Adjusting drug dosage during Ramadan
With the changes in the mealtime, certain drugs' dose-schedule have to be altered during Ramadan. Changing the time, the number of doses, interval between dosages without consulting a doctor may be ineffective and sometimes harmful too. However, many patients arbitrarily change the intake time and dosing of drugs. This behaviour could alter the efficacy and tolerance of drugs. In the face of this arbitrary use of drugs during Ramadan, drug intake needs to be adapted according to the prescription. Certain drugs nullify Ramadan fasting and certain do not. The compatibility of fasting with various drug administration routes and their choice during Ramadan remains a matter for the doctor's own judgment. To standardise the choice of routes, distinguished Muslim jurists and religion experts, medical practitioners, pharmacologists agreed that the following administration routes do not nullify fasting: * Eye and ear drops
* All substances absorbed into the body through the skin, such as creams, ointments, and medicated plasters
* Insertion into the vagina of pessaries, medical ovules, and vaginal washes
* Injections through the skin, muscle, joints, or veins, with the exception of intravenous feeding
* Oxygen and anaesthetic gases
* Nitroglycerin tablets placed under the tongue for the treatment of angina
* Mouthwash, gargle or oral spray, provided nothing is swallowed into the stomach
* Nose drops, nose sprays and inhalers
* Surgery involving general anaesthesia, if the patient decided to fast
Dose schedule
In fact, drug doses can be taken only between sunset and dawn, and the time span between them is shorter than outside Ramadan. Two different types of dosage schedule are commonly used during Ramadan-single daily dose and two or more daily dose. Single daily dose: The easiest situation is that of patients who have a usual evening dose. Their therapeutic scheme remains unchanged during Ramadan, as it does not interfere with fasting. When the usual intake is in the morning or during the day, the concerned doctor must be careful when delaying the intake to the evening that this will not alter the efficacy of treatment or the tolerance of the drug. Two or more daily doses: During Ramadan, accurate distribution of drugs prescribed twice a day is difficult to achieve between the break from fasting and the beginning of fasting. Refraining from fasting according to the Islamic rules could be a wiser prescription. Nonetheless, patients with two doses could take the first one at the break of fasting and the second one before the beginning of fasting, in which case the dosing time and the time span between the doses are both altered. These alteration could affect the drug's plasma concentration profile and therefore, its efficacy and tolerance. This is even more relevant for drugs with a narrow therapeutic index (which indicts safety level of a drug) as the risk of toxicity is higher. In the event of therapeutic problems during Ramadan, the number of doses should be reduced by using, when available, slow release formulations or chrono-therapeutic formulations. Otherwise, a drug with a longer elimination half life should be used. Such drugs will have a longer duration of action and can therefore be taken at longer intervals, such as once a day. For patients with chronic diseases, the new dosage regimen to be used during Ramadan needs to be established beforehand. Patients must also be informed about when they should take their drugs (before, during or after food intake), particularly when they are treated with drugs of which the absorption could be impaired by food intake. However, the choice of drugs to be studied during Ramadan could be determined by survey evaluating the therapeutic problems encountered during this month of fasting. Focus should be on drugs for chronic diseases and especially on those with a narrow therapeutic index. Extensive misuse of prescribed drugs during Ramadan may lead to therapeutic failures. The lack of survey data on this subject impairs effective evaluation of the problem. This lack of information is a problem for doctors, as they cannot give unbiased advice. Further studies should be carried out to provide more guidelines about the ways in which the administration of drugs should be modified. In the meantime, doctors and scientists in the Muslim world should be encouraged to follow up their patients with chronic diseases during Ramadan, in order to establish optimal dosage regimens. Wide dissemination of research results, as well as achievement of consensus on relevant clinical and therapeutic issues, would allow health professionals to provide accurate and standard advice on the appropriate use of drugs during the holy month of Ramadan.
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