RAMADAN FASTING FOR PATIENTS

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RAMADAN FASTING FOR PATIENTS

• Prof. Mohamad S. Al-Hadramy
• Professor of Medicine/Consultant

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Ramadan Fasting for Patients

• A young medical student has a viral upper
  respiratory tract infection. His temperature was
  38.9oC. Congested throat. Chest clear. Day 1
  Ramadan. What is your advice?

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• Generally, patients are dispensed from fasting.
  The illness is the intense one that increases by
  fasting, or recovery is delayed. Ahmad Bin
  Hanbal was asked, when is the patient dispensed
  from fasting. If he could not he answered.
  They asked fever, for example?. He answered
  What disease is more severe than fever?.

Ibn Godamah. Al-Maghny Al-Torky Al-Helo. eds,
1408,4403-4
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Three (3) categories of patients in fasting

1. Patients who are not harmed by fasting, and their
   recovery is not delayed (e.g., Type 2 DM,
   controlled by diet. Such patients are advised to
   fast.

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Three (3) categories (cont.)

1. Patients who are harmed by fasting or their
   treatment cannot be given with fasting (e.g.,
   IDDM pregnant lady, acute MI, advanced liver
   failure).

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Three (3) categories (cont.)

1. Patients who are not harmed by fasting but their
   treatment could be adjusted for proper control
   (e.g., hypertension, epilepsy, OA).

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Asthma

• Ibn Othaymeen
• The spray used for asthma does not reach the
  stomach and there is no harm from using it during
  fasting

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Asthma (cont.)

• Now, we have long acting inhalers (e.g.,
  Salmetrol which could be used after sunset and
  before dawn.

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• A 40-year-old smoker with dyspepsia. Upper GI
  endoscopy showed duodenal ulcer, 10 days before
  Ramadan. What is your advice?

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A study from Tunisia

• Fifty-seven (57) patients with acute duodenal
  ulcer. All received Lansoprazole 30 mg per day.
  Randomized to fasting or dispension. Endoscopy
  performed at end of Ramadan. Symptoms were not
  different. Healing rate Fasting 90,
  dispension 88.8. Patients on Lansoprazole may
  fast with any risk.

Mehdi A, Ajmi S. Gastyroenterol Clin Biol 1997,
(11)820-2
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• A 60-year-old male with long- standing
  hypetension who was on irregular treatment. He
  was on Metoprolol 50 mg BD, Frusemide 40 mg QD,
  Diltiazem 90 mg BD. His serum creatinine was 500
  umol/L, Na 131, K 4.5. He wants to fast Ramadan.
  What is your advice?

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• Thirty-six (36) patients with moderate to severe
  chronic renal failure, Creatinine gt3 mg/dl
  Clearance lt35 ml/min

Al-Muhanna Saudi Medical J 1998 19319-21
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Comparison of BUN, S. Creatinine, S. Uric Acid
and Caclculated Creatinine Clearance Pre, During
and Post Ramadan
BUN (mmol/l) S. Creatinine (umol/l) S. Uric Acid (umol/l) Calculated Creatinine Clearance (ml/m)
Pre-Ramadan 21.57 2.35 550 143 0.45 0.03 17.2 3.5
Mid-Ramadan 25.85 2.64 638 198 0.5 0.022 14.7 2.5
End Ramadan 29.7 2.8 737 110 0.53 0.022 13.2 2.2
Past Ramadan 28.37 3.39 726 132 0.52 0.033 13.7 3.2
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Conclusion

• During Ramadan, fasting patients with significant
  renal failure need close monitoring to offer
  appropriate advice.

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Renal transplant

• 11 transplant recipients
• No adverse effect from fasting on alograft. K?
  during fasting.

Barneih, B. O. et al Saudi K Kidney Dis
Transplant 1994 5470-473
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Renal transplant (cont.)

• Forty-three (43) transplant recipients with
  stable renal function. Concentration of urine
  similar to healthy.

Rashed Atl, et al. Lancet 1989, 11396
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• Cyclosporin can be taken during Ramadan at Sahoor
  and Fatoor.

Badrah HM, et al Saudi Kidney Dis Transplant Bull
1993, 4596
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• Haemodialysis breaks fasting.

Fatwa No. 9944 Ibn Baz Chairman Fatwa, Volume 10,
p. 19
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• One-hundred six (106) patients fasting three
  hundred nine (309) Ramadan month, on
  anticoagulant one hundred eighty-three (183) did
  not fast in five hundred ninety-four (594)
  Ramadan months. Incidence of thromboembolic
  events and haemorrhagic complications were not
  statistically significant between the two groups.

Saur J. N. et al. Annals of Saudi Medicine 1989,
(4)538-40
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• No significant differences in platelets
  aggregation responses between Ramadan and the
  non-fasting period.

Kordy, M. et al Annals of Saudi Medicine 1991,
(11)23-7
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Case 1

• A 55-year-old diabetic for 15 years is seen
  before Shaaban. She has polyuria and
  parasthesia in her feet. She has no retinopathy.
  She is on Glibenclamide 10 mg AM, 5 mg PM,
  Metformin 500 mg TDS, Atorvastatin 10 mg, and
  Corenitec 20/12/5 QD, Aspirin 100 mg QD. Her
  weight is 90 kgs. Height 155 cms. Bp 124/76
  mmHg. She has diminished pain sense in her feet.
•  
• FBS 220 mg , HbA1C 9 LDL Cholesterol 98
  mg/dl CPK, SGPT normal.

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Case 1 (cont.)

1. What other investigations would you consider
   before advising her for Ramadan fasting?
2. What is your advice for her for Ramadan?
3. What is your advice for Omrah?

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• No fasting for
• Brittle DM
• Poorly controlled
• Serious comorbidity (e.g., MI, stroke)
• History of DKA
• Pregnancy
• Severe intercurrent infection (e.g., pneumonia)

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• No skipping of meals
• Regimen of treatment
• No gorging after Maghreb

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• Adjust diet
• Adjust treatment (e.g., change to short acting
• Exercise. When?
• Recognize hypo, dehydration

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• Exercise
• Fasting does not interfere with exercise capacity
• Exercise causes no harm in NIDDM

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• Insulin
• R maghreb and Sahour, NPH late evening
• R N of breakfast at Maghreb R before dawn 0.1
  0.2 u/kg

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• Home glucose monitoring
• PP, before Sahour and sunset
• Urine ketone, weight for increase
• ? diet / decrease ? dehydration

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• Tabs
• BMJ switch dose of glibenclamide

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• Repaglinide
• Mafauzy, Malaysia
• 235 patients
• Repag TDS versus Glibenclamide QD or BD 6/52
  before and repa in Rama ? 2
• In Ramadan fructosamine decrease with Repag
• HbA1C NO CHANGE
• Hypo mid day lt with Repag

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LISPRO

• Kadiri et al, Diab Metab 2001 27482-6
• Morocco
• Type 1-64 pts BD NPH Lispro or regular for
  2/52 each, open label, randomised, crossover.
  Monitoring for 3 days at end of each cycle.
• 2 H after Maghreb better. Doses similar
  compliance with time of injection better with
  Lispro.
• Hypo Lispro 23 , regular 48
• Episodes Lispro 0.7, Reg 2.25 episodes/pt/30
  days
• Glycemic control improved and hypo sig Decreased
  with Lispro

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LISPRO

• Akram Diab Med 1999 16861-6
• Pakistan
• Type 2 70 patients
• Open Label, randomized crossover
• Regular versus Lispro
• Patient self reported hypo. Glucose, FBS, 1 h,
  2hpp on 3 days at end of period
• Results Before sunrise and after sunset were
  similar. Rise after meal with Lispro was less.
  Hypo for Lispro 1.3, for regular 2.6 per patient
  over 14 days. Most hypos in day
• Insulin Lispro may be more suitable

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Case 2

• A 28-year-old married lady with type 1 DM is
  counseled for fasting. She has one child and she
  plans to have pregnancy. She is on Mixtard 70/30
  36 units AM and 14 units PM. She exercises
  regularly and is sticking to her diet. Physical
  examination is negative. Sugar profile 99, 112,
  116 and 102 mg. U/Es, LFT, lipid profile, urine
  analysis are negative.
• A. What would you tell her?

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Thank You !