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Belal MM, Youssef AR, Baker H, Elalaky NA, Marey AA, Quaisy MA, Rabea EM. Effect of Ramadan fasting on thyroid functions in hypothyroid patients taking levothyroxine: a systematic review and meta-analysis. Ir J Med Sci 2024; 193:741-753. [PMID: 37733226 PMCID: PMC10961289 DOI: 10.1007/s11845-023-03526-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/12/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND The major changes in the timing of meals during Ramadan may be challenging for hypothyroid patients on levothyroxine. We aimed to study the effect of Ramadan fasting on thyroid functions in hypothyroid patients taking levothyroxine. METHODS We did a comprehensive search of 8 databases for Randomized controlled studies (RCTs) and observational studies investigating the effect of Ramadan fasting on thyroid functions in hypothyroid individuals taking levothyroxine. Relevant data was extracted and analyzed. Mean difference (MD) and standard deviation (SD) were used to evaluate the continuous data. Risk ratios (RR) with a 95% confidence interval were used for outcomes constituting dichotomous data. National Institutes of Health (NIH) tools were used to assess the risk of bias. RESULTS Fourteen studies met our inclusion criteria, 3 RCTs, and 11 observational studies, all designed as pre-post studies. Ramadan fasting was associated with a statistically significant increase in TSH in patients who were euthyroid before Ramadan (MD = -0.76 [95% CI; -1.27, -0.25]). However, free thyroxine (FT4) was found to be stable (MD = 0.01, [95% CI; -0.03, 0.06]). All timing points were associated with a significant increase in TSH levels after Ramadan, pre-iftar (MD = -0.69 [95% CI; -1.03, -0.36]), post-iftar (MD = -0.76 [95% CI; -1.12, -0.39]), and pre-suhoor (MD = -1.19 [95% CI; -2.18, -0.19]). CONCLUSION TSH increases significantly after Ramadan. No timing point has superiority in maintaining thyroid control. However, choosing the timing should be individualized according to the patient's preference to guarantee the most possible compliance.
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Affiliation(s)
| | | | - Hany Baker
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Elsherbiny TM. Impact of fasting on thyrotropin and thyroid status during Ramadan in 292 previously well controlled hypothyroid patients. IFTAR study. Endocrine 2023; 79:484-490. [PMID: 36344762 PMCID: PMC9988775 DOI: 10.1007/s12020-022-03242-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/22/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE Fasting during Ramadan affects thyrotropin both in healthy subjects and hypothyroid patients on adequate levothyroxine replacement. Few studies have addressed this effect in hypothyroid patients with pre-Ramadan euthyroidism. This study aims to report the impact of fasting in a relatively large cohort. METHODS This was a prospective study including hypothyroid patients who fasted Ramadan during the years 2018, 2019, and 2020 in Alexandria, Egypt. All patients were euthyroid. Patients chosen one of three levothyroxine regimens during Ramadan, regimen 1: 60 min before Iftar, regimen 2: 3-4 h after Iftar, 60 min before Suhor, regimen 3: before the start of next fast, 3-4 h after an early Suhor. Thyroid status was assessed in pre-Ramadan visit and reassessed in post-Ramadan visit within 6 weeks from the end of Ramadan. RESULTS The study included 292 hypothyroid patients. Most patients were adherent, 249 patients (85.3%), one sixth of patients were non-adherent, 43 patients (14.7%). Post-Ramadan TSH was 2.13 ± 1.88 mIU/L versus 1.60 ± 0.96 mIU/L pre-Ramadan [P = 0.001]. Most patients were still euthyroid post-Ramadan, 233 patients (79.8%), while 59 patients (20.2%) were dysthyroid. Post-Ramadan TSH significantly correlated to pre-Ramadan TSH [P < 0.001]. Post-Ramadan TSH was significantly higher in non-adherent patients, 3.57 ± 3.11 mIU/L compared to adherent patients, 1.88 ± 1.44 mIU/L [P < 0.001]. CONCLUSION Fasting Ramadan in well controlled hypothyroid patients resulted in a significant increase in post-Ramadan TSH, yet 80% the patients remain euthyroid after Ramadan. Post-Ramadan TSH and euthyroidism are related to adherence and pre-Ramadan TSH.
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Affiliation(s)
- Tamer Mohamed Elsherbiny
- Alexandria university, Endocrine division - Alexandria faculty of medicine, Khartoum square, Azarita, Alexandria, Egypt.
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3
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Mahzari M, Al Remthi F, Ajwah I, Al Hazmi M, Moafa W, Al Shahrani A, Al Shehri S, Badri M. Levothyroxine Timing during Ramadan: A Randomized Clinical Trial. Int J Endocrinol 2023; 2023:2565031. [PMID: 36818804 PMCID: PMC9937748 DOI: 10.1155/2023/2565031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/12/2023] Open
Abstract
INTRODUCTION Hypothyroidism requires lifelong thyroid hormone replacement with levothyroxine. For most hypothyroid patients fasting during Ramadan, compliance with the administration procedure is a challenge. This study aimed to determine the impact of different administration times of levothyroxine on thyroid-stimulating hormone (TSH) and free T4 (FT4) levels before and after the holy month of Ramadan. Materials and Methodology. Hypothyroid patients taking levothyroxine were randomized to 3 groups during Ramadan: group 1, 30 minutes before the iftar meal; group 2, 3-4 hours after the iftar meal, with no food taken for at least 1 hour after the meal; group 3, they were not given specific instructions for taking levothyroxine during Ramadan. Thyroid function tests were performed within 2 weeks before Ramadan and within 2 weeks after Ramadan. Pre- and post-Ramadan TSH and free T4 levels were compared. Mixed-effects analyzes were performed to identify factors associated with changes in TSH and FT4 levels. RESULTS Compliance was lower in patients taking levothyroxine 3-4 hours after iftar. In addition, the majority of patients who had not received a specific recommendation took levothyroxine 30 minutes before iftar. There was a statistically significant increase in TSH (P=0.006) and FT4 (P=0.044) levels after Ramadan. In multivariate analysis, the cause of hypothyroidism (Hashimoto's; postthyroidectomy; compared to postradioactive iodine) and levothyroxine dose significantly affected FT4 levels. In contrast, no variable was significantly associated with TSH level. The timing of levothyroxine intake during Ramadan did not significantly affect TSH or FT4 levels. CONCLUSION TSH and FT4 significantly increased after Ramadan. However, the timing of levothyroxine intake per se had no influence on TSH or free T4 levels. Therefore, hypothyroid patients might take levothyroxine either 30 minutes or 3-4 hours after iftar with no meal for 1 hour, depending on preference.
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Affiliation(s)
- Moeber Mahzari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Medicine, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Fahad Al Remthi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Medicine, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia
- Diabetes and Endocrine Center, King Abdullah Hospital, Ministry of Health, Bisha, Saudi Arabia
| | - Ibrahim Ajwah
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Medicine, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Mohammed Al Hazmi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Medicine, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Wesam Moafa
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Medicine, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Awad Al Shahrani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Medicine, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Sameerah Al Shehri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Medicine, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Motasim Badri
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Epidemiology and Biostatistics, College of Public Health and Health Informatics, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Al-Qahtani KM, Aldeeri IA, Alshaibi AM, Alshabib NS, Barghouthi RM, Alyusuf EY, Jammah AA. Optimal Timing of Thyroid Hormone Replacement During Ramadan Fasting: A Randomized Controlled Trial in Patients with Prior Total Thyroidectomy. Thyroid 2022; 32:1029-1036. [PMID: 35708106 DOI: 10.1089/thy.2022.0110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Fasting during Ramadan may be challenging for patients on levothyroxine (LT4), as the drug has a narrow therapeutic index and is administered on an empty stomach. The majority of Muslims who fast in Ramadan have two meals per day, iftar immediately after sunset and suhoor just before dawn. This study aimed at evaluating the impact of LT4 timing during Ramadan on thyrotropin (TSH) levels in patients who underwent total thyroidectomy to determine the best timing for intake and identify the predictors of TSH level changes. Methods: We conducted a parallel, double-blind, randomized controlled trial on Saudi patients diagnosed with hypothyroidism who underwent total thyroidectomy. Patients were required to have stable thyroid function for 6 months before the study period and fast ≥20 days of Ramadan. Participants were randomized to one of three times for LT4 administration: Group A, 30 minutes pre-iftar (n = 48); Group B, 3 hours post-iftar (n = 47); or Group C, 1 hour pre-suhoor (n = 47). The number of participants in the final analysis (excluding patients who dropped out) was as follows: Group A, (n = 31); Group B, (n = 34); and Group C, (n = 22). The changes in TSH and free thyroxine (fT4) levels two weeks before and after Ramadan were compared. Factors associated with a change in TSH levels were examined through multivariable analysis. Results: The TSH levels significantly increased in Group B (1.7 ± 1.8 mU/L vs. 3.1 ± 3.9 mU/L, p = 0.003) and Group C (2 ± 1.7 mU/L vs. 5.5 ± 10 mU/L, p = 0.011), but not Group A (1.8 ± 1.6 mU/L vs. 3.3 ± 4.2 mU/L, p = 0.158). The change in fT4 levels was comparable among the groups: Group A, 16.5 ± 2.7 mcg/dL vs. 15.9 ± 3.2 mcg/dL, p = 0.144; Group B, 15.8 ± 3.8 mcg/dL vs. 16.3 ± 3.6 mcg/dL, p = 0.620; and Group C, 17.5 ± 2.8 mcg/dL vs. 17.3 ± 3.9 mcg/dL, p = 0.770. In multivariable linear regression analysis, the following variables were significantly independently associated with TSH level change: age, weight gain, and the number of nonadherence days to LT4, where β = -0.2, p = 0.026; β = + 0.2, p = 0.026; and β = + 0.5, p < 0.0001, respectively. Conclusions: Fasting patients who took LT4 pre-iftar did not experience significant changes in TSH, whereas those who took LT4 post-iftar or pre-suhoor did. The TSH changes during Ramadan may be associated with age (inverse association), weight gain, and the number of non-adherence to LT4 days. Trial Registration: SCTR Application no. 21122002.
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Affiliation(s)
| | | | - Amal M Alshaibi
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Rakan M Barghouthi
- Department of Family Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ebtihal Y Alyusuf
- Division of Endocrinology, Department of Internal Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Anwar Ali Jammah
- Division of Endocrinology, Department of Internal Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Elsherbiny TM. Twice or Thrice Weekly versus Daily Thyroxine in Hypothyroid Fasting Ramadan: A Pilot Study. Indian J Endocrinol Metab 2022; 26:265-268. [PMID: 36248049 PMCID: PMC9555373 DOI: 10.4103/ijem.ijem_1_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 01/25/2022] [Accepted: 04/22/2022] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Hypothyroid patients require to take levothyroxine (L-T4) on an empty stomach, 60 min before next meal which is difficult to achieve while fasting Ramadan, on a daily basis. This pilot study aimed to assess the effect of twice or thrice weekly versus standard daily L-T4 dosing during Ramadan on adherence, post-Ramadan TSH, and thyroid status. METHODS AND MATERIALS The study included 2 groups; group 1 included 11 patients assigned to take L-T4 twice or thrice a week, and group 2 included 113 patients assigned to take L-T4 daily. Patients chose between three L-T4 regimens: regimen 1 - 60 min before Iftar; regimen 2 - 60 min before Suhor, on empty stomach for 3-4 h; regimen 3 - before the next fast, on empty stomach for 3-4 h. Thyroid status was assessed before and within 6 weeks after Ramadan. Only euthyroid patients were included. RESULTS No significant differences between the two groups regarding adherence, post-Ramadan TSH, or post-Ramadan thyroid status. 90.9% in group 1 and 88.5% in group 2 were adherent [p = 1.000]. Post-Ramadan TSH in group 1 was 1.9 ± 1.5 mIU/L, in group 2 was 2 ± 1.6 mIU/L [p = 0.809]. 81.8% in group 1 and 82.3% in group 2 were euthyroid post-Ramadan [p = 0.209]. CONCLUSIONS In this pilot study, taking L-T4 twice or thrice weekly during Ramadan achieved similar adherence and metabolic control to standard daily L-T4, making it an easier option for hypothyroid patients wishing to fast Ramadan.
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Affiliation(s)
- Tamer Mohamed Elsherbiny
- Endocrinology Unit, Alexandria Faculty of Medicine, Alexandria University, Khartoum Square, Azarita, Alexandria, Egypt
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Alkaf B, Siddiqui M, Ali T, Bakir A, Murphy K, Meeran K, Lessan N. Ramadan Fasting and Changes in Thyroid Function in Hypothyroidism: Identifying Patients at Risk. Thyroid 2022; 32:368-375. [PMID: 35152772 PMCID: PMC9048180 DOI: 10.1089/thy.2021.0512] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Ramadan fasting (RF) is associated with major changes in meal times. This can affect thyroxine absorption and thyroid function (TF) in patients with hypothyroidism. We aimed to examine the short- and long-term impact of RF on TF in patients with primary hypothyroidism on levothyroxine. Methods: TF tests in patients with primary hypothyroidism attending an endocrine center in the United Arab Emirates were retrospectively analyzed. The impact of RF on TF, namely serum thyrotropin (TSH) TSH, free thyroxine (fT4) and free triiodothyronine (fT3), was investigated in 481 patients within 3 months before Ramadan (BR), 1-2 weeks (PR1), and 3-6 months (PR2) post-Ramadan. Controlled TF was defined as TSH between 0.45 and 4.5 μIU/mL. Inadequate control was defined as TSH >4.5 μIU/mL. Loss of control was defined as having controlled TF at BR and inadequate control at PR1. Multivariable regression analyses were used to assess the association of baseline TSH, baseline levothyroxine dose, and medication use with loss of thyroid control in Ramadan. Results: TSH increased significantly from a median of 2.0 (0.8-3.7) μIU/mL at BR to 2.9 (1.4-5.6) μIU/mL at PR1 (p < 0.001). This was accompanied by a fall in fT4 and fT3 at PR1 (p < 0.001). 25.5% of patients with previously controlled TF at BR had deterioration in TF at PR1. Sixty-one percent of patients with previously uncontrolled TF at BR remained uncontrolled at PR1. Baseline TSH was significantly associated with loss of thyroid control in Ramadan with an odds ratio (95% confidence interval) of 1.5 (1.17-1.92) (p < 0.001), whereas other variables, including medications known to affect levothyroxine absorption were not associated with loss of control. TSH, fT4, and fT3 levels returned to normal at PR2. Conclusions: RF can negatively affect TF of patients on levothyroxine replacement. Although this effect is modest and transitory in most patients, a significant minority exhibit more pronounced, and clinically relevant changes. The latter includes those with higher TSH BR, and a smaller group whose thyroid disease appears to be particularly affected by the mealtime and lifestyle changes of Ramadan.
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Affiliation(s)
- Budour Alkaf
- Research Department, Imperial College London Diabetes Centre, Abu Dhabi, United Arab Emirates
- Address correspondence to: Budour Alkaf, MRes, Research Department, Imperial College London Diabetes Centre, 30th Al Khaleej Al Arabi Street, PO Box 48338, Abu Dhabi, UAE
| | - Mohsin Siddiqui
- Research Department, Imperial College London Diabetes Centre, Abu Dhabi, United Arab Emirates
| | - Tomader Ali
- Research Department, Imperial College London Diabetes Centre, Abu Dhabi, United Arab Emirates
| | - Ali Bakir
- Research Department, Imperial College London Diabetes Centre, Abu Dhabi, United Arab Emirates
| | - Kevin Murphy
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, United Kingdom
| | - Karim Meeran
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, United Kingdom
| | - Nader Lessan
- Research Department, Imperial College London Diabetes Centre, Abu Dhabi, United Arab Emirates
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Hassanein M, Afandi B, Yakoob Ahmedani M, Mohammad Alamoudi R, Alawadi F, Bajaj HS, Basit A, Bennakhi A, El Sayed AA, Hamdy O, Hanif W, Jabbar A, Kleinebreil L, Lessan N, Shaltout I, Mohamad Wan Bebakar W, Abdelgadir E, Abdo S, Al Ozairi E, Al Saleh Y, Alarouj M, Ali T, Ali Almadani A, Helmy Assaad-Khalil S, Bashier AMK, Arifi Beshyah S, Buyukbese MA, Ahmad Chowdhury T, Norou Diop S, Samir Elbarbary N, Elhadd TA, Eliana F, Ezzat Faris M, Hafidh K, Hussein Z, Iraqi H, Kaplan W, Khan TS, Khunti K, Maher S, Malek R, Malik RA, Mohamed M, Sayed Kamel Mohamed M, Ahmed Mohamed N, Pathan S, Rashid F, Sahay RK, Taha Salih B, Sandid MA, Shaikh S, Slim I, Tayeb K, Mohd Yusof BN, Binte Zainudin S. Diabetes and Ramadan: Practical guidelines 2021. Diabetes Res Clin Pract 2022; 185:109185. [PMID: 35016991 DOI: 10.1016/j.diabres.2021.109185] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 12/21/2021] [Indexed: 12/16/2022]
Abstract
Fasting during Ramadan is one of the five pillars of Islam and is obligatory for all healthy Muslims from the age of puberty. Though individuals with some illness and serious medical conditions, including some people with diabetes, can be exempted from fasting, many will fast anyway. It is of paramount importance that people with diabetes that fast are given the appropriate guidance and receive proper care. The International Diabetes Federation (IDF) and Diabetes and Ramadan (DaR) International Alliance have come together to provide a substantial update to the previous guidelines. This update includes key information on fasting during Ramadan with type 1 diabetes, the management of diabetes in people of elderly ages and pregnant women, the effects of Ramadan on one's mental wellbeing, changes to the risk of macrovascular and microvascular complications, and areas of future research. The IDF-DAR Diabetes and Ramadan Practical Guidelines 2021 seek to improve upon the awareness, knowledge and management of diabetes during Ramadan, and to provide real-world recommendations to health professionals and the people with diabetes who choose to fast.
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Affiliation(s)
| | | | | | | | | | | | - Abdul Basit
- Baqai Institute of Diabetology & Endocrinology, Baqai Medical University, Karachi, Pakistan
| | | | | | - Osama Hamdy
- Joslin Diabetes Center, Harvard University, Boston, MA, USA
| | | | | | | | - Nader Lessan
- Imperial College London Diabetes Centre, Abu Dhabi, UAE
| | | | - Wan Mohamad Wan Bebakar
- School of Medical Sciences, Universiti Sains Malaysia, Hospital Universiti Sains Malaysia, Kota Bharu, Malaysia
| | | | - Sarah Abdo
- Bankstown - Lidcombe Hospital, Sydney, Australia
| | | | - Yousef Al Saleh
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, KSA
| | | | - Tomader Ali
- Imperial College London Diabetes Centre, Abu Dhabi, UAE
| | | | | | | | | | | | | | - Said Norou Diop
- Department of Medicine, Universite Cheikh Anta Diop De Dakar, Senegal
| | | | | | | | | | | | | | - Hinde Iraqi
- Endocrinologie et Maladies Métaboliques, CHU de Rabat, Maroc
| | | | | | - Kamlesh Khunti
- University of Leicester, Leicester General Hospital, Leicester, UK
| | - Salma Maher
- Diabetes UK, Meethi Zindagi Pakistan, Baqai Institute Pakistan, MywayDiabetes UK, Digibete UK
| | - Rachid Malek
- Department of internal Medicine, Setif hospital University, Algeria
| | | | | | | | - Nazeer Ahmed Mohamed
- Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, South Africa
| | - Sameer Pathan
- International Diabetes Federation, Brussels, Belgium
| | | | | | | | | | | | - Ines Slim
- Multidisciplinary Private Clinic "Les Oliviers", Sousse, Tunisia
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Mahmood A, Dar S, Dabhad A, Aksi B, Chowdhury TA. Advising patients with existing conditions about fasting during Ramadan. BMJ 2022; 376:e063613. [PMID: 35101897 DOI: 10.1136/bmj-2020-063613] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Ammad Mahmood
- Institute of Neurosciences and Psychology, University of Glasgow, Imaging Centre of Excellence, Queen Elizabeth University Hospital, Glasgow
| | - Sahira Dar
- NHS Greater Glasgow and Clyde Primary Care Division, Glasgow
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El-Kaissi S, AbdelWareth L, Dajani R, Lee-St. John TJ, Santarina SA, Makia F, AlTakruri M, Kaskas A, Ahmed Y. Levothyroxine Administration during Ramadan: A Prospective Randomized Controlled Trial. Eur Thyroid J 2021; 10:455-460. [PMID: 34956918 PMCID: PMC8647124 DOI: 10.1159/000517706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 06/02/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND AIM We have previously shown in a retrospective analysis that the plasma thyroid-stimulating hormone (TSH) rises significantly post-Ramadan in levothyroxine-treated hypothyroid patients, possibly as a result of lifestyle alterations and time restrictions during the nonfasting period from dusk until dawn. The aim of this study is to determine the best time to instruct patients to take levothyroxine during Ramadan so as to minimize changes in thyroid function tests during this period. METHODS In a randomized prospective design, hypothyroid patients taking levothyroxine were randomized to receive instructions to take levothyroxine at one of the following 3 times during Ramadan: (group 1) at dusk 30-min before Iftar meal, (group 2) 3 or more hours after Iftar meal, or (group 3) at dawn 30-min before Suhur meal. Thyroid function tests were performed within 3 months before Ramadan and within 6 weeks post-Ramadan. Data from patients with at least 1 blood test before or after Ramadan were analyzed using mixed-effects regression models. RESULTS Plasma TSH levels were available at one or more time points for 148 patients, group 1 (n = 50), group 2 (n = 46), and group 3 (n = 52). A statistically significant within-patient increase in plasma TSH was seen in patients at the 25th percentile pre-Ramadan in groups 2 and 3 (p values <0.001), but not in group 1. A statistically significant within-patient decrease in plasma TSH was found in patients at the 75th percentile in group 1 only. For patients at the 50th percentile pre-Ramadan, no statically significant within-patient changes were found, though descriptively, increases in plasma TSH were observed for groups 2 and 3, while a decrease was observed in group 1. CONCLUSIONS Our data suggest that instructing patients to take levothyroxine at the time of breaking the fast 30 min before the Iftar meal minimizes unfavorable changes in plasma TSH post-Ramadan. In contrast, instructing patients to take levothyroxine 3 h post-Iftar or 30 min before Suhur led to a greater rise in post-Ramadan TSH.
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Affiliation(s)
- Samer El-Kaissi
- Department of Endocrinology, Medical Subspecialties Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
- *Samer El-Kaissi,
| | - Laila AbdelWareth
- Department of Laboratory Medicine, National Reference Laboratory and Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Ruba Dajani
- Department of Pharmacy, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | | | - Sherry Ann Santarina
- Research Department, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Fiona Makia
- Research Department, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Malak AlTakruri
- Department of Pharmacy, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - AbedElRahman Kaskas
- Department of Patient Education, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Yahya Ahmed
- Department of Pharmacy, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
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Kim BH, Joo Y, Kim MS, Choe HK, Tong Q, Kwon O. Effects of Intermittent Fasting on the Circulating Levels and Circadian Rhythms of Hormones. Endocrinol Metab (Seoul) 2021; 36:745-756. [PMID: 34474513 PMCID: PMC8419605 DOI: 10.3803/enm.2021.405] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/04/2021] [Indexed: 01/09/2023] Open
Abstract
Intermittent fasting has become an increasingly popular strategy in losing weight and associated reduction in obesity-related medical complications. Overwhelming studies support metabolic improvements from intermittent fasting in blood glucose levels, cardiac and brain function, and other health benefits, in addition to weight loss. However, concerns have also been raised on side effects including muscle loss, ketosis, and electrolyte imbalance. Of particular concern, the effect of intermittent fasting on hormonal circadian rhythms has received little attention. Given the known importance of circadian hormonal changes to normal physiology, potential detrimental effects by dysregulation of hormonal changes deserve careful discussions. In this review, we describe the changes in circadian rhythms of hormones caused by intermittent fasting. We covered major hormones commonly pathophysiologically involved in clinical endocrinology, including insulin, thyroid hormones, and glucocorticoids. Given that intermittent fasting could alter both the level and frequency of hormone secretion, decisions on practicing intermittent fasting should take more considerations on potential detrimental consequences versus beneficial effects pertaining to individual health conditions.
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Affiliation(s)
- Bo Hye Kim
- Department of Biochemistry and Molecular Biology, Seoul National University College of Medicine, Seoul,
Korea
- Genomic Medicine Institute, Medical Research Center, Seoul National University, Seoul,
Korea
| | - Yena Joo
- Seoul National University College of Medicine, Seoul,
Korea
| | - Min-Seon Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Diabetes Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Han Kyoung Choe
- Department of Brain and Cognitive Sciences, Daegu Gyeongbuk Institute of Science and Technology (DGIST), Daegu,
Korea
| | - Qingchun Tong
- Brown Institute of Molecular Medicine and Department of Neurobiology and Anatomy, McGovern Medical School of UTHealth, and MD Anderson Cancer Center & UTHealth Graduate School of Biomedical Sciences, Houston, TX,
USA
| | - Obin Kwon
- Department of Biochemistry and Molecular Biology, Seoul National University College of Medicine, Seoul,
Korea
- Genomic Medicine Institute, Medical Research Center, Seoul National University, Seoul,
Korea
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul,
Korea
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11
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Elsherbiny TM. Preference, Adherence, and Maintenance of Euthyroidism Using 3 Different Regimens of Levothyroxine Intake during the Fasting Month of Ramadan. DUBAI DIABETES AND ENDOCRINOLOGY JOURNAL 2021. [DOI: 10.1159/000513927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
<b><i>Introduction:</i></b> Millions of Muslim hypothyroid patients fast during Ramadan. Limited data are available on the effect of fasting during Ramadan and different levothyroxine (L-T4) timings on thyroid status. The present study aimed to report preference, adherence, and maintenance of euthyroidism using 3 different regimens of L-T4 intake during Ramadan. <b><i>Methods:</i></b> This is a prospective study including Muslim hypothyroid patients fasting during Ramadan between 2018 and 2019. Patients freely chose between 3 regimens, regimen 1: to take L-T4 at sunset and postpone food and beverages for 60 min; regimen 2: to have iftar (first meal) at sunset, stop food and beverages for 3–4 h, have L-T4, and wait for 60 min before suhor (last meal); regimen 3: have suhor at midnight, stop food and beverages for 3–4 h, and have L-T4 before next fast. Thyroid status was assessed before and within 6 weeks after Ramadan. <b><i>Results:</i></b> 393 patients were included. The first 2 regimens or a combination of both was the most preferred by patients 40.5, 36.7, and 17%, respectively. 323/393 patients were adherent to L-T4 regimens (82.2%). 273/393 patients were euthyroid after Ramadan (69.5%). TSH pre- and post-Ramadan were 4.35 ± 12.30 mIU/L and 2.73 ± 3.37 mIU/L, respectively, with no statistically significant change (<i>p</i> = 0.225). Adherence was predicted post-Ramadan euthyroidism (odds ratio [OR] 2.8 in univariate and OR 2.96 in multivariate models). <b><i>Conclusions:</i></b> The first and second regimens or a combination of both was preferred by most patients. High rates of adherence and post-Ramadan euthyroidism were observed. Adherence to the preferred regimen is the main determinant of post-Ramadan euthyroidism.
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12
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El-Kaissi S, Dajani R, Lee-St John TJ, Ann Santarina S, Makia F, AlTakruri M, Ahmed Y. Impact of Lifestyle Changes During Ramadan on Thyroid Function Tests in Hypothyroid Patients Taking Levothyroxine. Endocr Pract 2021; 26:748-753. [PMID: 33471643 DOI: 10.4158/ep-2019-0505] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 02/17/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The holy month of Ramadan poses a challenge for levothyroxine-treated patients due to altered eating habits and time restrictions. The aim of this study was to examine the impact of lifestyle changes during Ramadan on thyroid function tests in hypothyroid patients taking levothyroxine in the United Arab Emirates. METHODS Retrospective design whereby levothyroxine-treated hypothyroid patients who had thyroid function tests within 3 months pre-Ramadan and within 2 months post-Ramadan were included. We looked at adherence to levothyroxine, eating pattern, and levothyroxine administration in relation to meal times during Ramadan. Pre- and post-Ramadan thyroid function tests and the potential impact of independent variables using a random-intercept mixed effects linear model were examined. RESULTS A total of 112 patients (89 females) were recruited in the study, with a mean age ± standard error (SE) of 44.70±1.36 years (range, 19.0 to 79.0 years). The mean thyroid-stimulating hormone (TSH) within 3 months before Ramadan was 1.809±0.094 mIU/L (median, 41.5 days; interquartile range [IQR], 25.0 to 73.0 days), while the mean TSH within 2 months post-Ramadan was higher at 3.072±0.312 mIU/L (median, 27.5 days; IQR, 14.0 to 42.0 days). Post-Ramadan, 36 out of 112 patients had a plasma TSH outside of the normal reference range. The independent variable outcomes model showed that older patients and males were more likely to have an increased plasma TSH post-Ramadan. There was no relationship between the time of levothyroxine administration and change in TSH level. CONCLUSION Levothyroxine-treated hypothyroid patients showed a significant increase in plasma TSH post-Ramadan, amounting to 2.525 standard deviations, with older patients and males more likely to be affected. ABBREVIATIONS IQR = interquartile range; T4 = thyroxine; TSH = thyroid-stimulating hormone.
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Affiliation(s)
- Samer El-Kaissi
- Department of Endocrinology, Medical Subspecialties Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi, United Arab Emirates.
| | - Ruba Dajani
- Department of Pharmacy, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi, United Arab Emirates
| | - Terrence J Lee-St John
- Research Department, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi, United Arab Emirates
| | - Sherry Ann Santarina
- Research Department, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi, United Arab Emirates
| | - Fiona Makia
- Research Department, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi, United Arab Emirates
| | - Malak AlTakruri
- Department of Pharmacy, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi, United Arab Emirates
| | - Yahya Ahmed
- Department of Pharmacy, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi, United Arab Emirates
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13
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Or Koca A, Dağdeviren M, Altay M. Should the dose of levothyroxine be changed in hypothyroidism patients fasting during Ramadan? Turk J Med Sci 2020; 50:784-788. [PMID: 32151123 PMCID: PMC7379469 DOI: 10.3906/sag-1911-28] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 03/08/2020] [Indexed: 12/01/2022] Open
Abstract
Background/aim Muslims worship by fasting from predawn (suhoor) until sunset (iftar) for 30 days in the religious month of Ramadan. In addition to prolonged hunger, patients fasting with a diagnosis of hypothyroidism take their doses of levothyroxine (LT4) outside of daytime fasting hours. The purpose of our study is to compare the values of hypothyroid patients which have been obtained through thyroid function tests before and after Ramadan. Materials and methods Ninety-seven patients; ranging from 18 to 65 years old, who were followed with a diagnosis of hypothyroidism, who fasted during Ramadan, and who had no change of their LT4 dose for at least 6 months were included in the study. Results The median serum thyroid-stimulating hormone (TSH) level of patients prior to fasting was 2.19 mIU/L, while median serum TSH after fasting was 2.73 mIU/L. Serum TSH values after Ramadan increased significantly compared to those prior to Ramadan (P = 0.004). Conclusion Our study demonstrates a significant increase in serum TSH levels after Ramadan but no significant change in serum free thyroxine (fT4) levels in hypothyroidism patients who are fasting. It may be appropriate to take precautions by making a small increase in LT4 dose before Ramadan in some hypothyroid patients wishing to fast.
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Affiliation(s)
- Arzu Or Koca
- Department of Endocrinology and Metabolism, University of Health Sciences, Keçiören Health Administration and Research Center, Ankara, Turkey
| | - Murat Dağdeviren
- Department of Endocrinology and Metabolism, University of Health Sciences, Keçiören Health Administration and Research Center, Ankara, Turkey
| | - Mustafa Altay
- Department of Endocrinology and Metabolism, University of Health Sciences, Keçiören Health Administration and Research Center, Ankara, Turkey
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14
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Zaboon IA, Alidrisi HA, Hussein IH, Alabbood M, Alibrahim NTY, Almomin AMS, Al-Waeli DK, Alhamza AHA, Mohammed AG, Nwayyir HA, Al-Ali AJH, Mansour AA. Best Time for Levothyroxine Intake in Ramadan (THYRAM): Basrah Experience. Int J Endocrinol Metab 2020; 18:e94325. [PMID: 32636883 PMCID: PMC7322562 DOI: 10.5812/ijem.94325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 02/22/2020] [Accepted: 03/14/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Fasting the month of Ramadan should be achieved by every pubescent Muslim unless they have an excuse. Fasting involves complete abstinence of oral intake throughout daytime. Patients who have hypothyroidism usually require levothyroxine (L-thyroxine) replacement, which is typically given on an empty stomach away from meals. Taking L-thyroxine replacement without feeding is challenging during the nighttime of Ramadan, in addition to being prohibited during daytime. OBJECTIVES This study aimed to determine the best time of L-thyroxine intake during Ramadan. METHODS Fifty patients who were taking L-thyroxine treatment for primary hypothyroidism were involved in this prospective study for three months including the fasting and pre-fasting months. The patients were divided into three groups with different times of L-thyroxine intake. In the group one (pre-iftar), the patients were asked to take L-thyroxine at the time of iftar (the sunset meal) but to delay any oral intake for at least 30 minutes. In the group two (post-iftar), the patients were asked to take L-thyroxine two hours after iftar. The patients in the last group (pre-suhoor) were asked not to eat in the last two hours before suhoor (the predawn meal) and to take L-thyroxine tablet one hour prior to suhoor. RESULTS When thyroid stimulating hormone (TSH) levels were compared before and after Ramadan, there were no significant differences neither within each group nor among all the study groups. Moreover, the frequencies of the TSH control after Ramadan showed no significant differences within each of the study groups (P = 0.18, 0.75, 1.0 for pre-suhoor, pre-iftar, and post-iftar respectively). Similarly, comparison among the groups of the study showed no significant differences regardless of whether the patients had controlled or uncontrolled TSH prior to Ramadan (P = 0.75 and 0.67, respectively). In the patients with controlled TSH before Ramadan, 8 out of 10 (pre-suhoor), 8 out of 12 (pre-iftar), and 4 out of 6 (post-iftar) maintained their control after Ramadan. While in the patients with uncontrolled TSH before Ramadan, 7 out of 10 (pre-suhoor), 6 out of 8 (pre-iftar), and 2 out of 4 (post-iftar) achieved controlled TSH after Ramadan. CONCLUSIONS No significant differences in TSH control were observed in patients taking L-thyroxine at pre-iftar, post-iftar, or pre-suhoor time in Ramadan.
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Affiliation(s)
- Ibrahim Abbood Zaboon
- Faiha Specialized Diabetes, Endocrine, and Metabolism Center (FDEMC), Basrah Health Directorate, Basrah, Iraq
| | | | - Ibrahim Hani Hussein
- Faiha Specialized Diabetes, Endocrine, and Metabolism Center (FDEMC), Basrah Health Directorate, Basrah, Iraq
| | - Majid Alabbood
- Alzahraa College of Medicine, University of Basrah, Basrah, Iraq
| | | | - Ammar Mohammed Saeed Almomin
- Faiha Specialized Diabetes, Endocrine, and Metabolism Center (FDEMC), Basrah Health Directorate, Basrah, Iraq
- Corresponding Author: Faiha Specialized Diabetes, Endocrine, and Metabolism Center (FDEMC), Basrah Health Directorate, Basrah, Iraq. Tel: +964-7810705970,
| | | | - Ali Hussein Ali Alhamza
- Faiha Specialized Diabetes, Endocrine, and Metabolism Center (FDEMC), Basrah Health Directorate, Basrah, Iraq
| | - Adel Gassab Mohammed
- Thi-Qar Diabetic, Endocine, and Metabolism Center (TDEMC), Thi-Qar Health Directorate, Thi-Qar, Iraq
| | - Hussein Ali Nwayyir
- Faiha Specialized Diabetes, Endocrine, and Metabolism Center (FDEMC), Basrah Health Directorate, Basrah, Iraq
| | - Ahmed Jaafer Hindi Al-Ali
- Faiha Specialized Diabetes, Endocrine, and Metabolism Center (FDEMC), Basrah Health Directorate, Basrah, Iraq
| | - Abbas Ali Mansour
- Department of Medicine, College of Medicine, University of Basrah, Basrah, Iraq
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15
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Dabbous Z, Alowainati B, Darwish S, Ali H, Farook S, Al Malaheem M, Abdalrubb A, Gul W, Haliqa WA. A Prospective Study Comparing Two-Time Points of Thyroid Hormone Replacement during the Holy Month of Ramadan. Int J Endocrinol 2019; 2019:9843961. [PMID: 31428148 PMCID: PMC6681581 DOI: 10.1155/2019/9843961] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 05/08/2019] [Accepted: 05/20/2019] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Muslims all over the world fast during the month of Ramadan from dawn until dusk. There is little data regarding the best timing of levothyroxine intake during the month of Ramadan where taking it on an empty stomach represents a challenge to most patients. Our study aims to compare two-time points of levothyroxine intake during Ramadan in terms of change in thyroid stimulating hormone (TSH), compliance, and convenience. STUDY DESIGN AND METHODS This was an open-label, randomized, prospective trial. Adult patients known to have primary hypothyroidism with stable TSH for the last 6 months who intended to fast during the month of Ramadan were invited to participate in this prospective study. The study took place during Ramadan of H1438 (May-June 2017). All patients were randomly assigned to two groups. In group A (n= 50) patients took levothyroxine 30 minutes before breaking the fast at sunset (iftar), and in group B (n= 46) patients took it 30 minutes before an early morning meal before sunrise (suhour). RESULTS TSH levels increased in both group A (from 1.99 to 3.28 mIU/L) and group B (from 1.54 to 3.28 mIU/L) after Ramadan fasting. There was no difference between the two groups. Compliance with intake instructions, all of the time, was reported in 41.6% of group A and 35.7% of group B patients. In both the groups, 95% of patients said it was convenient for them to take the medication at the assigned time. CONCLUSION Choosing an optimal time for levothyroxine intake during the month of Ramadan remains a challenge. The current study did not provide any evidence on ideal time and dose of levothyroxine administration during fasting to manage hypothyroidism. Studies with a larger number of patients need to be done to further explore this issue.
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Affiliation(s)
- Zeinab Dabbous
- Department of Endocrine, Qatar Metabolic Institute, Hamad Medical Corporation, Doha, Qatar
| | - Buthaina Alowainati
- Department of Endocrine, Qatar Metabolic Institute, Hamad Medical Corporation, Doha, Qatar
| | - Sara Darwish
- Department of Endocrine, Qatar Metabolic Institute, Hamad Medical Corporation, Doha, Qatar
| | - Hamda Ali
- Department of Endocrine, Qatar Metabolic Institute, Hamad Medical Corporation, Doha, Qatar
| | - Seleena Farook
- Department of Endocrine, Qatar Metabolic Institute, Hamad Medical Corporation, Doha, Qatar
| | - Mariam Al Malaheem
- Department of Endocrine, Qatar Metabolic Institute, Hamad Medical Corporation, Doha, Qatar
| | - Abeir Abdalrubb
- Department of Endocrine, Qatar Metabolic Institute, Hamad Medical Corporation, Doha, Qatar
| | - Wajiha Gul
- Department of Endocrine, Qatar Metabolic Institute, Hamad Medical Corporation, Doha, Qatar
| | - Wajiha Abu Haliqa
- Department of Endocrine, Qatar Metabolic Institute, Hamad Medical Corporation, Doha, Qatar
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16
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Beshyah S, Badi A, El-Ghul A, Gabroun A, Dougman K, Eledrisi M. The Year in “Ramadan Fasting and Health” (2018): A Narrative Review. IBNOSINA JOURNAL OF MEDICINE AND BIOMEDICAL SCIENCES 2019. [DOI: 10.4103/ijmbs.ijmbs_77_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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