management of diseases in ramadan

Management manipulation of Different Medical Conditions 

during Ramadan 

Dr. Mansoor Khan

Resident Surgery “D”

Khyber Teaching Hospital,

Peshawar.

“Ramadan is the 9th month of Muslim 

calendar”

Fasting in Ramadan is one of thefive pillars of Islam

*Estimate

“Over 1.9 billion Muslims observeRamadan each year”

The sick, travelers, pregnant andbreastfeeding women who fear for

their well being or that of thefoetus/child) may be exempted until they

are again at peace or healthy

1st Ramadan Headache

Most of the studies suggests increased frequency of headaches in Ramadan

Awada A, al Jumah M Headache. 1999 Jul-Aug;39(7):490-3.

Pathophysiology

Hypoglycemia, caffeine withdrawal, change insleep pattern and stress

of fasting itself

Neurol J Southeast Asia 2001; 6 : 13 – 17.

Bilateral, fronto‐temporal, throbbing, mild to

moderate, often lasting for 1‐2 Hours, in afternoon & evening

Neurol J Southeast Asia 2001; 6 : 13 – 17.

Characteristics of Ramadan headache

Rest, sleep, analgesia and breaking fast often relieves

the headache

Characteristics of Ramadan headache

Neurol J Southeast Asia 2001; 6 : 13 – 17.

Prevention --

Cup of coffee before fast

Subsides as the body acclimatizes with the low levels of caffeine

Awada A, al Jumah M Headache. 1999 Jul-Aug;39(7):490-3.

Peptic ulcer disease

Pathophysiology

Gastrin, pepsin and acid secretions increase.

Median pH is 2.3 prior to Ramadan, 1 at

day 10 and day 24 of Ramadan

Iraki L, Abkari A, Vallot T, Amrani N, Khlifa RH, Jellouli K et al. [Effect of Ramadan fasting on intragastric pHrecorded during 24 hours in healthy subjects]. Gastroenterol Clin Biol 1997; 21:813-819.

Irritability, non-compliance to medications &

stressM. H. Emami, H. Rahimi, Effects of Ramadan fasting on acute upper gastrointestinal bleedingdue to peptic ulcer, 175 - 0 17 ): 3 ( 11 ; 2006 JRMS

Pathophysiology

Prolonged non-neutralized

secretion of gastric acids damages the

mucosa

Diagnostic and Therapeutic Endoscopy, 1996, Vol. 2, pp. 219-221

Pathophysiology

Active acute duodenal ulcers heal with medication during Fasting

Active chronic duodenal ulcers fails to heal & are at greater risk of bleeding/perforation

Diagnostic and Therapeutic Endoscopy, 1996, Vol. 2, pp. 219-221

Duodenal ulcers--

Duodenal ulcers--

88% of chronic duodenal ulcers bled with 71% ofthese with bleeding being drug defaulters

Diagnostic and Therapeutic Endoscopy, 1996, Vol. 2, pp. 219-221

Diagnostic and Therapeutic Endoscopy, 1996, Vol. 2, pp. 219-221

Gastric ulcers--

The gastric ulceralso bled even after drug therapy and showed no signs ofhealing

Dyspeptic symptoms are considered asalarming signs 

Caution in advising fasting with previous history of DU and dyspepsia

Concurrent prescription of PPI’sas prophylaxis

M. H. Emami, H. Rahimi, Effects of Ramadan fasting on acute upper gastrointestinal bleedingdue to peptic ulcer, 175 - 0 17 ): 3 ( 11 ; 2006 JRMS

Recommendations

Diabetes & fasting – A global concern

Diabetes

Normal individuals‐‐‐

Fasting > decrease glucose levels > Decreased secretion of insulin/inreased

levels of glucagon and catecholamines> Glycogenolysis/gluconeogenesis

> glycogen depletion > lipolysis > ketones for muscles > sparing glucose for brain and

erythrocytes

Trends in blood glucose during fastingDIABETES CARE, VOLUME 28, NUMBER 9, SEPTEMBER 2005 2305

Normal individuals‐‐‐Slight decrase in start of day to 3.3 mmol 

to 3.9 mmol (60mg/dl to 70mg/dl) 

Then gradually becomes normal due to gluconeogenesis, dec isulin, increased 

glucagon

Trends in blood glucose during fasting

In diabetics --Hypoglycemia

Glucagon secretion failurein response to hypoglycemia

Defective epinephrinesecretion type 1 diabetes due to

autonomic neuropathyleading to Hypoglysemia

Hyperglycemia

Severe insulin deficiency, can lead to excessive

glycogenolysis & increasedgluconeogenesis and ketogenesis,

leading to hyperglycemia and ketoacidosis

Trends in blood glucose during fasting

DIABETES CARE, VOLUME 28, NUMBER 9, SEPTEMBER 2005 2305

Compliant patients showed euoglycemia & mostly no

episodes of acute complications

Trends in blood glucose during fasting

Assessment of glycemic status

Diet protocol

Changing drug regimens

Appropriate physical activity

Recognition of complications

Pre-Ramadan preparations

All brittle type I diabetics

Poorly controlled type I & II

Non-complaint patients in terms of diet, medicine, activity

Diabetics with complications (angina, uncontrolled HTN)

Discourage fast in ---

History of recurrent ketoacidosis

Pregnant diabetics

Inter-current infections

Elderly patients with any degree of

alertness problems

Discourage fast in ---

Patients not falling under the above exclusion criteria

Over-weight & obese diabetics

Compliant & well educated patients

Allow fasting in ---

Consume slow digesting food (fiber diet, lasting for 8hrs)

Decreased intake of refined food (lasting for 2-3 hr)

Over-weight should not gain weight

Under-weight/normal should not loose weight

Nutrition adv --

Light to moderate exercise is recommended

Physical activity & fasting ---

Insulin adjustment in IDDM ---

Three doses insulin regimenTwo doses of regular (dawn & dusk)

One dose of intermediate acting at late evening

Two doses insulin regimenCombined short acting & intermediate acting at dawn & dusk before meals

Oral anti-diabetic adjustments ---

MetforminReverse doses ( morning dose in evening &

evening dose in morning)

SulphonylureasUse short acting prandial regulators

(Rapaglinides) instead long acting SFU

Blood glucose monitoring ---

Thrice daily monitoringBefore sunset meal

Three hrs after sunset meal

Before pre-dawn meal

Psychological problems in Ramadan

Relapses in bipolar patients

Relapses observed in previously stable patients in 45%

Mostly manic attacks, despite stable lithium levels

Toda M, Morimoto K. Ramadan fasting—effect on healthy Muslims. Soc BehPers 2004;32:13–18. Kadri N, Mouchtaq N, Hakkou F, Moussaoui D. Relapses in bipolar patients: changes in social rhythm? Int J Neuropsychopharmacol 2000;3:45–9.

Relapses in bipolar patients

Fasting‐related changes in circadian rhythms and insomnia are thought 

to contribute to psychiatric symptom exacerbation 

Toda M, Morimoto K. Ramadan fasting—effect on healthy Muslims. Soc BehPers 2004;32:13–18. Kadri N, Mouchtaq N, Hakkou F, Moussaoui D. Relapses in bipolar patients: changes in social rhythm? Int J Neuropsychopharmacol 2000;3:45–9.

Changes in behavior

During Ramadan, even persons without mental disorders have reported irritability, decreased 

sleep, difficulty concentrating, and anxiety

Toda M, Morimoto K. Ramadan fasting—effect on healthy Muslims. Soc BehPers 2004;32:13–18.

Chronic Kidney Diseases

Chronic Kidney Diseases

Decreased GFR

Tubular damage

Increased serum creatinine and urea

Increased serum potassium in CKD

Risk is multiplied in diabeticsSaudi J Kidney Dis Transplant 2007;18(3):349-354

Stroke in Ramadan

Turk J Med Sci 33 (2003) 237-241

As a whole no change in incidenceof stroke during Ramadan than 

other months 

Incidence of stroke

According to studies increase in a special type of stroke due to 

cerebral venous sinus thrombosis (CVST), is observed (3 X) ‐‐

hemoconcentration

Increased incidence of Special type of stroke

Turk J Med Sci 33 (2003) 237-241

Increased incidence of ischemic strokes especially in uncontrolled 

diabetics is observed  

Ischemic stroke --

Turk J Med Sci 33 (2003) 237-241

Decreased incidence of hemorrhagic strokes in hypertensive patients  is observed – good HTN control in 

fasting due to depressed sympathetic system

Hemorrhagic stroke --

Ramadan & acute appendicitis

Incidence of acute appendicitis was significantly lower in Ramadan, Bowel 

resting could reduce the risk of appendicitis

Iran J Med Sci March 2005; Vol 30 No 1 21

Ramadan & Immunity system--

CIC (circulating immune complex)levels were measured

before and after Ramadan bypolyethylenglycole method.

Ramadan does not have bad effecton immune system of healthy people.

A. Latifynia, M. Vojgani, T. Abofazeli, H.Jafarieh* J Ayub Med Coll Abbottabad 2007; 19(2)

Fasting and Pregnancy

Pregnant & lactating 

mothers are exempted

Fasting & pregnancy --

Annals of Alquds Medicine (1426, 2005) 2:58-62

Pregnant mothers experience more stress compared with

non-pregnant ones andfasting may increase

this stress

Fasting & pregnancy --

Annals of Alquds Medicine (1426, 2005) 2:58-62

Theoretically  fasting may cause hypoglycemia > leading to small size of gestational age (SGA) in fetus > Birth mortality and disabilities 

among newborn babies

Fasting & pregnancy --

Annals of Alquds Medicine (1426, 2005) 2:58-62

Dehydration and decrease glomerular filtration, which may increase serum levels of renallydependent drugs such as lithium

Modifying pharmacotherapy

Aadil I, Houti I, Moussamih S. Drug intake during Ramadan. BMJ 2004;329:778–82.

Changes in gastric pH and phase II liver metabolism, altering the 

pharmacokinetics of valproic acid

Aadil N, Fassi-Fihri I, Houti B, et al. Influence of Ramadan on the pharmacokinetics of a single oral dose of valproic acid administered at two different times. Methods Find Exp ClinPharmacol 2000;22(2):109–14.

Modifying pharmacotherapy

In patients taking antidepressants and antipsychotics, watch for anticholinergic side

effects —dry mouth, dehydration, and confusion—especially in the elderly

Switch before Ramadan to longer-acting medications or medications with once- or twice-

daily dosing

Modifying pharmacotherapy

Substance abstinence

Fasting mandates abstinence from alcohol, caffeine, and tobacco

Sudden abstinence can lead to withdrawal effects

Kadri N, Tilane A, Batal M, et al. Irritability during the month of Ramadan. Psychosom Med 2000;62:280–5.

Substance abstinence

Discuss a tapering approach to preempt possible withdrawal 

symptoms 

Kadri N, Tilane A, Batal M, et al. Irritability during the month of Ramadan. Psychosom Med 2000;62:280–5.

Number of CVS disorders deaths significantly decreased in Ramadan

No difference found in the episodes of Asthma during  Ramadan

Other diseases

THANKS

Questions Please