Medication Management During Ramadan

Cultural Sensitivity Training for Pharmacists

Outline

• What is Ramadan?• Physiological/Psychological Impact• Medication management• Pharmacist Opportunities• Patient Cases

Cultural Sensitivity

Cultural Sensitivity

What is Ramadan?

• A month of total abstention food, fluid, smoking, sexual activity from sunrise to sunset

What is Ramadan?

• Occurs in the 9th month of the lunar Islamic calendar, for 28-30 days

• Islamic calendar is 354 days, thus it precedes every year by 10-11 days

Why do Muslims Fast?

• Self-discipline• Self-restraint• Exert control of the mind• Understand the plight of

the less privileged and appreciate what one has• Increase good deeds, God-consciousness and purify the body and soul

• Feelings of anger nullify the benefit of fasting• Attain spiritual peace

Upon reaching puberty, all healthy Muslims are required to partake in

the fast

Exemptions

• Children • Elderly• Chronically ill • Traveling* • Acutely ill*• Pregnant*• Breast-feeding*• Menstruating*• *temporarily exempt and can be made up at a later date

Many Muslims who are eligible for exemption

choose to fast nonetheless

Physiological Impact

• No consistent data on the effect on lipid profiles

• No significant changes in blood pressure or heart rate

• Possible reduction in oxidative stress• Possible increase in gastric acidity • Weight gain/loss is largely dependent on

night-time diet

Psychological Impact

• Decrease in alertness• Increase in lethargy and irritability• Cognitive function decline• Alterations in normal circadian rhythms, with

individuals becoming more active through the evening and at night, and sleep deprivation

• Effects of tobacco, caffeine and energy and fluid intake

Medication Management

Life Adjustment

• First meal (large) at sunset (Iftar)• Second (lighter) meal before dawn (Suhur) • 2013: July 9th – August 7th • 9:00 PM – 4:00 AM • ~ 7 hours of eating time/day• Single daily dose – morning or evening• 2 or more doses

Medication Management

• Individualize therapy• Pay attention to drugs with a narrow

therapeutic index• Switch to long-acting medications• Pay attention to Drug-Drug Interactions and

Drug-Food interactions• Encourage extra monitoring• PLAN AHEAD!

Pre-Ramadan Medical Assessment

• 1-2 months before Ramadan• Order blood work, examine glycemic control,

blood pressure and lipids • Offer specific medical advice • Changes in diet or medication can be made

early, so the patient can initiate fasting on a stable and effective program

Pharmacist Opportunities

Pharmacist Role

• Encourage maintenance of a healthy diet• Encourage weaning off of caffeine and

nicotine to avoid withdrawal symptoms• Opportunities! Quit smoking?• Discourage fasting during chronic illness,

pregnancy and lactation

Dietary Advice

• Continue to choose healthy foods• Don’t reward yourself! Eat healthy!• Remain hydrated during evening hours• Don’t skip suhur (morning meal)• Consume slow digesting foods (complex

carbohydrates) and high protein foods• Don’t overeat. Don’t overindulge.

For more information…

Ramadanmanagement.weebly.com

Patient Cases

Real-Life Case

Patient #1• Type II Diabetes, controlled, A1c = 7.5• Hypertension• Hyperlipidemia

Current Medication• Lantus (Glargine) long acting insulin 33 units ~ 6 pm daily• Metformin 2 500 mg tabs bid • Trandalapril 4 mg • Rosuvastatin 20 mg

• Lifestyle: Moderate physical activity, bike-riding and jogging 3-4x per week

• How would you change his insulin?

Patient #1

New Regimen:• Morning (before dawn) take 2 metformin 500 mg • Evening (break-fast) 9 pm, take all other oral

medications, 2 metformin • Reduce long-acting insulin to 16 units at sunset meal• Add 8 units of Novo-rapid (Aspart) at sunset meal • Continue exercise – start light, increase workout later• Rationale: Would rather be on higher end than lower. • “By the time I master it, Ramadan is over”

Diabetes

• EPIDIAR study is the largest collection of data on type I and type II diabetic patients that fast

• 43% of patients with Type I Diabetes and 78% with Type II fasted for at least 15 days

• Overall, the number of severe hypoglycemic episodes per month per patient were significantly higher during Ramadan compared to the preceding year (4.7 fold, 7.5 fold increased risk)

• Increased risk of hyperglycemia associated with a change in diet

Insulin Management

Type II: Maintain basal insulin to prevent fasting hyperglycemia. Use intermediate- or long-acting insulin preparations plus a short-acting insulin administered before meals Type I: Once or twice daily injections of intermediate or long-acting insulin along with premeal rapid-acting insulin

Patient #2

• 32 year old female patient• Gabapentin 300 mg TID for epilepsy partial

seizures• Acetaminophen for headaches

You advise Patient #2 not to partake in fasting. While she appreciates your advice, she says her religion is more important and she’s going to do it anyways. What do you do?

Patient #2

• Be respectful• Outline the risks clearly• Offer other alternatives (donating meals,

charity, prayer)• Recommend she speaks with her religious

guide (Imam)

Seizure frequency

• Gomceli et al studied seizure frequency in Ramadan

• Out of 114 patients, 38 had seizures and one of these developed status epilepticus

• Statistically significant increase in frequency compared to months prior to Ramadan

• Even patients on monotherapy, who did not change drug regimens, had an increase in seizure frequency

Offer Respect

• Some patients may refuse your advice and continue fasting against medical wishes

• Present the risks respectfully and understand that their spiritual reasoning may be different from yours

• Fasting is a spiritual issue for which patients make their own decision after receiving advice from religious teachings and from health care providers

• Our role is to provide information and let them decide

Opportunity to build patient care

Questions?

References1. Leiper JB, Molla AM, Molla AM. Effects on health of fluid restriction during fasting in Ramadan. Eu J

Clin Nutrition 2003 57 31-382. Aslam M, Healy MA. Compliance and drug therapy in fasting Moslem patients. J Clin Hosp Pharm

1986;11:321-5.3. Aadil B, Houti IE, Moussamih S. Drug intake during Ramadan. BMJ Volume 329. 2004. 778-782.4. Trepanowski JF, Canale RE, Marshall KE et al. Impact of caloric and dietary restriction regimens on

markers of health and longevity in humans and animals: a summary of available findings. Nutrition Journal 2011, 10: 107

5. Recommendations for Management of Diabetes During Ramadan. Diabetes Care. 2010 33(8): 1895-1902

6. Etemadyfar M. Effect of Ramadan on frequency of seizures. Abstract book, Congress on Health and Ramadan, October 2001. Tehran: Iranian Journal of Endocrinology and Metabolism, 2001: 32.

7. Mafauzy M, Mohammed WB, Anum MY et al. A study of the fasting diabetic patients during the month of Ramdan. Med J Malaysia 1990; 45: 14-7.

8. Dikensoy E, Balat O, Cebesoy B et al. The effect of Ramadan fasting on maternal serum lipids, cortisol levels and fetal development. Arch Gynecol Obset 2009; 279: 119-23.

9. Salti I, Benard E, Detournay B, et al. EPIDIAR study group. A population-based Study of Diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001(EPIDIAR) study. Diabetes Care 2004;27:2306-11.