Drugs adjustment during ramadan

Medications During Ramadan
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Dr/AL SAYED ALSPAGH Page | 1
Introduction
Ramadan is the ninth month of the Islamic lunar calendar (Hijra) and lasts for 28 to 30
days.
The Islamic year is 354 days so Ramadan occurs 10 to 11 days earlier each year.
Each period of fasting lasts from dawn to dusk and varies in length depending on the
season and the follower’s location.
Fasting means refrain from eating, drinking, smoking, sexual activity, consuming oral
medicines and using intravenous fluids.
Between dusk and dawn the restrictions are removed. The meals consumed at dawn and
dusk are known in Arabic as suhur and iftar, respectively.
Persons who are exempt from fasting
➢ Children under the age of puberty
➢ Those with learning difficulties or cognitive impairment such that they are unable to
comprehend the nature and purpose of the fast
➢ The old and frail who are not capable of fasting
➢ The acutely unwell for whom fasting will exacerbate their condition
➢ The chronically sick, eg diabetes, COPD, cardiovascular disease, in whom fasting
may be detrimental to health
➢ Travelers (long distances approximately 50 miles or over)
➢ Women who are pregnant, breastfeeding or menstruating
Medications during Ramadan
The use of drugs during Ramadan can be an area of contention and uncertainty.
However, a meeting of medical practitioners and Islamic jurists in Morocco (June 1997)
reached a consensus as to acceptable drug use during Ramadan. They unanimously
agreed that use of the following will not nullify a fast:
➢ Eye and ear drops
➢ Vaginal pessaries and washes
➢ Injections through the skin, muscle, joints or veins (excluding intravenous feeds)
➢ Oxygen and anesthetic gases
➢ Sublingual glyceryl trinitrate tablets
➢ Mouthwashes, gargle or oral sprays provided none is swallowed
➢ Any substance absorbed through the skin (eg, creams, ointments, medicated
plasters)
A majority of the group also agreed that use of nose drops, nose sprays, inhalers and
anal injections do not nullify a fast.

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Dietary advice for those fasting during Ramadan
Sunset (Iftar) meal
➢ Dates (following prophetic tradition)
➢ Maintain adequate fluid intake
➢ Healthy balanced diet
➢ Protein, eg fish, meat, lentils
➢ Moderate amount of fat and sugar
Predawn (Suhur) meal
➢ wholesome and filling to provide enough energy for several hours, eg grains,
seeds, barley, wheat, oats, cereal, beans, lentils, wholemeal flour, basmati rice
➢ Fiber-rich foods are recommended, eg bran, green beans, figs, prunes, apricots
➢ Maintain adequate fluid intake
➢ Avoid caffeine-containing beverages, eg tea, coffee
➢ Avoid spicy food
Schedules for oral medications during Ramadan
1) Once-daily dose
Doses taken at the evening provided that this will not alter the efficacy or the tolerance of
the drug.
2) Twice-daily dose
First dose could be taken at Iftar and the second at Suhur. However, altering the dosing
time and the time span between the doses 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 such as theophylline and phenytoin as the risk of toxicity is
higher.
Another solution is to reduce the number of daily doses by using a slow-release
formulation of the same drug, where available.
3) More than twice-daily doses
Drugs that require three- or four-times-a-day dosing could be replaced by another drug
from the same therapeutic class but with a more suitable schedule for fasting patients, eg
slow-release formulations.

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Medications during Ramadan
Type of Medication Administration
Drugs for Hypertension Admin: Once - Twice daily
The food: No effects
Avoid of taking ACE Inhibitors with large amount of
Dates, Bananas, Oranges, green vegetables.
Time of admin: after Iftar
Interchange: If using short acting you can Switch to
long acting therapy
Drugs for Cardiac Arrhythmias Admin: Once daily
Interchange: Switch to long acting therapy
Drug for Pain Admin: Once daily
Time of admin: after Sun set (Iftar)
Drugs for GIT Admin: Once daily
Time of admin: before suhur
Drugs for Asthma Admin: variable
The food: No effects except theophylline.
Using Bronchodilator with caffeine (Tea or
Beverages) can increase the chance of side effects,
such excitability, nervousness, and tachycardia
Time of admin: Any time
Drug for Lipid Disorder Admin: Once daily
Interchange: Switch to Statin therapy
Antiplatelets and Anticoagulations Admin: Once daily
The food: Aspirin may induce ulcer at empty
stomach, Warfarin action is affected by vegetables,
like broccoli, spinach, kale, turnip greens, cabbage.
Avoid garlic, ginger, glucosamine, ginseng, and
ginkgo may increase the bleeding.
Interchange: Switch Heparin to LMWH
Drug for Infectious Diseases Admin: Once – Twice daily
The food: Variable
Anti-Epileptic Drugs Admin: Once – Twice daily except Valoproic Acid
The food: may decrease the absorption
Time of admin: after 1-2 hours of Iftar
Interchange: No, can be on specific situation
Anti-Psychiatrics Drugs Admin: Most of them Once daily, some are given
Twice daily
The food: may decrease the absorption
Time of admin: at Suhur
Interchange: No, can be on specific situation

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Drugs modifications during Ramadan
1- Anti-diabetic medications during Ramadan
A) Oral Hypoglycemic drugs (OHDs):
Metformin − Total Daily dose remains unchanged
− Prolonged release: Take at iftar
− Immediate release:
− OD: Take at iftar;
− BID: Take at iftar and suhoor;
− TID: 1 dose at suhur, 2 doses at iftar
Glitazones − No dose modifications.
− Dose can be taken with iftar or suhoor.
Acarbose − No dose modifications.
− Dose can be taken with iftar and suhoor.
Meglitinides − Short-acting Meglitinides can be taken twice
daily before Iftar and Suhur meals.
Sulfonylureas − Switch to newer SU (gliclazide, glimepiride)
where possible: associated with lower risk of
hypoglycemia.
− Glibenclamide should be avoided
− If OD: take at Iftar, dose may be reduced in
patients with good glycemic control
− If BID, Iftar dose remains unchanged, and
half the dose at Suhur.
DPP-4 inhibitors − No dose modifications.
− Dose can be taken with iftar and suhoor.
GLP-1 RAs − Once appropriate dose titration has been
achieved before Ramadan (6 weeks before),
no further dose modifications are needed.
SGLT2 inhibitors − No dose modifications
− Dose should be taken with iftar
− Extra clear fluids should be ingested during
non-fasting periods (keep hydrated)
− Should not be used in the elderly, renal
impairment, hypotensive individuals or those
taking diuretics.

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B) Insulin therapy:
Long- or intermediate-acting basal
insulin
(NPH/detemir/glargine/degludec)
OD − Take preferably at iftar and
Reduce the dose by 15–30%
BID − Take usual morning dose at
iftar. Reduce evening dose by
50% and take it at suhoor.
Rapid or short-acting insulin − Take usual morning dose at iftar, omit
lunch dose, Reduce evening dose by
25-50% and take it at suhoor.
Premixed insulin OD − Take normal dose at iftar.
BID − Take usual morning dose at
iftar. Reduce evening dose by
25–50% and take at suhoor.
TID − Omit afternoon dose. Adjust
iftar and suhoor doses and
carry out dose titration every 3
days as in table. 3.
Insulin pump − Basal rate: Reduce dose by 20–40% in
the last 3–4 h of fasting and increase
dose by 0–30% early after iftar
− Bolus rate: Normal carbohydrate
counting and insulin sensitivity
principles apply.
Table.3
Fasting/pre-iftar/pre-suhoor blood glucose Premixed insulin modification
<70 mg/dL or symptoms Reduce by 4 units
70–90 mg/dL Reduce by 2 units
90–126 mg/dL No change required
126–200 mg/dL Increase by 2 units
>200 mg/dL Increase by 4 units

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2- Cardiac patients during Ramadan Fasting
➢ Ramadan fasting is a healthy non-pharmacological means for improving
cardiovascular risk factors.
➢ The impact of fasting during Ramadan on patients with stable cardiac disease is
minimal and does not lead to any increase in acute events. Most patients with
stable cardiac disease can fast safely.
➢ Most of the drug doses and their regimen are easily manageable during this month
and may need not to be changed.
➢ Patients with unstable angina, recent myocardial infarction, uncontrolled
hypertension, decompensated heart failure, recent cardiac intervention or cardiac
surgery or any debilitating diseases should avoid fasting.
2.1- Anti-hypertensive medications during Ramadan
➢ Many factors may theoretically influence the blood pressure (BP) during Ramadan.
These include feeding patterns, sleep changes, and changes in the timing of
intake of medication.
➢ Patients with controlled HTN can safely fast Ramadan provided they adhere to
their medications.
➢ Based on these observations, recommendations were made on the management
of HTN during Ramadan by two professional bodies in the Arabian Gulf region.
They include that:
1) Physician’s advice and management should be individualized.
2) Patients should seek medical advice before Ramadan so that their clinical
status is assessed and medications can be adjusted.
3) Education should emphasize the adherence to both non-pharmacological
and pharmacological measures.
4) Diuretics are better avoided, particularly in hot weather or to be taken in the
early evening.
5) A once‑daily medication with long‑acting preparations is recommended.
6) Patients should be advised to take a low‑salt, low‑fat diet.
7) Patients with difficult to control HTN, are advised not to fast until their BP is
controlled.
8) Patients with hypertensive emergencies should be treated appropriately
regardless of fasting.

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Category Specifications Recommendations
ACE-I and ARBs OD – monitor for postural
hypotension
Take after Ishaa prayer
CCBs Dihydropyridine e.g.
Amlodipine, Nifedipine
Take after Iftar or Suhur
Non-dihydropyridine e.g.
Verapamil and Diltiazem
Take after suhur, due to
circadian effect of the drug
BBs OD – e.g. Bisoprolol Take after Suhur
BID – e.g. Metoprolol Take after Iftar and Suhur
Thiazide diuretics OD – monitor for dehydration Take after Ishaa prayer
Alpha blockers OD – monitor for postural
hypotension
Take at bed time
2.2- Anti-failure medications during Ramadan
➢ Fasting during Ramadan does not seem to increase hospitalizations for heart
failure. Nevertheless, patients with decompensated heart failure or those requiring
large doses of diuretics are strongly advised not to fast.
➢ During Ramadan fasting, Patients are advised to limit daily intake of fluid to less
than two liters and sodium to less than 2500 mg.
➢ Ramadan fasting is safe for most patients with chronic heart failure and reduced
ejection fraction. Patients are advised to adhere to fluid and salt restrictions, and
do not omit any doses of drugs. For drugs with two daily doses, take them with as
wide a gap as possible during non-fasting hours or change them to once daily
sustained release medications
Medication Specifications Recommendations
Diuretics Loop diuretics Take after Ishaa prayer
Loop diuretics combined with
thiazides
Advise not to fast. If fasting,
monitor for dehydration and
electrolyte imbalance
Spironolactone Take after Iftar or Suhur
Digoxin Monitor for possible toxicity due
to hypokalemia and dehydration
Take after Suhur
ACE-I, ARBs and
BBs
As before

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2.3- Anti-arrhythmic medications during Ramadan
➢ Amiodarone is the most widely prescribed antiarrhythmic medication. It may be
administered once daily or given twice daily with meals to minimize the gastric
upset which is seen with higher doses.
➢ Amiodarone interacts with many drugs as BBs and CCBs and also increases the
blood levels of Digoxin. So during Ramadan fasting, patients who take
Amiodarone are at risk for drug interaction, as they tend to take their drugs
simultaneously.
Amiodarone OD – Patient is sensitive to
electrolyte disturbance
Take with Iftar or Suhur
Mexiletine TID – Patient is sensitive to
electrolyte disturbance
Advise not to fast.
Flecainide BID Take after Iftar and Suhur
with interval ≥ 8 hours.
Sotalol BID Take after Iftar and Suhur
Oral electrolyte
replacement
OD Preferred after Suhur
BID Take after Iftar and Suhur
2.4- Medications for Dyslipidemia during Ramadan
Statins Long acting e.g. Rosuvastatin and
Atorvastatin - OD
Take after Iftar or Suhur
Short acting e.g. Pravastatin and
Simvastatin - OD
Take at bedtime
Fibrates OD - Risk of rhabdomyolysis might
increase during fasting and
dehydration especially if combined
with statin
Take after Iftar – monitor for
muscle pain and muscle
profile
Ezetimibe OD Take after Iftar or Suhur

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2.5- Medications for coronary heart disease during Ramadan
➢ Patients with stable CAD were able to observe Ramadan fast safely, and their
symptoms were not significantly different from that of the non-fasting ones.
Antiplatelet OD – e.g. Aspirin, clopidogrel
and prasugrel
Take after Iftar (to avoid gastric
irritation) – strict adherence is
recommended.
BID – e.g. Ticagrelor Take after Iftar and Suhur with
interval ≥ 8 hours.
Nitrates OD Take after Ishaa prayer or after
Suhur.
BID Option 1: Convert to SR and take OD
Option 2: Take after Iftar and Suhur
TID Distribute the total dose into BID
BBs, CCBs and
Statins
As before
Contrast for
Angioplasty
increase the risk of CIN due to
dehydration
Advise not to fast
2.6- Anticoagulant medications during Ramadan
➢ Ramadan fasting does not appear to influence adversely the efficacy or safety of
oral anticoagulation.
Medication Specification Recommendations
Warfarin OD – Take the dose in the
same time every day
Should be taken 2 hours after
Iftar on empty stomach
Rivaroxaban OD Take after Iftar
Apixaban BID Take after Iftar and Suhur
Dabigatran BID – might induce GIT upset Take after Iftar and Suhur

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3- Asthma medications during Ramadan Fasting
➢ Some Muslim scholars believe that inhalers do not break the fast because of the
gaseous nature of the inhaled agents. Other scholars disagree.
➢ Most preventer asthma medications are prescribed twice daily. With good timing,
patients can stick to their therapeutic regimens and still observe fasting. They can
take daily preventer inhalers of ICS or ICS+LABA at Iftar and Suhur.
Medication Specification Recommendations
Inhalers Once or Twice daily –
Doesn’t invalidate the fast
No dose change – stay
hydrated – avoid foods that
might trigger the asthma
e.g. peanut, eggs, milk,.…
Nebulizers PRN - invalidate the fast No dose change
Inhalation Capsules
4- Thyroid medications during Ramadan Fasting
➢ In Ramadan, minimal changes are observed in the levels of T3, T4, and TSH in a
normal person.
➢ Patients with thyroid diseases, most of the time, do not need drug adjustments and
can fast safely without any health hazards.
➢ Patients with hypothyroidism taking thyroxine can take their tablets on an empty
stomach at bedtime instead of half an hour before Suhur.
➢ Patients with hyperthyroidism, on carbimazole can continue their dose in once or
twice daily regimes, while those on propylthiouracil might need to be switched
during Ramadan fasting.
Disease Medication Specification Recommendations
Hypothyroid Levothyroxine OD Should be taken 2 hours
before the last meal (Suhur)
or at bedtime on empty
stomach.
Hyperthyroid Carbimazole OD Take after Iftar or Suhur
BID Take after Iftar and Suhur
Propylthiouracil Clinical judgement for
possibility of switching.

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Sources:
1. Managing medications during Ramadan fasting. Can Pharm J (Ott). 2017.
2. Drug intake during Ramadan. BMJ. 2004
3. https://drc.bmj.com/content/bmjdrc/3/1/e000108.full.pdf
4. https://www.researchgate.net/publication/317180074
5. The Pharmaceutical Journal, Vol. 287, p93 | URI: 11080635
6. https://www.ukmi.nhs.uk/NonCMS/conferenceDB2014/Documents/postersandpresenta
tions/DIABESITY.pdf
7. Recommendations of the 9th Fiqh-Medical seminar “An Islamic View of Certain
Contemporary Medical Issues,” Casablanca, Morocco, 14–17 June 1997. Available
atwww.islamset.com (accessed 12 July 2011).
8. https://onlinelibrary.wiley.com/doi/pdf/10.1002/psb.774
9. Caring for Muslim patients. 2nd ed. Oxford
10.Keeping healthy in Ramadan. Leaflet. Barts and the London NHS Trust,2010.
11.Drug intake during Ramadan, BMJ 2004;329:778–82
12.Aviod Food Drug Interaction, A guide from National Consumer League and U.S. Food
and Drug Adminstration;www.fda.gov/drugs,
13.https://gulfnews.com/uae/hypertension-patients-can-fast-during-ramadan-1.1838787
14.Chamsi-Pasha M, Chamsi-Pasha H. The cardiac patient in Ramadan. Avicenna J Med.
2016.
15.Chamsi-Pasha H, Ahmed WH, Al-Shaibi KF. The cardiac patient during Ramadan and
Hajj. J Saudi Heart Assoc. 2014.
16.https://www.escardio.org/The-ESC/Press-Office/Press-releases/Ramadan-fasting-can-
be-safe-for-patients-with-heart-failure
17.Thyroid diseases and Ramadan. Indian J Endocrinol Metab. 2012.
18.https://www.ncbi.nlm.nih.gov/pubmed/31691934
Prepared by:
Dr/ALSAYED ALSPAGH,
MSc, internal medicine
Consultant of internal medicine, Aim’s clinic, Maldives

Drugs adjustment during ramadan

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