Does Ramadan Fasting Complicate Anticoagulation Therapy
1989; King Faisal Specialist Hospital and Research Centre; Volume: 9; Issue: 6 Linguagem: Inglês
10.5144/0256-4947.1989.538
ISSN0975-4466
AutoresJalal Saour, Jens O. Sieck, Mehmood Khan, Layla Mammo,
Tópico(s)Religion, Spirituality, and Psychology
ResumoOriginal ArticlesDoes Ramadan Fasting Complicate Anticoagulation Therapy Jalal N. Saour, MD Jens O. Sieck, MD Mehmood Khan, and MD Layla MammoPhD Jalal N. Saour Address reprint requests and correspondence to Dr. Saour: Department of Medicine, King Faisal Specialist Hospital and Research Centre, P.O. Box 3354, Riyadh 11211, Saudi Arabia. From the Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh , Jens O. Sieck From the Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh , Mehmood Khan From the Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh , and Layla Mammo From the King Saud University, Riyadh Published Online:1 Nov 1989https://doi.org/10.5144/0256-4947.1989.538SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutABSTRACTABSTRACTBetween 1981 and 1985, a total of 289 patients were seen at our anticoagulation clinic. Two hundred and forty-seven received long-term oral anticoagulation therapy because of a cardiac condition, 42 for deep vein thrombosis with or without pulmonary embolism. While on treatment, 106 patients fasted 309 Ramadan months and 183 patients elected not to fast during 594 Ramadan months. The incidence of thromboembolic events and hemorrhagic complications in the two groups was compared and no statistically significant differences were found. We conclude that Ramadan fasting, or any other form of short-term fasting, has no adverse effects on the efficacy and safety of long-term oral anticoagulation.IntroductionIt is currently estimated that more than 555 million people belong to the Muslim faith.1 Complete fasting during the daytime hours of the month of Ramadan is a unique requirement of this religion. Most Muslims live in Asia and the Middle East where rheumatic heart disease is still very prevalent, and an increasing number of Muslim patients are being treated with long-term oral anticoagulant drugs, particularly after insertion of prosthetic valves. Yet very little is known about the possible adverse effects of Ramadan fasting on such therapy. To our knowledge this is the first study addressing this question.PATIENTS, METHODS, AND RESULTSBetween 1981 and 1985 we advised all our 289 patients receiving long-term anticoagulant therapy that its efficacy and safety could theoretically be adversely affected by Ramadan fasting. Despite this, 106 patients elected to fast the Ramadan month each year, taking their oral anticoagulant medication at night rather than at day time. Whether the patient fasted or not, each patients' course was carefully documented every year. All thromboembolic events and hemorrhagic complications during the Ramadan month, and every other month, were recorded, and their incidence in the patients who had fasted (Group 1) and in those who did not (Group 2) compared in a retrospective chart review.Patients were seen at the anticoagulation clinic once every four to six weeks if their prothrombin time (PT) ratio was in a therapeutic range. When the PT ratio was undesirable, the warfarin dosewas adjusted and the patient's PT ratio determined every few days until a therapeutic level was reached. Patients were advised to call the clinic or report to the emergency room with any thromboembolic or bleeding complication.The diagnosis of thromboembolic events was made clinically and always confirmed by radiology, including ultrasonography of the abdomen, computerized tomography of the abdomen and brain, and angiography when indicated. Major bleeding was defined as a cerebral or retroperitoneal hemorrhage or any bleeding that required hospitalization and transfusion. All other hemorrhagic complications were defined as minor.Table 1 shows the relevant clinical data. The number of patients with cardiac disease and those with deep vein thrombosis (DVT) or without pulmonary embolism seen each year are shown in Table 2.Table 1. Clinical details.Table 1. Clinical details.Table 2. Total number of patients seen each year.Table 2. Total number of patients seen each year.Group 1 consisted of 81 cardiac patients who fasted 284 Ramadan months and 25 patients with DVT with or without PE who fasted 25 Ramadan months, making a total of 106 patients fasting for 309 months. Group 2 comprised 166 cardiac patients who spent 577 Ramadan months not fasting and 17 patients with DVT with or without PE who did not fast through 17 Ramadan months, making a total of 183 patients nonfasting for 594 months. Table 3 shows the incidence of thromboembolic events and hemorrhagic complications in the two groups. Ten patients, five from each group, were lost to follow-up during the five-year period and were excluded from this study.Table 3. Number of complications.Table 3. Number of complications.Warfarin Dose and Anticoagulation EffectWarfarin dose during the Ramadan months in Groups 1 and 2 was 6.5 ± 2.1 mg and 6.7 ± 2.2 mg, respectively. The anticoagulation effect was at a therapeutic range (PT ratio, 1.5-2.5) in 90% and 92% of visits, respectively. Warfarin dosage and anticoagulation effect were compared in the two groups during the months of Ramadan and Safar. Results are shown in Table 4.Table 4. Warfarin dosage and anticoagulation effect.Table 4. Warfarin dosage and anticoagulation effect.Statistical AnalysisThe adverse events relative to the total number of patient-months for both fasting and nonfasting individuals yielded a chi-square of 0.00001 and P = 0.999.DISCUSSIONThe indications, safety, and efficacy of long-term anticoagulation therapy have been extensively studied.2–11 Two recent reviews critically analyzed available data and highlighted remaining controversies due to the lack of well-documented clinical trials.12,13Each year the vast majority of Muslims fast during the month of Ramadan. This entails major changes in physical activity, sleep patterns, as well as timing, type, and volume of food and fluid intake. Fasting may thus adversely influence anticoagulation therapy causing relative dehydration, low cardiac output, increased stasis and viscosityof the blood, and changes in drug absorption and metabolism.Our study compares a Ramadan fasting and nonfasting group of patients over a five-year period. Results in the two groups were comparable. The incidence of thromboembolic events, as well as major and minor hemorrhagic complications, was also similar in the two groups (P = 0.999) and compares favorably with previously published data.10,14 Furthermore, both oral anticoagulation dosage and effect were similar in the two groups during the fasting month of Ramadan and the nonfasting month of Safar. We therefore conclude that Ramadan fasting, or any other form of short-term fasting, does not adversely influence the efficacy and safety of long-term oral anticoagulation, nor does it affect the dosage or anticoagulation effect of these drugs.ARTICLE REFERENCES:1. The World Almanac and Book of Facts. Newspaper Enterprise Inc, 1985;357. Google Scholar2. Brozurie M. "Oral anticoagulation in clinical practice" . Sem Hematol. 1978; 15: 27. Google Scholar3. Seckely P. "Systemic embolization and anticoagulant prophylaxis in rheumatic heart disease" . Br Med J. 1964; 12: 1209–11. Google Scholar4. Berger S, Salzman EW. "Thromboembolic complication of prosthetic devices" . Prog Hemostasis Thromb. 1974; 2: 273–309. Google Scholar5. Duvoisin GE, Brandenburg RO, McGoon DC. "Factors affecting thromboembolism associated with prosthetic valves" . Circulation. 1976; 34 (suppl 1): 1970–6. Google Scholar6. Fuster V, Gersh BJ, Giuliani ER, et al. "The natural history of idiopathic dilated cardiomyopathy" . Am J Cardiol. 1981; 47 (3): 525–31. Google Scholar7. Hinton RC, Kistler JP, Fallon JI, et al. "Influence of etiology of atrial fibrillation on incidence of systemic embolization" . Am J Cardiol. 1977; 40 (4): 509–13. Google Scholar8. Bodley S. Price's Textbook of the Practice of Medicine, ed 12. Oxford: Oxford Medical Publications, 1978: 834. Google Scholar9. Coon WW, Willis PW. "Hemorrhagic complications of anticoagulant therapy" . Arch Intern Med. 1974; 133: 386–92. Google Scholar10. Levine MN, Raskob G, Hirsh J. "Hemorrhagic complications of long-term anticoagulant therapy" . Chest. 1986; 89 (suppl2): 16S–25S. Google Scholar11. Peterson CE, Kwaan HC. "Current concepts of warfarin therapy" . Arch Intern Med. 1986; 146 (3): 581–4. Google Scholar12. Hirsh J, Cairns JA. "Antithrombotic therapy in acute myocardial infarction and unstable angina" . J Intens Care Med. 1987; 2: 299–312. Google Scholar13. Dalen JE, Hirsh J. "Introduction to ACCP-NHLBI National Conference on Antithrombotic Therapy" . Chest. 1986; 89 (suppl 2): 1. Google Scholar14. Stein PD, Collins JJ, Kantrowitz A. "Antithrombotic therapy in mechanical and biological prosthetic heart valves and saphenous vein bypass grafts" . Chest. 1986; 89 (suppl 1): 46S–53S. Google Scholar Previous article Next article FiguresReferencesRelatedDetailsCited byAzizi F (2002) Research in Islamic Fasting and Health, Annals of Saudi Medicine, 22:3-4, (186-191), Online publication date: 1-May-2002.Sulimani R (1991) Ramadan Fasting: Medical Aspects in Health and in Disease, Annals of Saudi Medicine, 11:6, (637-641), Online publication date: 1-Nov-1991.Kordy M and Gader A (1991) The Effect of Fasting in Ramadan on Hemostatic Variables, Annals of Saudi Medicine, 11:1, (23-27), Online publication date: 1-Jan-1991. Volume 9, Issue 6November 1989 Metrics History Accepted4 March 1989Published online1 November 1989 InformationCopyright © 1989, Annals of Saudi MedicinePDF download
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