Drug regimens and fasting during Ramadan: a survey in Kuwait

Monitoring of changes in illicit drugs, alcohol, and nicotine consumption during Ramadan via wastewater analysis

Illicit drug use is a global problem imposing social, economic, and health burdens on society. Wastewater-based epidemiology is an approach based on calculating the consumption of substances in the target population by analyzing the concentrations of human metabolic excretion products of licit and illicit substances in wastewater. This study estimated the changes in illicit drugs (cocaine, amphetamine, methamphetamine, ecstasy (3,4-Methylenedioxymethamphetamine), heroin, and marijuana (THC)), alcohol, and nicotine consumption in Adana Province during Ramadan compared to normal periods using wastewater-based epidemiology. An overall decrease was observed during the Ramadan Period, most strongly for ecstasy (29%) followed by heroin (19%). For cocaine, the variation was the slightest (8.6%). The differences were statistically significant for ecstasy, heroin, nicotine, and alcohol but not for cocaine, amphetamine, methamphetamine, and marijuana. This study is the first to show changes in the use of illicit drugs, alcohol, and nicotine under the influence of religious beliefs. In addition, there is limited data about illicit drugs, alcohol and nicotine abusers/users in Ramadan. This study provides information on the literature on this subject.

Barriers to stroke prevention in Atrial Fibrillation: Insights from the global anticoagulation Roundtable

Atrial fibrillation (AF) accounts for one-quarter of the global ischemic stroke burden. Population growth and an increasing prevalence of stroke risk factors underscores the critical need to recognize and address the worldwide crisis in underutilization of antithrombotic therapy for patients with AF. Failure to address key patient, clinician, and societal gaps in AF care will result in a worldwide increase in stroke-related morbidity and mortality while overwhelming global healthcare systems. The failure to adhere to evidence-based guideline recommendations for stroke prevention in AF reflects a critical gap in implementation of best clinical practice among providers and healthcare systems. Globally, these include inadequate provider education, limited public awareness, underdiagnosis, and underutilization of treatments, including antithrombotic therapy. In specific regions, efforts are further complicated by availability of specific medications, variation in drug metabolism across racial and ethnic populations, socioreligious considerations, and lack of universally available electronic health records. Efforts are needed at both global and regional levels to address key barriers to evidence-based care for patients with AF. Investing in clinical tools and teams that improve stroke prevention for patients with AF will likely improve population health.

Communicating with Clinicians on Fasting during Ramadan: The Patients' Perspective

Caring for millions of Muslim patients who decide to fast during Ramadan can be challenging for clinicians. Using a theory-guided approach, this study explores Muslim patients' perspectives on factors influencing communication with clinicians in relation to fasting during Ramadan. Semi-structured interviews were conducted with a sample of patients in Egypt (9) and the USA (8). Participants were purposefully sampled to assure variance in age, gender, education, decision to fast and ethnicity. Data emerging from narratives were mapped to constructs within the Linguistic Model of Patient Participation in Care (LMOPPC). Using framework analysis, iterative sampling and analysis continued until saturation. Drawing on LMOPPC, participants' narratives were mapped and clustered into patient participation and quality of care; predisposing factors (perceptions about fasting and its significance including sense of spiritual benefit when fasting and sense of guilt when not fasting, prior experiences including prior conversations with clinicians on fasting and experience of fasting while sick, patients' personality and locus of control, belief in the legitimacy of participation, motivations and perception of need to communicate with clinicians about fasting, provider verbal and nonverbal responses, and provider-patient rapport); and enabling factors (knowledge about the topic and repertoire of communicative skills, presence of companions during appointment, and timing of appointments). The LMOPPC framework provided insight into patients' perspectives on barriers and facilitators for communication with clinicians about fasting during Ramadan. It is important for stakeholders to consider those issues when implementing interventions aiming to adopt a concordant approach in providing care for this group of patients.

Perceptions among Muslims regarding fasting, medication use and provider engagement during Ramadan in the United States

BACKGROUND

Muslims with chronic diseases tend to fast during Ramadan, although Islam allows them not to fast. Therefore, understanding their perceptions and how they manage their health, especially as a minority population, is very important.

OBJECTIVE

To examine Muslims' (1) perceptions of fasting exemptions, (2) medication usage behaviour, (3) perceptions of relationships with healthcare providers and (4) factors impacting health management during Ramadan.

METHOD

This was a qualitative study employing four focus groups (two groups of women and two groups of men). Adult Muslims (aged 18 years or more) with chronic diseases were invited to participate. Participants were asked open-ended questions about their fasting ability, medication usage behaviours, healthcare access and collaboration with providers during Ramadan. Trained researchers conducted the focus groups interviews in both English and Arabic. Each focus group was recorded, and three investigators independently transcribed the data and extracted themes and categories. Coding terminology issues were resolved through discussion.

RESULTS

Twenty-five Muslims with chronic diseases (e.g., diabetes, hypertension, renal failure and anaemia) participated. The most prominent themes/subthemes were as follows: (1) fasting exemption (e.g., uncontrolled medical conditions), (2) fasting nonexemption (e.g., controlled medical conditions), (3) nonoral medication use during Ramadan, (4) healthcare provider involvement during Ramadan, and (5) factors impacting health management during Ramadan.

CONCLUSION

Muslim patients perceive fasting as an important religious practice, so they tend to self-modify their medication-taking behaviours. Educating pharmacists and other healthcare providers about Muslim culture, especially their strong desire to fast, may lead to Muslims better managing their medications and viewing pharmacists and other healthcare providers as knowledgeable healthcare providers.

Patient-guided modifications of oral anticoagulant drug intake during Ramadan fasting: a multicenter cross-sectional study

Fasting Ramadan is known to influence patients’ medication adherence. Data on patients’ behavior to oral anticoagulant (OAC) drug intake during Ramadan is missing. We aimed to determine patient-guided modifications of OAC medication regimen during Ramadan and to evaluate its consequences. A multicenter cross-sectional study conducted in Saudi Arabia. Data were collected shortly after Ramadan 2019. Participants were patients who fasted Ramadan and who were on long-term anticoagulation. Patient-guided medication changes during Ramadan in comparison to the regular intake schedule before Ramadan were recorded. Modification behavior was compared between twice daily (BID) and once daily (QD) treatment regimens. Rates of hospital admission during Ramadan were determined. We included 808 patients. During Ramadan, 53.1% modified their intake schedule (31.1% adjusted intake time, 13.2% skipped intakes, 2.2% took double dosing). A higher frequency of patient-guided modification was observed in patients on BID regimen compared to QD regimen. During Ramadan, 11.3% of patients were admitted to hospital. Patient-guided modification was a strong predictor for hospital admission. Patient-guided modification of OAC intake during Ramadan is common, particularly in patients on BID regimen. It increases the risk of hospital admission during Ramadan. Planning of OAC intake during Ramadan and patient education on the risk of low adherence are advisable.

Practical perspectives on the use of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with nonvalvular atrial fibrillation: A view from the Middle East and North Africa

Clinical guidelines for the prevention of stroke in patients with nonvalvular atrial fibrillation (NVAF) are available from several international cardiology associations. Patients with NVAF in the Middle East and North Africa (MENA) region present unique challenges and opportunities related to differences in geography, practice patterns, and patient demographics that are as yet unaddressed in practice guidelines. This review aims to offer a practical perspective on the management of NVAF in patients in MENA and draws on evidence-based guidelines as well as real-world evidence and expert opinion. The literature was searched for relevant original research articles, systematic reviews, meta-analyses, and guideline recommendations addressing the prevention of stroke in patients with NVAF with a focus on issues relevant to the MENA region. Guideline recommendations, best practices, and expert opinion were discussed and agreed on by a working group consisting of cardiologists from across the MENA region. The incidence of stroke secondary to atrial fibrillation in patients across the MENA region is higher than rates reported globally, and this might be attributed to a higher incidence of vascular risk factors and underuse of anticoagulants in patients in the MENA. The available evidence supports the established role of non-vitamin K antagonist oral anticoagulants (NOACs) in the prevention of stroke in patients with NVAF. There is a consistent body of clinical trial and real-world evidence supporting their efficacy for stroke prevention in NVAF, with more favorable bleeding risk profiles relative to vitamin K antagonists, such that guidelines now recommend the use of NOACs in preference over vitamin K antagonists. There are important opportunities to improve the management of NVAF outcomes for patients with NVAF by applying evidence-based guidelines for stroke prevention. Growing experience with NOACs in the MENA region will help guide patient selection and elucidate optimal dosing strategies to maximize the clinical benefits of the NOACs.

Effects of Ramadan fasting on aspirin resistance in type 2 diabetic patients

Aims

Ramadan fasting (RF) may affect aspirin resistance. We conducted this study in patients with cardiovascular risk (CVR) factors to assess the effect of RF on aspirin resistance and explore whether type 2 diabetes mellitus (DM) would influence this effect.

Methods

A total of 177 stable patients with ≥2 CVR factors were recruited. All patients observed RF and were taking aspirin. Physical exam and standard biological tests including glycaemia and serum lipids data were performed before Ramadan (Pre-R), at the last week of Ramadan (R) and four weeks after the end of Ramadan (Post-R). In the same visits caloric intake was calculated and platelet reactivity to aspirin was assessed using Verify Now point-of-care assay.

Results

In the overall population, there was no significant change in absolute aspirin reaction unit (ARU) values and in metabolic parameters. In DM patients (n = 127), ARU change from Pre-R values was+19.7 (p = 0.01) and +14.4 (p = 0.02) respectively at R and Post-R. During Ramadan, glycaemia, triglycerides, and cholesterol levels increased significantly and returned to Pre-R values thereafter. These changes were not observed in non-DM patients.

Conclusions

During RF aspirin resistance increased only in DM patients. This effect persisted one month after Ramadan. Simultaneous alteration of glycemic control and increase of serum lipids levels could potentially be a favorable factor.

Study registration

The protocol was registered at clinicaltrials.gov under: NCT02720133.

Effects of Ramadan fasting on platelet reactivity in diabetic patients treated with clopidogrel

Background

The effects of Ramadan fasting (RF) on clopidogrel antiplatelet inhibition were not previously investigated. The present study evaluated the influence of RF on platelet reactivity in patients with high cardiovascular risk (CVR) in particular those with type 2 diabetes mellitus (DM).

Methods

A total of 98 stable patients with ≥2 CVR factors were recruited. All patients observed RF and were taking clopidogrel at a maintenance dose of 75 mg. Clinical findings and serum lipids data were recorded before Ramadan (Pre-R), at the last week of Ramadan (R) and 4 weeks after the end of Ramadan (Post-R). During each patient visit, nutrients intakes were calculated and platelet reactivity assessment using Verify Now P2Y12 assay was performed.

Results

In DM patients, the absolute PRU changes from baseline were +27 (p = 0.01) and +16 (p = 0.02) respectively at R and Post-R. In addition, there was a significant increase of glycemia and triglycerides levels with a significant decrease of high-density lipoprotein. In non DM patients there was no significant change in absolute PRU values and metabolic parameters. Clopidogrel resistance rate using 2 cut-off PRU values (235 and 208) did not change significantly in DM and non DM patients.

Conclusions

RF significantly decreased platelet sensitivity to clopidogrel in DM patients during and after Ramadan. This effect is possibly related to an increase of glycemia and serum lipids levels induced by fasting.

Trial registration

Clinical Trials.gov NCT02720133. Registered 24 July 2014.Retrospectively registered.

An assessment of the current treatment landscape for rheumatology patients in Qatar: Recognising unmet needs and moving towards solutions

Objective This study assessed the mode of application (oral, intravenous or subcutaneous (SC)) currently employed in the treatment of rheumatoid arthritis (RA) in patients from Qatar in comparison with patients' individual preferences for the mode of application of their treatment. Methods This study included 294 RA patients visiting three clinics at the main referral hospital in Qatar who were interviewed using a standard questionnaire to determine their preference of mode of application for their disease-modifying antirheumatic drug (DMARD) treatment in relation to their currently employed mode of application. Results The majority of patients were female (76%), and 93% of male patients and 61% of female patients in the study clinics were of a nationality other than Qatari. The highest patient preference recorded was for an oral therapy (69%), compared with injection (23%) and intravenous (8%) therapy. In total, 85% of patients expressed a preference to remain on oral therapy compared with 63% and 58% of intravenous and SC injection patients indicating a preference to remain on their current method of administration. Conclusions This high preference for oral therapies highlights the considerable need for incorporation of new oral targeted synthetic DMARD therapies into clinical practice within the region.

Evaluation of forensic deaths during the month of Ramadan in Konya, Turkey, between 2000 and 2009

Ramadan is a holy month for Muslim people and includes long fasting periods. During Ramadan, practicing Muslims not only fast, but they also abstain from any kind of medication, smoking, sexual intercourse, and alcohol from sunrise to sunset. In the 10-year period between 2000 and 2009, it was determined that a total of 4881 death examinations and autopsies were performed at the Konya Branch of the Forensic Medicine Council (Turkey). All of the reports were retrospectively evaluated for demographic features of the cases and the manner of death. In the studied time period, a total of 491 deaths (10.1%) occurred in Ramadan. The manner of death was accident in 369 (75.2%) of the cases in Ramadan, 3107 (70.8%) of the other cases; suicide in 27 (5.5%) of the cases in Ramadan, 367 (8.4%) of the other cases; and homicide in 28 (5.7%) of the cases in Ramadan, 375 (8.5%) of the other cases. There was a significant statistical difference in terms of the manner of death between the deaths in Ramadan and in the remaining part of the year (P < 0.05). Our study suggested that there was an increase in accidental and natural deaths and a decrease in suicide and homicides in Ramadan.

How do patients with asthma and COPD behave during fasting?

BACKGROUND-OBJECTIVE

Several factors might affect the adherence to treatment in patients with asthma and COPD. Among these factors, the effect of religious beliefs and behaviours has been less studied so far. In this study, the effect of fasting on drug use behaviours of patients with asthma and COPD were comparatively analysed.

METHODS

A total of 150 adult patients with asthma and 150 adult patients with COPD were consecutively enrolled into this cross-sectional study. The patients were asked whether they fast during Ramadan and if the answer was yes, they were kindly asked to respond to further questions related to use of inhaled medications during that particular time.

RESULTS

The majority of the cases from both groups [98 (65.3%) of asthma patients and 139 (92.6%) of COPD] were fasting during Ramadan. The majority of the patients with COPD (n=126; 90.6%) reported that they quitted their regular therapy basis during Ramadan. On the other hand, the majority of asthma patients used their controller inhaled medications during Ramadan and preferred to use them on iftar and sahur times (n=81, 82.6%).

CONCLUSION

Our results showed that in a Muslim population, the patients with asthma and COPD do not feel their diseases to be an inhibitory factor for fasting during Ramadan. However, fasting seems to be an important determining factor in medication compliance by modifying the drug use behaviours in each group in a different way. Therefore, the patients should be informed about the effects of fasting on their disease and the allowed drugs during fasting.

Antibiotic-prescribing patterns for Iraqi patients during Ramadan

BACKGROUND

During Ramadan, Muslims fast throughout daylight hours. There is a direct link between fasting and increasing incidence of infections. Antibiotic usage for treatment of infections should be based on accurate diagnosis, with the correct dose and dosing regimen for the shortest period to avoid bacterial resistance. This study aimed to evaluate the practices of physicians in prescribing suitable antibiotics for fasting patients and the compliance of the patients in using such antibiotics at regular intervals.

MATERIALS AND METHODS

An observational study was carried out during the middle 10 days of Ramadan 2014 in two pharmacies at Baghdad. A total of 34 prescriptions (Rx) for adults who suffered from infections were examined. For each included Rx, the researchers documented the age and sex of the patient, the diagnosis of the case, and the name of the given antibiotic(s) with dose and frequency of usage. A direct interview with the patient was also done, at which each patient was asked about fasting and if he/she would like to continue fasting during the remaining period of Ramadan. The patient was also asked if the physician asked him/her about fasting before writing the Rx.

RESULTS

More than two-thirds of participating patients were fasting during Ramadan. Antibiotics were prescribed at a higher percentage by dentists and surgeons, for which a single antibiotic with a twice-daily regimen was the most commonly prescribed by physicians for patients during the Ramadan month.

CONCLUSION

Physicians fail to take patient fasting status into consideration when prescribing antibiotics for their fasting patients. Antibiotics with a twice-daily regimen are not suitable and best to be avoided for fasting patients in Iraq during Ramadan - especially if it occurs during summer months - to avoid treatment failure and provoking bacterial resistance.

Health beliefs and practices of Muslim women during Ramadan

There are clear exemptions in Islam from fasting in Ramadan during sickness, pregnancy, and breastfeeding. Yet, some Muslim women still elect to fast while sick, pregnant, or breastfeeding because of a confluence of social, religious, and cultural factors. Little is known about the physiological effects of fasting during Ramadan on the mother or her unborn baby, and thus nurses and other healthcare providers are faced with the difficult task of providing appropriate medical advice to Muslim women regarding the safety and impact of their fasting. This article describes what is known about this topic and suggests that healthcare professionals learn as much as possible about the multicultural best practices and research-driven information about fasting in order to help Muslim women make informed decisions.

Chronobiological aspects of food intake and metabolism and their relevance on energy balance and weight regulation

Overweight and obesity are the result of a chronic positive energy balance, and therefore the only effective therapies are a diet which, on the long term, provides lower calories than the daily expended energy and exercise. Because nearly every physiological and biochemical function of the body shows circadian variations it can be suggested that also different chronobiological aspects of food intake, like time of day, meal frequency and regularity, and also circadian desynchronizations like in shift work may affect energy metabolism and weight regulation. The aim of this review is therefore to summarize and discuss studies that have addressed these issues in the past and to also provide an overview about circadian variations of selected aspects of metabolism, gut physiology and also factors that may influence overall energy regulation. The results show that a chronic desynchronization of the circadian system like in shift work and also sleep deprivation can favour the development of obesity. Also, regarding energy balance, a higher meal frequency and regular eating pattern seem to be more advantageous than taking the meals irregularly and seldom. Additional studies are required to conclude whether time of day-dependent food intake significantly influences weight regulation in humans.

Maintenance of glycaemic control with the evening administration of a long acting sulphonylurea in male type 2 diabetic patients undertaking the Ramadan fast

BACKGROUND

In Ramadan, misuse of hypoglycaemic agents, alterations in diet and hypoglycaemia are frequent. This study assessed whether switching to an evening administration of a long acting sulphonylurea during the 29-day, dawn to dusk fast, can maintain glycaemic control in patients with type 2 diabetes.

PATIENTS AND METHODS

Male type 2 diabetic patients from Bangladesh, Pakistan and India, under glycaemic control with gliclazide modified release (MR) 60 mg monotherapy, switched to evening administration of the same dose during Ramadan, and reverted to the morning schedule thereafter. The primary outcome was the difference in fasting plasma glucose (FPG) before and after Ramadan.

RESULTS

In 136 patients, mean (95% CI) FPG decreased by 0.01 mmol/l (0-0.2, p = 0.3) with evening medication by the end of the fast, and increased by 0.2 mmol/l (0.1-0.3, p = 0.01) after reverting to morning medication 20 days later. There were 5 (3.7%) hypoglycaemic episodes before, 3 (2.2%) during and 2 (1.5%) after Ramadan.

CONCLUSION

Male type 2 diabetic patients undertaking the Ramadan fast can safely maintain glycaemic control with evening administration of gliclazide MR 60 mg during the fast, and reverting to a morning schedule thereafter.

Ramadan and eyedrops: the muslim perspective

PURPOSE

To assess views of Muslims with regard to the use of eyedrops during fasting periods of Ramadan and to determine if demographic, religious, and educational factors or the perceived severity of an ocular condition influence these views.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Two hundred adult Muslims.

METHODS

A questionnaire-based survey.

MAIN OUTCOME MEASURES

The main outcome measures studied were the proportion of respondents who believe that the use of eyedrops during fasting hours of Ramadan would break the fast and the proportion of respondents who would use drops during fasting hours of Ramadan.

RESULTS

Of the 200 questionnaires collected, 10 were excluded because of incomplete data entry (n = 190). Among respondents, 63.7% (n = 121) believe that using eyedrops during fasting periods of Ramadan would break the fast, and only 34.2% (n = 65) would use drops during this period. A further 34.2% (n = 65) would continue their regular treatment, 35.8% (n = 68) would use drops for a nonpainful eye condition, 66.8% (n = 127) for a painful eye condition, 35.3% (n = 67) for a condition that did not affect vision, and 75.8% (n = 144) would use drops during the fasting period for an eye condition if vision was affected. No significant association was noted when comparing views of respondents based on gender, occupation, education, and number of days the fast is observed. Statistical significance was reached when comparing the views of Muslims who would fast additional days if a fast was broken compared with those who would not (P<0.001).

CONCLUSIONS

Ramadan could be an important cause for noncompliance with prescribed ophthalmic treatment. This study provides an insight into views of Muslims regarding use of eyedrops during Ramadan. The results suggest that extensive misuse of prescribed drops should be anticipated during Ramadan.

Is there any effect of Ramadan fasting on acute coronary heart disease events?

OBJECTIVE

We investigated whether Ramadan fasting, which concerns billions of Muslims in the world, has a negative effect on coronary heart disease patients.

METHODS

Patients who were hospitalized at Emergency Center of Ankara Numune Hospital were evaluated retrospectively between the years 1991 and 1997. Patients with acute coronary heart disease events, who were hospitalized and those who died of this disease within the period of before, during, and after Ramadan were evaluated and the ratio of these cases in the total number of patients was determined along with mortality rates.

RESULTS

In all the years of the study the number of cases with acute coronary heart disease events was significantly lower in Ramadan than before or after Ramadan (P=0.03). But, the ratio of this population to all patients was not statistically significant between the periods (P>0.05). In conclusion, we speculate that Ramadan fasting does not increase acute coronary heart disease events. We believe that further prospective studies should provide an opportunity to examine the relation of fasting to coronary events.

Appetite changes under free-living conditions during Ramadan fasting

During the fasting month of Ramadan, Muslims abstain from food and drink from sunrise until sunset. This change of eating pattern provides an opportunity to investigate factors controlling hunger and thirst. A group of healthy Muslims (15 men and 26 women) living in Reading, U.K. made hourly ratings of their hunger, mood and thirst, and recorded their food and drink intake on specified days before, during and after Ramadan between January and March 1996. There were no significant changes in body weight over Ramadan. Rated hunger increased substantially during the daily fast, and hunger was higher for the women than the men during the earlier days of Ramadan, whereas later, on average, fasting levels of hunger were very similar for both sexes (significant gender x day interaction,p<0. 001). During Ramadan, the men tended to spend much of their time away from home, and may therefore have largely avoided eating-related cues during the daily fast. The women, however, were frequently involved in preparing food to be eaten later after sunset, which suggests an explanation for the results based on the external cue control of hunger. That is, unreinforced exposure to food cues in this context may have led to a decrease in the capacity of these cues to stimulate hunger.