“O Ye Who Believe! Fasting is Prescribed to You as it was Prescribed to Those Before You, That Ye May (Learn) Self-Restraint,-” [Al-Qur'an 2:183].

Ramadan is the month to cultivate God-consciousness, self-control, improvement of health by reducing or eliminating impurities from the body, and to become aware of the plight of the poor, hungry, and the sick. Ramadan is a month of spiritual consciousness and high sense of social responsibility. However, those with disease need counselling about the safety of their observance of fast and any special precaution they need in diet, medication and life style to observe fast.   Advice needs to be extended under several situations which are listed below:

(1) ACUTE ILLNESSES: Acute illnesses which make patients pretty sick need a strong advice against fast for the period of their illness and the recovery period thereafter. Once patient recovers fully from his acute illness and can sustain effects of fasting he can be advised to observe fast and make up the days lost as per Quranic verse 2:184-185.   Patients to be included in this category can be left to the discretion of the physician. The criteria should be that fasting and its implications (restricted diet, restricted water intake, inability to administer medication for over 12 hours etc) influence adversely recovery from illness or affect outcome of illness. 

(2) CHRONIC ILLNESSES: Several chronic illnesses need special advice and can be categorized as below:

(i). Diabetes mellitus: During the last two decades, a better understanding of pathophysiological changes during Ramadan fasting in diabetic patients has provided a few guidelines on how to advice diabetics who want to fast. HbAIC values (an important parameter to assess control of metabolic status in diabetics) show no change or even improve during Ramadan. Physicians should  advice diabetic patients against fasting under following conditions: (i) All brittle type I diabetic patients (on Insulin therapy); (ii) Poorly controlled type I or type II diabetic patients; (iii)  Diabetic patients with serious complications such as unstable angina or uncontrolled hypertension; inter-current infections; alert problems; history of diabetic ketoacidosis; (iv) Pregnant diabetic patients. Fasting should be encouraged in diabetics who are overweight and on anti-diabetic pills or diet advice alone. Diabetics should be advised on assessment of physical well being; assessment of metabolic control; adjustment of the diet protocol for Ramadan fasting; adjustment of the drug regimen e.g. change long-acting hypoglycaemic drugs to short-acting drugs to prevent hypoglycaemia; encouragement of continued proper physical activity; recognition of warning symptoms of dehydration, hypoglycaemia and other possible complications. Diabetics must be reminded to abstain from the high-calorie and highly-refined foods prepared during this month. If a diabetic who is on insulin therapy chooses to observe fast, insulin therapy needs to be readjusted. Home blood glucose monitoring should be performed just before the Iftaar (sunset meal) and three hours afterwards. It should also be performed before the sahoor (pre-dawn meal) to adjust the insulin dose and prevent any hypoglycaemia and post-prandial hyperglycemia following over-eating. Regarding oral medication, half the dose can be taken before sahoor and half immediately after Iftaar.  

 (ii). Hypertension and Heart Disease: Patients suffering from mild to moderate high blood pressure should be encouraged to fast as it may help control of blood pressure. It is advisable to use sustained release drug formulations whose effect can last through the fasting period. Patients with severe uncontrolled hypertension, unstable heart disease or those who have complications like renal failure, recent stroke or heart failure should be advised against fasting as such patients need active life saving treatment and fasting can impede disease recovery and influence adversely disease outcome.

(iii) Migraine:  People with uncontrolled frequently occurring migraine or cluster headaches should be advised against fast as fasting may worsen migraine and interfere in managing acute attacks. However, if migraine is well controlled and attacks are infrequent fast may be allowed under supervision.

(iv). Pregnancy: There is medical evidence to show that fasting in pregnancy is not a good idea. If a pregnant woman feels strongly; is healthy enough to fast, she may do so especially during the early part of the pregnancy. If she doesn't feel well enough to fast, Islamic law gives her clear permission not to fast, and to make up the missed fasts later. 

(v). Renal failure and dialysis: People with renal failure must not fast and should perform fidyah. Haemodialysis is performed about three times a week, and causes significant shifts of fluids and salts within the body. Such patients must not fast and should perform fidyah.

(vi). GI diseases: Patients with gas, irritable bowel syndrome, altered bowel habits and dyspepsia (presenting as bloating or indigestion) can be allowed to fast safely and symptoms in many such patients regress during fast period. Heart burn which is a symptom of acid reflux in to food pipe may worsen during fast and advice on such patients can be individualized. Many of such patients may fast with no problem if symptoms are controlled with acid reducing pill taken once a day. Patients with active ulcer disease cannot fast till ulcer heals and any precipitating cause of ulcer like Helicobacter pylori infection is eradicated or ulcerogenic drugs withdrawn. Patients with silent ulcers or those who have had bleeds from ulcers should not fast as fast may precipitate bleed or cause ulcer perforation. Patients with chronic eventful illnesses like ulcerative colitis or Crohn’s disease should not fast while the disease is on active medication and remission is yet to occur. Patients with chronic liver diseases which are stable impose no added risk with fasting. However, chronic liver disease which shows signs of liver failure may worsen with fast and such patients need advice accordingly.

(3). MODIFICATION OF DRUG DOSE AND THERAPY:
This is a complex issue and physician needs considerable information on modifying drug doses and frequency during fasting. It is advisable that physicians take advice from pharmacy services or refer to literature on advising patients on drug therapy during fast. One of the major problems occurs, once patient stops medication during Ramadan. This causes exacerbation of underlying diseases like Asthma, epilepsy, heart failure, clots (if patient withdraws anticoagulants) and reflux disease. Patients on long term medication for otherwise stable chronic illnesses need advice on route of administration of drugs, the rhythm and schedule of administration and interaction with food intake.

(i). Route of administration of drugs: It is a matter of personal judgement of physician and even personal preference of patient (depends upon his beliefs) as to what he regards allowance of drugs during fast. Generally in Middle East countries following drug administration does not break fast and can be allowed during Ramadan fast: Eye and ear drops; all substances absorbed into the body through the skin, such as creams, ointments, and medicated plasters; nitroglycerin tablets placed under the tongue for the treatment of angina; mouthwash, gargle, or oral spray, provided nothing is swallowed into the stomach; nose drops, nose sprays, and inhalers. 

(ii). Dosage schedule:  Drug dosing schedules have to be altered during Ramadan. In fact, drug doses can be taken only between Iftaar (sunset) and Sahoor (dawn), and the time span between them is shorter than outside Ramadan. Two different types of dosage schedule are commonly used during Ramadan. For patients on single daily dose the easiest situation is that of patients who have a usual evening dose. Their therapeutic scheme remains unchanged during Ramadan, as it does not interfere with fasting. When the usual intake is in the morning or during the day, the doctor must be careful when delaying the intake to the evening that this will not alter the efficacy of treatment or the tolerance of the drug. The efficacy and toxicity of many drugs can vary depending on the time of administration in relation to the circadian rhythms of biochemical, physiological, and behavioural processes. Thus, circadian time has to be taken into account as an important factor influencing a drug’s pharmacokinetics or its effects or side effects. For patients on two or more daily doses during Ramadan, accurate distribution of drugs prescribed twice a day is difficult to achieve between the break from fasting (Iftaar) and the beginning of fasting (Sahoor). Refraining from fasting according to the Islamic rules could be a wiser prescription, but not possible. Nonetheless, patients with two doses could take the first one at the break of fasting (Iftaar) and the second one before the beginning of fasting (Sahoor), in which case the dosing time and the time span between the doses are both altered. These alterations could affect the drug’s plasma concentration profile and, therefore, its efficacy and tolerance. This is even more relevant for drugs with a narrow therapeutic index as the risk of toxicity is higher.

Lastupdate on : Wed, 11 Aug 2010 21:30:00 Mecca time
Lastupdate on : Wed, 11 Aug 2010 18:30:00 GMT
Lastupdate on : Thu, 12 Aug 2010 00:00:00 IST