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Overview

This Guidelines summary outlines practical tips for clinicians on how to counsel and manage Muslim patients who are fasting in Ramadan, with some consideration for the context of COVID-19.

View this summary online at guidelines.co.uk/456809.article

What is Ramadan?

  • As one of the five pillars of the Islamic faith, the fast of Ramadan concurs with the ninth month of the Islamic calendar and is observed by the majority of Muslims across the globe
  • In the UK, nearly 3 million British Muslims refrain from food and drink between dawn and sunset, which in the summer months can be a period of up to 18 hours
  • Fasting is considered an obligatory ritual for all healthy adults, with exceptions given for certain groups, including those who are advised that they will come to harm from fasting owing to an acute illness or from complications related to an existing chronic condition.

Risk stratifying patients

  • The authors have carried out a series of rapid evidence reviews and formed recommendations from experts who have experience of managing patients fasting in Ramadan
  • This has been done considering the uncertainty that COVID-19 poses and a general need for such guidance. These recommendations are informative and do not form a directive
  • Table 1 can be used by healthcare professionals to assign a risk level and provide fasting advice accordingly. Patients in the two higher tiers—‘very high risk’ and ‘high risk’—should receive medical advice that they ‘must not fast’ and ‘should not fast’ respectively
  • Those in the ‘low/moderate risk’ category are advised that the medical advice is on the discretion of the physician, along with the ability of the individual to tolerate the fast
  • Multiple comorbidities will likely be compounding and could upgrade the patient’s risk category
  • COVID-19 may pose additional risks, either directly or indirectly from the effect on healthcare services, and as a result some conditions may be reclassified as being higher risk
  • At the time of writing, there were no predictions or evidence to suggest that people who are healthy, (that is, who do not have any diagnosed medical conditions) and who were previously able to observe the fast of Ramadan without any harm, are at any additional risk from fasting in the context of COVID-19, which is affirmed by the World Health Organization interim guidance on Ramadan.

Managing acute illness

  • Muslims are religiously exempt from fasting if there is a reasonable fear that fasting will lead to harm, or if their recovery will be delayed by fasting. Each person would evaluate their circumstance on an individualised basis in accordance with the degree of symptoms they are experiencing, and any risks associated with fasting during that illness
  • In the context of a COVID-19 pandemic, this presents challenges, as there is much we do not know about the virus, and many individuals will experience mild symptoms that do not need medical attention. In these patients, there is no evidence to suggest fasting would be deleterious, and thus it may well be possible. Again, this needs to be judged individually based on pre-existing risk factors
  • However, patients with fever and prolonged illness secondary to COVID-19 can become severely dehydrated and are at risk of sudden acute deterioration. As such, these patients should not fast (or cease fasting) and ensure adequate hydration. Further caution should be taken where other comorbidities are present
  • Patients who have experienced an acute illness may resume fasting once they have made a recovery. They may seek clinical advice about when to restart fasting. This would be dependent on the risk of relapsing into illness, their ability to tolerate the fast, and if their recovery will be delayed by fasting.

Managing chronic conditions

Algorithm 1: Decision making tool for those fasting with chronic conditions 

Decision making tool for those fasting with chronic conditions

  • Patients should be asked if they intend to fast and then risk stratified according to the severity of their condition, as per Table 1, and advised accordingly. This is based on clinical discretion considering age, frailty, previous experience of fasting, multiple comorbidities, and any other factors the GP deems important. Algorithm 1 may be used by clinicians to help stratify patients
  • Patients may be reluctant to heed clinical advice to the contrary, and if so, should be counselled with the following suggestions:
    • explore their experience of fasting in previous years, especially if that led to an exacerbation of illness, as well as their motivation for fasting against clinical concerns
    • discuss the importance of medicines optimisation. Focus on the practicability of dosing regimens and the sequalae of events if chronic conditions progress out of control
    • discuss fasting during the shorter winter months (where fasting duration is around 11 hours in the UK) or fasting a few days a week as alternative options
    • advise seeking the opinion of a trusted religious authority, if preferred, for pastoral and religious guidance to reassure them that clinical concern is a valid religious contraindication to fasting. Here, they can explore making up these fasts in the shorter winter months. If their condition is severe enough, they may have an exemption from fasting
  • If, despite all effort, patients choose to fast against clinical advice, they should still be supported. Advise vigilance in monitoring their health while fasting (for example, blood sugar, blood pressure, and weight); adequate sleep; and, where safe, adjust medication regimens. The importance of hydration in non-fasting hours should be emphasised, as well as having a low threshold for breaking the fast if experiencing any adverse effects
  • For most Muslims, Ramadan remains a month of spiritual gains and has been associated with a positive effect on mental wellbeing.

Table 1: Risk stratification by condition/disease

Condition

Very high risk[A]

Advise MUST NOT fast

High risk[A]

Advise should NOT fast

Low/moderate risk

Decision to not fast based on discretion of medical opinion and ability of the individual to tolerate fast

Respiratory disease

  • Those experiencing an acute exacerbation of their chronic lung disease
  • Asthma/COPD sufferers at high risk of exacerbation whose preventative inhaler timings cannot be altered to a fasting compatible regimen
  • Poorly controlled lung disease with frequent exacerbations/hospital admissions
  • Poorly controlled symptoms requiring frequent rescue inhaler and/or nebuliser use throughout the day
  • Those receiving immunosuppressants for active lung disease
  • Those receiving anti-fibrotic therapy
  • Well controlled asthma/COPD requiring intermittent inhaler use only
  • Stable disease with infrequent exacerbations
  • Those receiving immunosuppressants for stable disease (in remission)

Cardiovascular disease[B]

  • Advanced heart failure (optimal medical therapy, LVEF <35%, with class III–IV NYHA symptoms, ≥1 hospitalisation in the last 6 months due to decompensated heart failure and severely impaired functional capacity (e.g. 6-minute walk distance <300m)
  • Severe pulmonary hypertension (defined as WHO/NYHA III–IV classification, right ventricular dysfunction and objective markers on right heart catheterisation (e.g. SvO2 <60%)  
  • Recent acute coronary syndrome/myocardial infarction (<6 weeks)
  • HOCM with significant left ventricular outflow tract gradient (e.g. peak gradient ≥50 mmHg)
  • Severe valvular disease (defined by echocardiographic criteria)
  • Severe heart failure without advanced features
  • Poorly controlled arrhythmias (as defined by your specialist)
  • Hypertension
  • Stable angina (episodes of angina are not occurring at rest or increasing significantly in frequency or severity)
  • Mild HFrEF (LVEF ≥45%), moderate HFrEF (LVEF 35–45%), or HFpEF (diagnosed by a combination of symptoms, LVEF ≥45–50%, Heart Failure Association score, natriuretic peptide levels +/-imaging—refer to specialist confirmation)
  • Intracardiac devices (pacemaker, ICD, CRT-D)
  • Mild/mild–moderate valvular disease (as defined by echocardiographic criteria)
  • Supraventricular tachycardias/atrial fibrillation/non-sustained ventricular tachycardia
  • Mild/moderate pulmonary hypertension (pulmonary artery systolic pressure >25 mmHg without severe echocardiographic or right heart catheterisation features)

CKD

  • CKD patients in stage 4–5 with eGFR <30 ml/min
  • Patients on all forms of haemodialysis and peritoneal dialysis
  • Pregnant CKD patients
  • Patients with inflammatory conditions of the kidney requiring immunosuppression
  • CKD stage 3–5 patients with history of pre-existing cardiovascular disease
  • CKD patients on tolvaptan
  • CKD patients in stage 3 (eGFR 30–60 ml/min)
  • CKD patients with known electrolyte abnormalities
  • Patients at risk of dehydration due to fluid restriction requirements or need for diuretics
  • CKD patients in stage 1–3 on ACEi/ARB
  • CKD patients in stages 1–2 with stable kidney function
  • CKD patients prone to urinary tract infections or stone formation

Gastrointestinal disease

  • Patients with established cirrhosis, especially Child-Pugh B and C
  • Patients who are <6 months post liver transplant
  • Patients with symptomatic active IBD
  • Patients with significant acute or chronic diarrhoea
  • Patients with high output ileostomy
  • Liver transplant patients taking tacrolimus are at high risk of renal toxicity if they become dehydrated. They are also at risk of rejection if adherence to immunosuppression medication is not maintained due to fasting
  • Patients on prednisolone at doses >20 mg per day
  • Patients with stable chronic liver disease without cirrhosis
  • Patients with stable chronic IBD in remission, including those on immunosuppressants
  • Patients with peptic ulcer disease, reflux oesophagitis, and IBS

Neurological disease

  • Any condition predisposing to respiratory complications, e.g. bulbar weakness, neuromuscular disorders[C]
  • Myasthenia gravis on regular pyridostigmine more than 3 times per day
  • MND
  • Poorly controlled epilepsy, on multiple antiepileptic medications, history of status epilepticus
  • Parkinson’s disease requiring regular levodopa
  • Neurodegenerative disorders with cognitive impairment
  • Epilepsy requiring a medication regimen incompatible with fasting which cannot be modified safely in time for the next Ramadan
  • Myasthenia gravis on pyridostigmine 3 times daily or less
  • Parkinson’s disease with low requirement for levodopa in younger patients

Diabetes

  • Poorly controlled type 1 diabetes
  • Acute hyperglycaemic diabetes complications within 3 months prior to Ramadan (DKA, HHS)
  • Disabling hypoglycaemia: severe hypoglycaemia within 3 months prior to Ramadan, hypoglycaemia unawareness, recurrent hypoglycaemic episodes
  • Advanced macrovascular diabetic complications
  • Type 2 diabetes requiring insulin (MDI/biphasic) with no prior experience of safe fasting[C]
  • Chronic dialysis and CKD (stage 4 and 5)
  • Pregnancy in pre-existing diabetes or GDM treated with insulin or SUs
  • Acute illness
  • Old age with ill health
  • Well-controlled type 1 diabetes
  • Type 2 diabetes with sustained poor control (consider: HbA1c >75 mmol/mol for over 12 months)
  • Type 2 diabetes requiring insulin (MDI/biphasic) with prior experience of safe fasting
  • Type 2 diabetes on SGLT2 antagonists[C] (consider alternatives/stopping)
  • Stable macrovascular diabetes complications
  • CKD stage 3
  • Pregnant women with type 2 diabetes or GDM on diet or metformin
  • Comorbidities with additional risk factors
  • Treatment with drugs that can affect cognitive function
  • People with diabetes performing intense physical labour
  • Well-controlled type 2 diabetes (on one or more of the following therapies):
    • diet and lifestyle
    • metformin
    • gliptins
    • GLP-1 agonists
    • glitazones
    • acarbose
    • second generation sulfonylurea[C] (moderate risk: regular BM monitoring advised)
    • basal insulin[C] (moderate risk: regular BM monitoring advised)

Adrenal disease

  • Any of the following:
    • multimorbidity: major organ system involvement
    • diabetes mellitus on insulin treatment
    • pituitary (diabetes) insipidus
    • adrenal crises in the last 12 months
    • untreated mineralocorticoid deficiency
    • untreated TSH deficiency
    • pregnancy (>28 weeks)[C]
  • Any of the following:
    • recent diagnosis of steroid dependence within the last 12 months[C]
    • no prior experience of fasting, or steroid alterations, or adjustments in Ramadan[C]
    • aldosterone deficiency (i.e. on fludrocortisone or mineralocorticoid replacement)[C]
    • pregnancy (<28 weeks)
  • Must meet ALL criteria:
    • stable and well-controlled steroid insufficiency
    • previous experience of fasting and risk assessments
    • no significant comorbidities
    • understanding of adjustment and changes to steroid dosing during fasting, when to terminate fasts, and sick day rules
    • access to prednisolone 5 mg once daily or healthcare professional who can support prescriptions
    • access to emergency (IM) hydrocortisone and understanding of how to use this

Benign haematological disorders

  • Sickle cell disease, including HbSS, HbSC, HbS/beta thalassaemia, HbSO, HbSD, and those prone to sickle cell crisis
  • Cold haemagglutinin disease with ongoing haemolysis
  • Amyloidosis with renal impairment
  • Antiphospholipid syndrome with history of blood clots
  • Paroxysmal nocturnal haemoglobinuria with active haemolysis or history of recurrent thrombosis
  • Thrombophilias with history of recurrent thrombosis, despite being on anticoagulation
  • Warm autoimmune haemolytic anaemia with active haemolysis
  • Other haemolytic anaemias with active haemolysis
  • Clotting disorders like the thrombophilias with history of thrombosis
  • Aplastic anaemia on immunosuppression
  • Thrombophilia with a history of thrombosis within the last 3 months, and on anticoagulation
  • Thalassaemia carriers and sickle cell carriers who are not prone to crises
  • Aplastic anaemia not on active treatment
  • White cell disorders with low count
  • Inherited bleeding disorders
  • Immune thrombocytopenias in remission
  • Thrombophilia with history of thrombosis on anticoagulation

Haematological malignancies

  • Patients requiring inpatient treatment for cancer or complications of cancer, e.g. acute leukemias, high grade lymphomas, aggressive/refractory myeloma
  • Patients requiring inpatient treatment undergoing autologous or allogeneic stem cell transplantation or its complications
  • Patients requiring inpatient treatment for complications of cancer treatment, e.g. neutropenic sepsis, severe vomiting, diarrhoea, pain, and other symptoms
  • Newly diagnosed myeloma patients who are at risk of kidney injury
  • Patients taking tacrolimus or ciclosporin where risk of kidney injury is increased by dehydration
  • Patients newly commenced on induction chemotherapy for haematological malignancies such as myeloma, lymphoma, chronic leukaemias, or experiencing significant side effects
  • Patients receiving oral chemotherapy or targeted therapy, that:
    • requires twice daily dosing
    • must be taken with food
    • is causing significant side effects
  • Patients receiving a course of radiotherapy
  • Patients who have undergone autologous or allogeneic transplantation within the last 6 months
  • Patients receiving treatment for post-transplant complications such as GVHD
  • Patients receiving oral chemotherapy or targeted therapy, if:
    • on a once daily dosing regimen
    • drug pharmacokinetics allow fasting
    • well established (>3 cycles) on treatment
    • not experiencing significant side effects
  • Patients receiving outpatient parenteral chemotherapy beyond induction phase (except on drug administration days) if:
    • well established on treatment
    • no/few manageable side effects
  • Patients on parenteral maintenance immunotherapies with no/few manageable side effects, e.g. rituximab, obinutuzumab
  • Outpatients with haematological cancers who are not receiving any active treatment and are on active surveillance only, e.g. MGUS, chronic leukaemias, low grade lymphomas
  • Patients with previously treated cancers who are currently in remission and on active surveillance

Rheumatological disease

  • Active SLE with renal involvement
  • Active vasculitis with renal involvement
  • Low eGFR secondary to connective tissue diseases/vasculitis
  • Scleroderma leading to pulmonary hypertension
  • Uncontrolled gout
  • Higher dose of steroids >20 mg/day[C]
  • Rheumatological conditions in remission e.g. rheumatoid arthritis, polymyalgia rheumatica, connective tissue diseases, and vasculitis
  • Osteoarthritis
  • Osteoporosis
  • Sjogren’s syndrome
  • Well controlled gout

Obesity

  • BMI >40kg/m2 with any of the following:
    • established end-organ cardiovascular disease (e.g. previous myocardial injury, cardiac failure, previous CVA/TIA)
    • advanced CKD (stage 4–5)
    • advanced chronic pulmonary diseases
    • severe obstructive sleep apnoea
  •  BMI >40kg/m2 with complicated metabolic syndrome and related complications e.g. those associated with high risk conditions (diabetes, hypertension, dyslipidemia, PCOS, hypothyroidism)
  • BMI >40 kg/m2 with stable non-metabolic comorbidities (e.g. osteoarthritis, fibromyalgia)
  • Simple obesity without any comorbidities

Pregnancy[D]

  • Pregnancy with severe underlying maternal health conditions
  • Complicated pregnancy
  • Uncomplicated pregnancy in an otherwise healthy woman in first trimester
  • Pregnancy with moderately severe underlying maternal health conditions
  • Uncomplicated pregnancy in an otherwise healthy woman beyond first trimester
  • Pregnancy with mild/well-controlled underlying maternal health conditions

Organ transplants

  • SOT recipients who underwent a transplant in the last 6 months
  • Patients on twice daily immunosuppression
  • Pregnant transplant patients
  • Transplant patients diagnosed with new onset diabetes post-transplant requiring twice daily oral hypoglycaemics or insulin treatment
  • Kidney transplant recipients with reduced kidney function (eGFR <30 ml/min)
  • Patients with unstable graft function, rejection episodes, and opportunistic infections
  • Kidney transplant recipients with reduced kidney function (eGFR 60–30 ml/min)
  • Heart, lung, liver, small bowel, pancreas, and multi-organ transplant recipients with reduced graft function
  • Patients at risk of dehydration due to fluid restriction requirements, need for diuretics, or if they would be unable to meet their daily fluid intake requirement set by their transplant team
  • Transplant patients not in the above categories. The authors advise patients to discuss the suitability of fasting and monitoring necessary with their relevant transplant teams

Solid tumours

  • Patients on clinical trials
  • Patients requiring inpatient treatment for cancer (or complications of cancer)
  • Patients undergoing radical radiotherapy (especially head and neck, CNS, and upper GI malignancies)
  • Patients receiving immunotherapy
  • Patients receiving intravenous chemotherapy who:
    • have newly commenced (cycles 1–2) their treatment regimen
    • are experiencing significant side effects
  • Patients receiving oral chemotherapy or targeted therapy:
    • that requires twice daily dosing
    • that must be taken with food
    • who are experiencing significant side effects
  • Patients receiving a course of radiotherapy (with or without chemotherapy)
  • Patients immediately following cancer surgery
  • Patients receiving oral chemotherapy or targeted therapy, if:
    • they are on a once daily dosing regimen
    • the drug pharmacokinetics allow it to be taken while fasted
    • they are well established on treatment
    • they have no/few manageable side effects
  • Patients receiving intravenous chemotherapy, if:
    • they are well established (cycle 3 or beyond) on their treatment regimen
    • they have no/few manageable side effects
  • Patients on intravenous maintenance therapies (e.g. trastuzumab, bevacizumab) with no/few manageable side effects
  • Patients on endocrine therapy or androgen deprivation therapies with no/few manageable side effects
  • Patients receiving radiotherapy for skin cancer or breast cancer (if otherwise well)
  • Patients receiving palliative (single fraction) radiotherapy (if otherwise well)
  • Patients under cancer surveillance, who are more than 3 months beyond completion of cancer therapies (including surgery) and have recovered sufficiently

Mental health

  • Anorexia/bulimia nervosa with purging by vomiting; severe laxative abuse
  • Severe substance dependence disorder where stopping regimen may cause harm
  • Medication dosing interval shorter than fasting hours, and necessary to prevent relapse/harm
  • Poorly controlled SMI disorders (including clozapine use)
  • Risk of electrolyte imbalance (e.g. lithium or metformin) or medication out of range
  • Stable bipolar/psychosis with medication regime compatible with fasting hours, >6 months since relapse. Monitor during Ramadan
  • Mild mental health illness not affecting functioning
  • Well-controlled mental illness (no relapses in previous 12 months) with previous history of safe fasting

[A] If patients in these categories wish to fast, is shorter fasting in the winter a safe alternative? If this is not an option, or the patient is not willing to defer fasts and still wishes to fast, then they should be supported and should:

  • receive structured education (where appropriate)
  • be followed by an appropriate specialist/primary care contact whilst fasting
  • monitor their health regularly
  • adjust medication dose, frequency, and timing as per recommendations
  • be prepared to break the fast/abstain from fasting in case of adverse events

[B] Patients with GUCH and/or heart transplant must consult their specialist for an individual risk assessment

[C] Expert-recommended upgrading of risk due to COVID-19. Recommendations subject to review if relevant evidence suggests re-grading

[D] For breastfeeding, refer to the Muslim Council of Britain Ramadan Health Factsheet

Abbreviations: ABN=Association of British Neurologists; ACEi=angiotensin-converting enzyme inhibitor; ARB=angiotensin receptor blocker; BM=capillary blood glucose; BMI=body mass index; CKD=chronic kidney disease; CNS=central nervous system; COPD=chronic obstructive pulmonary disease; CRT-D=cardiac resynchronisation therapy defibrillator; CVA=cerebral vascular accident; DKA=diabetic ketoacidosis; GDM=gestational diabetes mellitus; eGFR=estimated glomerular filtration rate; GI=gastrointestinal; GLP-1=glucagon-like peptide-1; GUCH=grown-up congenital heart disease; GVHD=graft-versus-host disease; HBA1c =haemoglobin A1c; HbS=sickle haemoglobin; HbSC=sickle cell haemoglobin SC; HbSD=sickle cell haemoglobin SD; HbSO=sickle cell haemoglobin SO; HbSS=sickle cell anaemia; HFpEF=heart failure with preserved ejection fraction; HFrEF=heart failure with reduced ejection fraction; HHS=hyperosmolar hyperglycaemic state; HOCM=hypertrophic obstructive cardiomyopathy; IBD=inflammatory bowel disease; IBS=irritable bowel syndrome; ICD=implantable cardioverter defibrillator; IM=intramuscular; LVEF=left ventricular ejection fraction; MDI=metered dose inhaler; MGUS=monoclonal gammopathy of undetermined significance; MND=motor neurone disease; MS=multiple sclerosis; NYHA=New York Heart Association; PCOS=polycystic ovary syndrome; SGLT2=sodium-glucose transport protein 2; SLE=systemic lupus erythematosus; SMI=serious mental illness; SOT=solid organ transplantation; SU=sulfonylurea; SvO2=venous oxygen saturation; TIA=transient ischaemic attack; TSH=thyroid stimulating hormone; WHO=World Health Organization

  1. This is not an exhaustive list and is to be used for informative and shared decision making by healthcare professionals with patients. It does not form a directive. In all categories, patients should be advised to follow medical opinion due to probability of harm. Where appropriate, expert individualised medical advice must be sought before any decisions around fasting in Ramadan are made
  2. If a patient’s condition is not on this table and they have uncertainty or concerns about fasting, then they should seek medical advice before doing so. If this is not possible and they decide to fast, the advice given regarding terminating the fast should be followed
  3. The decision to fast is a personal decision for the individual concerned, who should be supported to achieve best possible outcomes
  4. Consider upgrading risk if unable to seek timely medical attention and make necessary changes to medication regimen, arrange baseline blood tests, or other preparation that usually precedes fasting, due to the effect of COVID-19 on health services
  5. Frailty is recognised by NICE as a predictor of worse outcomes with COVID-19. Use the Rockwood clinical frailty score to assist with making assessments on risks of fasting in frail patients. Also take caution with obesity (noting lower cut off for South Asian patients) risk in COVID-19
  6. Ensure adequate hydration and nutrition; social distancing, isolation, and shielding may be beneficial in this respect
  7. In the context of the COVID-19 pandemic, episodes of illness should be taken seriously and strong consideration should be given to breaking the fast, as the onset of illness can be rapid. Recovery from COVID-19 may also be prolonged. See Algorithm 1 and the section on acute illness for details
  8. Islamic jurists advise that any missed fasts should be made up in the future. However, if one’s health takes a permanent decline, such that even fasting during the winter period becomes unsafe or impossible, the fidyah would have to be paid. Patients should speak to a trusted religious authority before doing so.

 

Full guideline:

Waqar S and Ghouri N. Managing Ramadan queries in COVID-19. BJGP Open. 2020. Available at: bjgpopen.ocg/content/4/2/bjgpopen20X101097

Published date: 18 May 2020.

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Lead image: eldarnurkovic/stock.adobe.com