Does Ramadan fasting disrupt international normalised ratio control in warfarin-treated medically stable patients?

Burden and Patterns of Medical Emergencies during Ramadan Fasting: A Narrative Review

Introduction Acute medical problems may occur more frequently during Ramadan fasting (RF). We aimed to provide a narrative overview of the global literature on medical emergencies during RF.

Methods This is a nonsystematic review of the international literature from one major medical online database (PubMed, National Institutes of Health, United States). The relevant literature was narrated in a concise thematic account.

Results There is a variable impact in the burden and time distribution of emergency services and hospitalization during RF that may require readjustment of resource allocation. Studies of the risk of accidents and injuries may be increased overall or at specified times, around Iftar time. A classical impact of emergencies has been the risk of worsening peptic ulcer disease. RF impacts diabetic emergencies such as severe hypoglycemia, hyperglycemia, and diabetic ketoacidosis, particularly in type 1 diabetes and poorly controlled patients. Glucocorticoid replacement therapy may represent a challenge to patients and physicians that require education and dose adjustment. Acute neurological conditions of interest include the “first day of Ramadan headache,” epilepsy, and strokes. Several studies evaluated the risk of the acute coronary syndrome and heart failure with inconsistent findings. RF may impact the renal and urological systems through stone disease, renal colic, and acute kidney. The impact on hematological conditions was mostly focused on the safety of anticoagulant therapy during Ramadan.

Conclusion The review addresses the emergency medical encounters of the fasting patient during Ramadan to allow a holistic and ethnically sensitive approach to medical care under circumstances where decisions have to be taken with no delay.

Islamic fasting: cardiovascular disease perspective

INTRODUCTION

Ramadan is a month of obligatory fasting observed by the majority of 2 billion Muslims living around the globe. The guidelines for 'risk-free' fasting exist for chronic diseases, including diabetes mellitus, but recommendations for cardiovascular disease (CVD) patients are deficient due to the paucity of literature.

AREAS COVERED

Databases were screened to find relevant studies for an evidence-based consensus regarding the risk stratification and management of CVD. Using practical guidelines of the European Society of Cardiology (ESC), we categorized patients into low-, moderate-, and high-risk categories and proposed a pre-Ramadan checklist for the assessment of cardiac patients before fasting. Regular moderate-intensity exercise is recommended for most cardiac patients, which has been demonstrated to provide an anti-inflammatory and antioxidant effect that improves immune function.

EXPERT OPINION

In Ramadan, many physiological changes occur during fasting, which brings about a balanced metabolic homeostasis of the body. In addition, Ramadan fasting is a nonpharmacologic means of decreasing CV risk factors. As Islam exempts Muslims from fasting if they are unwell; therefore, patients with the acute coronary syndrome (ACS), advanced heart failure (HF), recent percutaneous coronary intervention (PCI), or cardiac surgery should avoid fasting.

Ramadan Fasting in Health and Disease in 2021: A Narrative Review

Introduction: The literature on the health aspects of Ramadan fasting (RF) is widely spread in many journals.

Materials and Methods: This is a narrative review of data obtained from the PubMed database (National Library of Medicine, Bethesda, Maryland, United States). We used the search term “Ramadan fasting,” and relevant records were examined. The publications are narrated thematically.

Results: The publications spanned fundamental, clinical, professional, cultural, and advocacy facets. The publications crossed conventional disciplinary lines and geographical locations and appeared in journals with different access systems. The contents are presented under the themes that emerged depending on the retrieved literature. This year basic coverage included changes in physiology and nutrition during Ramadan. However, the clinical issues included a wide range of topics. These included the impact of RF on nonalcoholic fatty liver disease and adjustments needed in endocrine replacement therapy for hypothyroidism and adrenal insufficiency. Coverage also included chronic kidney disease. The impact on maternal health, fetal well-being, and long-term effects of RF exposures were addressed in several studies. Studies in cardiovascular medicine focused on blood pressure and cardiovascular risk factors. Sports medicine and athletes' well-being received somewhat prominent coverage. The impact on renal function, particularly in patients with chronic kidney disease, was investigated by a few authors. Several groups addressed the eyes' structure and function, neurological conditions, especially headache disorders, and hematological and oncological conditions. Finally, the impact of RF on several aspects of mental health and well-being was addressed by various groups.

Conclusions: Health aspects of RF received a sustained academic interest with a broad spectrum in 2021. This narration provides an overview of the year's scholarly health-related literature on various aspects of health and disease. It should help researchers and clinicians catch up quickly with the health concerns during Ramadan.

Does ramadan fasting affect the therapeutic and clinical outcomes of warfarin? a systematic review and meta-analysis

BACKGROUND

Warfarin's therapeutic effect is affected by many factors, including diet modifications. The impact of Ramadan fasting on warfarin is controversial. The aim of this systematic review and meta-analysis was to investigate the effect of Ramadan fasting on patients taking warfarin.

METHODS

A literature search was done in PubMed, WOS, Scopus, and Embase from inception to May 24, 2021. All relevant studies measuring the international normalized ratio (INR), time in therapeutic range (TTR), or the number of patients within therapeutic range before, during, and after Ramadan were assessed by full-text screening for achieving all of the inclusion criteria. We used the Newcastle-Ottawa Scale for quality assessment and RevMan 5.4 software for meta-analysis.

RESULTS

A total of five studies with 446 patients were included in the meta-analysis. The patients served as their own control. Our pooled analyses showed no significant difference during Ramadan compared to pre-Ramadan (MD: 0.08; 95% CI: - 0.00, 0.15; P = 0.06) and post-Ramadan (MD: - 0.00; 95% CI: - 0.14, 0.14; P = 1.00, respectively). There was only a significant increase in the risk ratio of supratherapeutic INR when comparing post-Ramadan vs. pre-Ramadan (RR: 1.69; 95% CI: 1.22, 2.33; P = 0.001). However, there was no significant risk for supratherapeutic INR during Ramadan compared to pre-Ramadan or post-Ramadan; the number of patients within the therapeutic range of INR during Ramadan compared to pre-Ramadan; and TTR during Ramadan, pre-Ramadan, and post-Ramadan.

CONCLUSION

Ramadan fasting did not affect INR level, TTR, or the number of patients within the therapeutic range before, during, and after Ramadan. However, there was a possibility of achieving a supratherapeutic INR post-Ramadan compared to pre-Ramadan. Therefore, INR monitoring and warfarin dose adjustments accordingly are recommended after Ramadan.