Islam was built based on five billers (the statement of Faith, prayers of five times daily, charity to poor people, and Fasting of
one Month yearly called Ramadan, and pillgrime to Mecca once in a lif). Fasting the holy Month of Ramadan is stop taking or
ingection any food or drinks from sunrise to sunset, this madate to all adults either male or female, unless tarvelers, risk dangrous of
pregrant and lactatin women, and elderly can not tolerate the fasting, and sick people
In Islam the Sick people allow them to break fasting, then postbond fasting next month if the illness is temporary. If the illnees
perment and the patinet can not fast at all she or he to pay money to poor people as subsiture of fasting for each day breaking fasting.
Not all the illnesses are allowable to break fasting, its only if the fasting affect the patients health negatively, otherwise; if the patient
can fast she or he to fast Ramadan. The problem is raising of medications for chronic disaeses , how can I switch from regular days
time to Fasting Days Times, at what time excatly, does the fasting some medication and increase or decrease their activity, is there
any changes in pharmacokinetics of medications, does the food affect absorption of medication after peoriod of fasting, all thease
question we try to answer them in the remaining of this paper
It estimated there are 1.11.5 billion Muslims worldwide, Most Muslims would like not to break fasting, even the fasting will
affect their health. Some studies showed that Muslims receiving medical treatment during Ramadan will deliberately not taken tablets
or other medicine at the prescribed time if that falls drug the day light hours, or alternatively will overdose during night to makeup for
missed day time doses. A study 1 by Aslam M, et.al , reported that 37 (45.7%) patients of 81 were found to change their drug dosage
pattern while fasting; 35 (43.2%) missed doses; 8 (9.8%)took their tablets at different times and 4 (4.9%) patients took all their
medication as one single daily dose after breaking fast in the evening. Another survey 2 of 325 outpatients in a Kuwaiti hospital
found that most of them changed their drug regimens during Ramadan. Sixty four per cent of the patients changed their therapeutic
scheme during the month; 18% took their daily medicines in a single intake, either before the first meal (sunset) or straight after the
last one (before dawn). Another hospital-based study of 334 patients conducted in during the month of Ramadan in 2006 to illustrate
thevarious characteristics including care of patients and changes in lifestyle of type 2 diabetics during Ramadan in Dhahira region,
Oman. Most of the type 2 diabetes patients in the study (93.1%) fasted 30 days during Ramadan. It was noticed that nearly 83% of the
type 2 diabetes patients in our study had poorly controlled FBS levels (83.2%). Insulin/Oral Anti Diabetic Drug (OAD) doses were
unchanged in 49.5% of diabetic patients during Ramadan. 3
Some authors reported that two patients with chronic reversible respiratory disease were admitted to an intensive care unit two
weeks after the start of Ramadan, Both patients admitted due to not having taken their treatment, including inhalers, during daylight
hours. Another study evaluated the changes in frequency of seizures during Ramadan in 124 patients with idiopathic epilepsy,
seizures occurred in 27 patients during this month; 20 of them did not use any antiepileptic drugs from dawn to sunset. The author
concluded that withdrawal of drugs was the most important cause of recurrence of epilepsy during Ramadan. 4
A recent study of wide population-based Epidemiology of Diabetes and Ramadan 1422/2001 (EPIDIAR) study, which showed (in
12,243 people with diabetes from 13 Islamic countries) 43% of patients of type 1 diabetes, and 79% of patients
with type 2 diabetes were fasting during Ramadan; with an estimation of 4050 million people with diabetes worldwide , and 3.6 -
1,9 Million in Saudi Arabia will fast during Ramadan, 5-7
Although all previous studies, with patients perception and attitude toward their medications, and dangerous impact of their diseases;
there is no consensus guideline of drug therapy during. Recommendation drug therapy regimen for the disaeses during fasting is very
difficult, due to very little experiences, and no clinical trials about drug fasting during Ramadan or pharmacokinetics of drugs during
fasting. It is not appropriate to change the drug regimen, or dose from several dose per day to two big dose once or twice daily
without scientific evidence that alternative dose is equivalence in efficacy and safety. Further, the patient should stabilized with the
new drug or dose before or during Ramadan. Here are some advices and recommendations by some authors to explore Drug Therapy
During Ramadan as following:
General Recommendation
Mark Ramadan on your office calendar, and prepare to be the one that brings up the topic for discussion. Patients are unlikely
to initiate the discussion.
Ask about the patients beliefs regarding fasting, his/her illness, and the use of oral and injectable drugs when fasting.
Inquire about current control of symptoms and comorbidities.
Inquire about past experiences during Ramadan fasts, and plans for the upcoming Ramadan.
Provide information and Medical education about his or her mental illness as medical, physically-mediated illness
Clearly communicate risks of medication changes, changes in sleeping and eating schedules, and withdrawal from substances.
Explain that decision is ultimately the patients, but you can advise him/her and help maximize chances of fasting safely.
Give general preference to medications that will allow for the easiest compliance during Ramadan, e.g. slow-release
preparations, longer elimination half-lives, and once daily dosing.
Consider a switch to slow-release or once-daily medications for the month of Ramadan. These forms may more expensive,
and may require some planning ahead, but it may be worth a switch for some patients.
Recommend dosing schedules coincident with pre-dawn (Suhoor) and sunset (Iftar) meals.
Recommend refraining from fasting according to Islamic rules for those that must take medications at a frequency of more
than twice a day.
Work to find creative compromises, balancing the patients preferences and your knowledge of the risks and benefits of
possible plans.
If a patient insists on discontinuing medications, plan a taper in advance.
Recommend tapering use of caffeine and nicotine in the weeks before Ramadan to avoid unpleasant withdrawal syndromes.
Encourage a moderate amount of physical activity; too much exertion may contribute to dehydration, but some activity is
better than a completely sedentary month.
Encourage patient to bring up the issue with their primary care doctor, to discuss which medications may be amenable to
change in dosing schedule.
Consult an imam of masijid or Shiek with help in interpreting rules, and in communicating with and reassuring the patient.
Arrange for follow-up appointments during Ramadan and when concerns arise.
Fasting and Drug dosing schedule
There are many drugs can given to the patient without affecting fasting Ramadan or nullify fasting, accoring An Islamic view
of certain contemporary medical issues that was in Morocco 1997; for instant 8
1. Eye and ear drops
2. All substances absorbed into the body through the skin,such as creams,ointments,and medicated plasters
3. Insertion into the vagina of pessaries, medical ovules, and vaginal washes
4. Injections through the skin, muscle, joints, or veins, with the exception of intravenous feeding
5. Oxygen and anaesthetic gases
6. Mouthwash, gargle, or oral spray, provided nothing is swallowed into the stomach.
7. Nose drops, nose sprays, and inhalers
8. Anal injections
Any medication can be enjection through mouth and reach to stomach break fasting. Health care provider can help mulsim patient if
he wish to fasting eith The Holy Month of Ramadan or any Holy Days throug the year, by changing admintartiom time instead of
three or fout time a day and switch to tiwce or once aday without Break-Fast. In Ramadan, instead of morning and evening, it needs
to change to dawn and sunset respectively. Twice daily dose can be taken on 04:30, and 19:00 special in this year 2013 for Riyadh
time, Saudi Arabia. Once daily dose can be taken on 04:30, or 19:00.
We attached Up-to-date 2013 suggested table1 describe type of medication, affect of food, frequency of adminstration, preferable
time of adminstration, and clinical evidence. An table 2 showed Medications, adult maintenance dose in the nornal renal function,
and frequency per day, on regular day, and Medications, adult dose, and frequency per day as alternative during Ramadan, the doses
stated for general indication, table 3 showed medications registration status at Saudi Food and Drug Authority and Ministry of
Health Drug Formulary.
The treating physcian or pharmacist should refer to other referances to doses for specific indications, and FDA or SFDA labeled
indications during conversion to other medications. Any suggestion will be highly appreciated.
Table 1
Medication During Holy Month of Ramadan 8,9
Type of Medication Adminstration Evidence Based
Anti-Epileptic Drugs Once Twice daily except Valoproic Acid General Evidence : No Evidence administration
The food: may decrease the absorption during Ramadan
Time of admin: after 1-2 of Sun set (Iftar) Specific Evidence: No Evidence of
Interchange: No, can be on specific situation Pharmacokinetics during fasting Ramadan
Drug for Infectious Admin: Once Twice daily General Evidence : No Evidence administration
Diseases The food: Variable during Ramadan
Time of admin: after Sun set (Iftar) Specific Evidence: No Evidence of
Interchange: Switch to long acting therapy Pharmacokinetics during fasting Ramadan
Drug for GIT Admin: Once daily General Evidence : No Evidence administration
The food: No effects during Ramadan
Time of admin: pre-dawn (Suhoor) Specific Evidence: No Evidence of
Interchange: Switch to long acting therapy Pharmacokinetics during fasting Ramadan
Drugs for Hypertension Admin: Once - Twice daily General Evidence : No Evidence administration
The food: No effects during Ramadan
Aviod of taking ACE Inhibitors with latge a mount Specific Evidence: No Evidence of
of Dates, Bananas, Oranges, green leafly vegetables Pharmacokinetics during fasting Ramadan
Drugs for Cardiac Admin: Once daily General Evidence : No Evidence administration
Arrhythmias The food: No effects during Ramadan
Time of admin: after Sun set (Iftar) Specific Evidence: No Evidence of
Interchange: Switch to long acting therapy Pharmacokinetics during fasting Ramadan
Drug for Pain Admin: Once daily General Evidence : No Evidence administration
The food: No effects during Ramadan
Time of admin: after Sun set (Iftar) Specific Evidence: No Evidence of
Interchange: Switch to long acting therapy Pharmacokinetics during fasting Ramadan
Medications During Fasting Program
I do suggest to start this program specially during fating the holy month of Ramadan
Table 2
No Drug therapy during Regular days 10-29 Drug therapy during Holy Ramadan 10-29
Regular Days Doses/ Day Frequency Per day Regular Days Doses/Day Frequency Per day
1. Acebutolol 200-1200 mg Divided in 1-2 doses Acebutolol 200-1200mg Divided in 1-2 doses
2. Aliskiren 150-300 mg In 1 dose Aliskiren 150-300 mg In 1 dose
3. Amiloride HCl 5-10 mg In 1-2 diveded dose Amiloride HCl 5-10 mg In 1-2 diveded doses
4. Amitriptyline 50-150 mg In 1 dose or divided doses Amitriptyline 50-150 mg In 1 dose
5. Amlodepine besylate 2.5- 10 mg In 1 dose Amlodepine besylate 2.5- 10 mg In 1 dose
6. Amoxicillin 250- 500 mg 3 times/day Cotrimoxazole 490- 960 mg 2 times/day
7. Aspirin 100 mg (prophylactic In 1 dose Aspirin 100 mg In 1 dose
dose) (prophylactic dose)
8. Atenolol 25-100 mg In 1-2 doses Atenolol 25-100 mg In 1-2 doses
9. Atorvastatine 10-80 mg In 1 dose Atorvastatine 10-80 mg In 1 dose
10. Aripiprazol 10-30 mg In 1 dose Aripiprazol 10-30 mg In 1 dose
11. Betoxalol 5-40 mg In 1 dose Betoxalol 5-40 mg In 1 dose
12. Bisoprolol 5-20 mg In 1 dose Bisoprolol 5-20 mg In 1 dose
13. Candesartan 8 -32 mg In 1 dose Candesartan 8 -32 mg In 1 dose
14. Captopril 12.5- 150 mg Divided in 2-3 divided Enalapril 2.5 - 40 mg In 1-2 doses
doses Lisinopril 5 - 40 mg In 1 dose
Fosinopril 10-80 mg In 1-2 doses
Perindopril 4-8 mg In 1-2 doses
Quinapril 5-80 mg In 1-2 doses
Ramipril 1.25-20 mg In 1-2 doses
Trandolapril 1-8 mg In 1-2 doses
15. Carbamazepine 800 1600 mg In 2-3 divided doses Carbamazepine 800 1600 mg In 2 divided doses
(Blood Level 8-12 (Blood Level 8-12
mcg/ml) mcg/ml)
Carbamazepine SR 800 1600 mg In 2 divided doses
(Blood Level 8-12
mcg/ml)
16. Carteolol 2.5-10 mg In 1 dose Carteolol 2.5-10 mg In 1 dose
17. Carvedilol 12.5- 50 mg Divided in 2 doses Carvedilol 12.5- 50 mg Divided in 2 doses
18. Cefacolr 250- 500 mg 3 times Cefuroxim axitel 250- 500 mg 2 times
19. Celeoxib 200 mg 2 times Celeoxib 200 mg 2 times
20. Cephalexin 250 -500 mg 4 times Cefadroxil 500-1000 mg 2 times
21. Cerivastatin 0.3mg In 1 dose Cerivastatin 0.3mg In 1 dose
22. Chlorthalidone 12.5- 50 mg In 1 dose Chlorthalidone 12.5- 50 mg In 1 dose
23. Cholestyramine 12-36 mg Divided in 1- 4doses Cholestyramine 12-36 mg In 1 dose
24. Cimitidine 400 2 times Cimitidine 800 mg In 1 dose
800 mg In 1 dose
25. Ciprofloxacin 250-750 mg 2 times Ciprofloxacin 250-750 mg 2 times
26. Citalopram 20-40 mg In 1 dose Citalopram 20-40 mg In 1 dose
27. Clobazam 20-40 mg In 1-2 divided doses Clobazam 20-40 mg In 1-2 divided doses
28. Clonazepan 1.5-8 mg In 2-3 divided doses Clonazepan 1.5-8 mg In 2 divided doses
Clobazam 20-40 mg In 1-2 divided doses
29. Clopidogrel 75 mg PO daily In 1 dose Clopidogrel 75 mg PO daily In 1 dose
30. Clonidine 0.1-0.6 mg Divided in 2-3 doses Clonidine 0.1-0.6 mg Divided in 2 doses
31. Cloxacillin 250 -500 mg 4 times Cefadroxil 500-1000mg 2 times
32. Cotrimoxazole 490- 960 mg 2 times/day Cotrimoxazole 490- 960 mg 2 times/day
33. Dalteparin 5000-10,000 IU SC daily In 1-2 doses Dalteparin 5000-10,000 IU SC In 1-2 doses
or q12h daily or q12h
34. Diclofenac 50- 200mg Divided in 3-4 dses Diclofenac 75 mg 2 times
75 mg 2 times Diclofenac SR 100 mg In 1 dose
35. Diflunisal 500-1500 mg Divided in 2-3 doses Diflunisal 500-1500 mg Divided in 2-3 doses
36. Digoxin 0.125- 0.5 mg In 1 dose Digoxin 0.125- 0.5 mg In 1 dose
37. Diltiazem HCl 60-360 mg Divided in 3 doses Diltiazem SR HCl 120 -360 mg Divided in 1-2 doses
38. Doxazocin Mesylate 1-16 mg In 1 dose Doxazocin Mesylate 1-16 mg In 1 dose
39. Doxycyline 100-200 mg Divided in 1-2 doses Doxycyline 100-200 mg Divided in 1-2 doses
40. Duloxetine 60 mg In 1 dose Duloxetine 60 mg In 1 dose
41. Eplerenone 25-100 mg In 1-2 doses Eplerenone 25-100 mg In 1-2 doses
42. Eprosartan 400-800 mg In 1-2 doses Eprosartan 400-800 mg In 1-2 doses
43. Enalpril maleate 5- 40 mg Divided in 1-2 doses Enalpril maleate 5- 40 mg Divided in 1-2 doses
44. Enoxaparin 1 mg/kg bid or 1.5 mg/kg In 1-2 doses Enoxaparin 1 mg/kg bid or 1.5 In 1-2 doses
SC daily; mg/kg SC daily;
45. Erythromycin 250-500 mg 4 times Clarithroycin 250-500 mg 2 times
Azithromycin 500-1000 mg 1 time
46. Ethosuximide 750- 1250 mg Divided in 2 doses Ethosuximide 750- 1250 mg Divided in 2 doses
(blood level 40-100 (blood level 40-100
mcg/ml) mcg/ml)
47. Escitalopram 10-20 mg In 1 dose Escitalopram 10-20 mg In 1 dose
48. Esomeprazole 20-40 mg In 1 dose Esomeprazole 20-40 mg In 1 dose
49. Felodipine 2.5- 10 mg In 1 dose Felodipine 2.5- 10 mg In 1 dose
50. Flucloxacillin 250-500 mg 4 times Cefadroxil 500-1000mg 2 times
51. Fluconazole 50- 400 mg In 1 dose Fluconazole 50- 400 mg In 1 dose
52. Fluoxetine 10-20 mg In 1 dose Fluoxetine 10-20 mg In 1 dose
53. Folic acid 1- 5 mg In 1 dose Folic acid 1- 5 mg In 1 dose
54. Famotidine 20 mg 2 times Famotidine 40 mg In 1 dose
40 mg in 1 dose
55. Fosinopril sodium 10- 80 mg Divided in 1-2 doses Fosinopril sodium 10- 80 mg Divided in 1-2 doses
56. Furosemide 20- 320 mg Divided in 2 doses Furosemide 20-320 mg Divided in 2 doses
Torsemide 5-20 mg In 1 or 2 doses
57. Heparin (Unfractionated) 60-100 units/kg IV Divided in 2-3 doses Enoxaparin OR 1 mg/kg bid or 1.5 In 1-2 doses
bolus, then 12-18 mg/kg SC daily;
units/kg/hr IV; or, 5000 Daltaparin OR 5000-10,000 IU SC In 1-2 doses
units SC q8-12h daily or q12h
Tinzaparin 175 IU/kg SC daily In 1 dose
58. Hydralazine HCl 40-200 mg Divided in 2-4 doses Hydralazine HCl 40-200 mg Divided in 2 doses
59. Hydrochlorothaizide 12.5- 50 mg In 1 dose Hydrochlorothaizide 12.5- 50 mg In 1 dose
60. Ipratropium 17 mcg/inhalation 2 inhalations qid PRN Tiotropium 8 mcg In 1 dose