Drug intake during Ramadan

Abstract

Introduction During Ramadan, the ninth month of the Islamic lunar calendar, adult Muslims are required to refrain from taking any food, beverages, or oral drugs, as well as from sexual intercourse, between dawn and sunset. Ramadan can occur in any of the four seasons, and the hours spent fasting vary accordingly from 11 hours to 18 hours a day. Rhythms of life and habits during this fasting period differ from one country to another. In Morocco, two to three meals daily are eaten within a short overnight span during this month. The first meal might be taken immediately after sunset (Iftar) and the second one around three hours later (dinner); the last meal might be taken shortly before dawn (Sohour). Intake of drug doses is therefore not easy, and its adjustment to the life rhythm of Ramadan is often not rational. Aslam et al surveyed 81 patients to determine the alterations they made to their drug regimens during the fasting period of Ramadan.1 They found that 42% of the patients adhered to their usual treatment, and 58% changed their intake pattern. Among the second group, 35 patients stopped their treatments, eight changed the administration schedule, and four took all the daily doses in one intake. Another survey of 325 outpatients in a Kuwaiti hospital found that most of them changed their drug regimens during Ramadan.2 Sixty four per cent of the patients changed their therapeutic scheme during the month; 18% took their daily medicines in a single intake, either before the first meal (sunset) or straight after the last one (before dawn). The authors warned about the high risk of drug interactions in such cases. In fact, a 57 year old woman with heart failure experienced side effects of digitalis after being treated with both a thiazide diuretic and a digitalis compound. According to the authors, the concomitant intake of those two drugs induced a drop in potassium following a diuretic induced decrease in water retention, which led to an increase in sensitivity of heart muscle to digitalis. Wheatly and Shelly reported that two patients with chronic reversible respiratory disease were admitted to an intensive care unit two weeks after the start of Ramadan. Both patients subsequently admitted to not having taken their treatment, including inhalers, during daylight hours.3 A prospective study evaluated the changes in frequency of seizures during Ramadan in 124 patients with idiopathic epilepsy. Seizures occurred in 27 patients during this month; 20 of them did not use any antiepileptic drugs from dawn to sunset. The author concluded that withdrawal of drugs was the most important cause of recurrence of epilepsy during Ramadan.4 Summary points Ramadan, a month of fasting, is a daily abstinence from any food, beverage, or oral drug from dawn to sunset Patients with chronic diseases often insist on fasting even though they are permitted not to by Islamic rules Patients with acute diseases would similarly be allowed to stop fasting and make up for it after Ramadan Several studies have shown that patients arbitrarily change the intake time and dosing of drugs without taking medical advice This behaviour could alter the pharmacokinetics and pharmacodynamics of drugs, especially those with a narrow therapeutic index, and consequently their efficacy and tolerance The main emphasis of the authors of these studies was that most of the patients did not receive any particular information about changing their treatment during Ramadan. In the face of this arbitrary use of drugs during Ramadan, drug intake needs to be adapted according to the prescription components—the route of administration, the rhythm and schedule of administration, and interaction with food intake. In this paper we review current knowledge on this subject. Footnotes Extra references are on bmj.com Contributors NA had the original idea for the article. All three authors contributed to the literature search. NA and IEH wrote the review. NA is the guarantor. Funding None. Competing interests None declared.