinal disturbance of drugs that are taken on an empty stomach. Such drugs are advised to be taken before Suhoor. Drugs that are taken after food are advised to be taken 1 hour after the main meal (Iftar), allowing normalization of the pH.
Urinary excretion: Drug excretion is not expected to be altered in patients with normal renal function, including patients with renal transplant. However, patients with chronic kidney disease are more likely to have adverse outcomes secondary to dehydration and decreased drug excretion.
Liver and Cytochrome P 450 ( CYP 450 ): Short-term fasting alter CYP450-mediated drug metabolism, which might lead to altered (increased/decreased) hepatic metabolism during Ramadan. However, these findings are inconclusive and further research is needed. Therefore, patients with hepatic impairment are managed on individual bases (clinical judgment).
Challenges faced by HCPs during Ramadan High risk patients: High risk patients, such as type 1 diabetes and heart failure patients, who insist to fast, pose a great challenge to the HCPs in the management of their disease. Structured education and pre-Ramadan medication management planning is crucial.
Fasting without HCPs awareness: Patients arbitrarily change their drug regimen without seeking medical advice, e.g. they: stop their medications modify the timing of administration/intake change the frequency change the total daily dosage take their total daily dose in one intake.
Knowledge about patient practices regarding their medication use in Ramadan is paramount. Such modifications may result in significant drug-drug or drug-food interactions and abnormal drug levels, and may results in serious adverse outcomes. Patients may not disclose this issue if not discussed. Therefore, HCPs are advised to be proactive and initiate this conversation with their patient to ensure a proper medication Ramadan management plan.
Pregnant and breastfeeding women Pregnant and breastfeeding women are allowed to fast if they are healthy, unless they are advised not to fast such as pregnancy with diabetes, hypertension, or anemia and mothers with exclusively breastfed babies aged less than 6 months. Pregnant and breastfeeding women are advised to take a healthy diet, to keep hydrated and to seek medical opinion if they experienced any of the following symptoms: dizziness, palpitations, severe headache, fever, nausea or start vomiting, vision disorders, weakness, decreased fetal movement while fasting.
Elderly patients are prone to dehydration during long fasting hours that might affect their kidney function. Also, they are likely to have a polypharmacy. Pre-Ramadan planning and careful distribution of their medication is important.
Fasting becomes obligatory for pediatrics at puberty. Children are trained to fast gradually at an earlier age. Because of increased metabolic needs and water loss due to large surface area, it is advised to keep hydrated (drink 30 ml/kg of water) during fasting break hours. On the other hand, they should not fast if they use chronic medications as it might negatively affect their disease status.
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