Transcript Fasting and Medical Issues During Ramadan

Fasting and Medical
Issues During Ramadan
Dr Wafa Ababtain .MD
21,may,2012
• Introduction
• Metabolic effect of Ramadan fasting
• Medical Issues in Ramadan
- Cardiac patient and fasting
- stroke in Ramadan
- kidney transplantation and fasting
- peptic ulcer disease
-chronic liver disease
- DM
• conclusion
2009 demographic study, Islam has 1.57 billion
adherents, making up 23% of the world
population of 6.8 billion, and is growing by
∼3% per year
Important facts about Ramadan
• Ramadan is the 9th month of the Hijry
calendar year in which the holy Qur”an was
revealed to islams” holy prophet.
• The Islamic calendar is lunar and the start of
the islamic year advances 11 days each year
compared with the seasonal year.
• Ramadan occurs at different times of the
seasonal year over a 33-year cycle .
• This can result in the Ramadan fast being
undertaken in markedly different
environmental conditions between years in
the same country (a different season every 9
years)
• The time of sunrise and sunset varies
between 12 h at the equator and about 22 h
at the 64* of latitude in summertime.
• Not only is the eating pattern greatly altered
during the Ramadan period, but the amount
and type of food eaten during the night may
also be significantly different to that usually
consumed during the rest of the year.
• In many cultures, special festival foods that
are richer in fat and protein than the usual
diet, or that contain large quantities of sugar,
are eaten.
• Muslims observing the fast must not only
abstain from eating and drinking, but also
from taking oral medications, smoking, as well
as receiving intravenous fluids and nutrients
carbohydrate metabolism during experimental
short-term fasting
1- Post-absorptive period for the first
8-16 hrs after eating.
2- Glycogenlysis 1,200 calories are
stored as carbohydrate in the
liver providing the basal
requirement for glucose for only
5–6 h.
3- Gluconeogenesis refers to the
formation of glucose from lactate,
pyruvate, amino acids and
glycerol.
4- lipolysis -fatty acid oxidation and
keton body formation which
replaces glucose as the essential
fuel for use by other tissues of
the body
Metabolic effects of Ramadan fasting
• Fasting is associated with improvement in several
hemostatic risk markers for cardiovascular disease.
• Reduction in plasma triglyceride and plasma LDLcholesterol level.
• Improvement in insulin sensitivity, leptin, adiponectin
and HDL cholesterol.
• Reduction in plasma homocysteine, D-dimer level, Creactive protein (CRP) and IL-6 and fibrinogen.
• Similar beneficial effects of fasting have been reported
in diabetic individuals.
Cardiac patients and Ramadan fasting
• Whether Ramadan fasting has any adverse
effect on their cardiac status ?
• The answer has not yet been clarified.
• Ramadan may have negative effects on
cardiovascular disease patients, the obligation
that the daily calorie intake has to be taken in
one or two meals instead of three to five, is an
effort.
• In Ramadan medications may not be taken
regularly.
Is there any effect of Ramadan fasting on
acute coronary heart disease events 1
• A. Temizhana reported in his retrospective study
1991 - 1997 during ,befor ,and after Ramadan
• 1655 of 5016 patients were found to have acute
coronary heart disease events.
• The ratios of the cases with acute coronary heart
disease to all patients were not statistically
significant (P value > 0.05)
• No significant difference was found in mortality
rates of patient with acute coronary heart disease
events between the periods (P value > 0.05)
1 -International Journal of Cardiology 70 (1999)
• retrospective review in Qatar on all Qatari
patients who were hospitalized with heart
failure for a period of 10 years (1991 - 2001) .
• The number of hospitalization for patients
with CHF was compared between the month
of Ramadan and one month befor and one
month after.
• 2160 patients were hospitalized for CHF.
• The overall mortality was 9.7%.
• The number of hospitalization for CHF was not
significantly different in Ramadan (208 cases)
when compared to a month before Ramadan
(182 cases) and a month after Ramadan (198
cases) p > 0.37.
• There was no significant difference in the
baseline clinical characteristics or mortality
(11.5%, 7.7% and 9.6%, respectively; p>0.43).
• Fasting patients are under volume deprivation
and, possibly, salt restriction
• This might explain reducing the signs and
symptoms of HF and the hospitalization
during the month of Ramadan.
J. Al Suwaidi et al. / International Journal of Cardiology 96 (2004) 217–221
Impact of fasting in Ramadan in patients with
cardiac disease
• Al Suwaidi J etal analysed 465 patients from
various medical centers in the Gulf region.
• one month before Ramadan, during Ramadan
and one month after Ramadan and analyzed
predictors of outcome.
• found that 91.2% could fast and only 6.7% felt
worse while fasting in Ramadan. Of the studied
subjects, 82.8% were compliant with cardiac
medications and 68.8% were compliant with
dietary instructions.
CONCLUSION:
• The effects of fasting during Ramadan on
stable patients with cardiac disease are
minimal. Most patients with stable cardiac
disease can fast.
Cerebrovascular disease
• Retrospective study over 5 years period- patients
hospitalized in Isparta Province's hospitals
between, 1991 -1995 with a diagnosis of stroke.
• Patients admitted in Ramadan were compared to
those admitted in the other months of the year.
• Incidence of stroke in Ramadan and other
months were 12.1 and 11.4 per 100,000 people,
respectively which was statistically insignificant
(P=0.82).
• Retrospective study, reviewed a 13-year
stroke database on Muslim patients who were
hospitalised with stroke between 1991 - 2003
at Hamad General Hospital, Doha.
• Patients admitted with stroke were compared
in relation to the month of Ramadan, one
month before, and one month after Ramadan.
• 335 Muslim patients were admitted over a 13years period .
• The incidence of stroke was ( 30,29,29 patients).
• The clinical characteristics of such as age ,
gender, CVS risk factor profiles ,medications -no
significant difference between the periods .
• Conclusion ; fasting during Ramadan does not
increase the frequency of hospitalisation for
stroke.
• No statistically significant difference between
stroke rates in the Ramadan fasting month and
other non-fasting months.
Ramadan fasting and kidney
transplantation
• In healthy persons Ramadan fasting does not
induce any abnormalities of urinary PH
volume,osmolality,solute and electrolyte
excretion.
• Changes in serum urea , creatinine,sodium
and potassium are usually insignificant.
• With increasing number of renal transplants
the question of ramadan fasting is being asked
more frequently.
• El-Wakil et al. performed a prospective study on
15 predialysis (CKD) patients who did fast during
Ramadan.
• The study showed that the change in GFR was not
significantly different in CKD patients compared
to the control group .
• All CKD patients tolerated fasting without any
new complaints and had no difficulties regarding
timing or dosing of their medications.
El-Wakil et al Saudi J Kidney Dis Transpl 18:349–354
Arganie et al-2003
24 patients
All fast
Stable renal
transplant
B. Einollahi et al2005
39 patients
20 fast
19 no fast
Stable renal
transplant
B. Einollahi et al2009
82 patients
41 fasted
41 control no fast
Patients with GFR
>60 ml/min can
fast Ramadan
safely.
Abdull et al-1998
23 patients
17 stable
6 Impaired RF
Galib et al-2008
68 patients
35 Fast
33 no fast
Said et al -2003
145 patients
71 fasted
74 no fast
Boobes et al-2009
22 female
All fast
Cr < 300 mmol
prospective study on 41 healthy kidney transplant recipient
volunteers who choose to fast and 41 recipients who had
not fasted during Ramadan (September–October 2007) at
five transplant centers in Iran.
• B. Einollahi et al. reported that GFR did not change
significantly in kidney recipients with normal as well as
impaired renal allograft function during Ramadan
• No significant change in serum creatinine and GFR
from before and after Ramadan in either the group
that fasted or the group that had not fasted for equal
to or more than 3 consecutive years.
• No increase in acute complications, acute rejection or
ATN during Ramadan.
• No adverse effects on systolic and diastolic BP.
• Ghalib et al. have published a prospective cohort
study in renal transplant patients who fasted or
who did not fast for three consecutive Ramadans.
• 68 patients with renal transplant ,35 patients in a
fasting study group and 33 in nonfasting control
group There were no significant differences
between the fasters and the nonfasters with
regards to changes in GFR, mean arterial pressure
and urinary protein excretion between baseline
and the third Ramadan.
• These studies demonstrate that fasting is safe
among kidney transplant recipients with
normal as well as mild to moderate impaired
renal allograft function.
• Patients with moderate to severe renal
allograft dysfunction are discouraged fasting.
Int Urol Nephrol (2009)
Recommendations of the author
• Compliance to drug intake and proper diet .
• Fasting under medical supervision .
• The timing of immunosuppressive agents
should be divided between iftar and sohour
• The dose of diuretics should be reduced to
avoid dehydration.
• sustained release formulations especially of
anti-hypertensive drugs, can be given once a
day before the pre-dawn (sohour) meal.
• serum creatinine values should be closely
monitored especially before, during and after
Ramadan.
• If patients develop high levels of creatinine,
they should end the fast immediately.
Peptic ulcer disease
• There is a fall in gastric secretion during
prolonged fasting and gastrointestinal tract
movements occur every 2 h. The gallbladder
empties one to three times every 4 h, less
frequently than in the fed state.
• Complications of ulcers in fasting patients
have been reported
• Incidence of duodenal ulcer perforation is
relatively high in Ramadan among the people
who are fasting.
• History of dyspepsia in patients who are
fasting is an important predisposing factor for
duodenal ulcer perforation.*
• Patients with complicated peptic ulcer may be
advised against fasting
*Z. Censur et al Indian Journal of Surgery. (July-August 2005)
• Asymptomatic patients may try fasting .
• If hyperacidity continues to be a problem take
ranitidine or small dose PPI at Iftar and Sohour
Effect of Ramadan fasting on Muslim patients
with chronic liver diseases
• Elnadry MH et al, studied a total of 202 patients with chronic liver
disease
• Fasting -103 (51%) and the non-fasting - 99 (49%) patients.
• Dyspeptic symptoms in the fasting (53.4%) and (38.4%) the nonfasting group (p=0.032).
• G.I. bleeding in the fasting group (17.5%) ,non-fasting (14.1%)
• The bleeding due to o.v. was significantly higher in the non-fasting
group (9.1%) compared to (1%) in the fasting group (p=0.004).
• liver function in the fasting group showed non significant changes
pre, during and post-Ramadan regarding in the chronic hepatites.
• Fasting cirrhotic patients developed child class C in (13%) during
and (32.6%) after Ramadan compared to (0%) before (p=0.001)
Elnadry MH et al, J Egypt Soc Parasitol. 2011 Aug
Diabetes and fasting Ramadan
Guidelines
• The Casablanca guidelines were the first
international attempt to provide a consensus
on the psychological and physiological aspects
of Ramadan.
• The Diabetes and Ramadan Advisory Board
have provided international medical
recommendations for Muslims with diabetes
who fast during Ramadan
Recommendations for management
of diabetes during Ramadan.
• Al-Arouj M, Bouguerra R, Buse J, et al
• A working group for the American Diabetes
Association have reviewed the literature on
the risks of fasting during Ramadan and
provided guidance on clinical assessment
prior to fasting followed by recommendations
on how best to manage patients with type 1
and type 2 diabetes .
• Diabetes Care 2005-and an updated 2010
• First International Congress on Health and
Ramadan. Jan. 19-22, 1994, Casablanca,
Morocco
• Second International Congress on Health and
Ramadan. Dec. 1-3, 1997, Istanbul, Turkey.
• Third international congress on health and
Ramadan 2001 tahran,Iran.
• 4.6% prevalence of diabetes worldwide.
• DM prevalence in KSA 23.7%
• (EPIDIAR) study - population-based Epidemiology
of Diabetes and Ramadan 1422/2001 in 12,243
people with diabetes from 13 Islamic countries
• Result- 43% of patients with type 1 diabetes and
79% of patients with type 2 diabetes fast during
Ramadan.
• Around 40–50 million people with diabetes
worldwide fast during Ramadan.
• Many patients with diabetes insist on fasting
during Ramadan, creating a medical challenge
for themselves and their physicians.
• It is important that medical professionals be
aware of potential risks that may be
associated with fasting during Ramadan.
PATHOPHYSIOLOGY OF FASTING
• During fasting, circulating glucose levels tend to fall,
leading to decreased secretion of insulin.
• levels of glucagon and catecholamines rise, stimulating
the breakdown of glycogen, while gluconeogenesis is
augmented.
• After 16–24 hours fasting, glycogen stores become
depleted, and the low levels of circulating insulin allow
increased fatty acid release from adipocytes.
• Oxidation of fatty acids generates ketones that can be
used as fuel by skeletal and cardiac muscle, liver,
kidney, and adipose tissue, thus sparing glucose for
continued utilization by brain and erythrocytes.
DIABETES CARE, VOLUME 28, NUMBER 9, SEPTEMBER 2005 2305
In patients with type 1 diabetes
• Glucagon and Epinephrine secretion may fail
to increase in response to hypoglycemia.
• During a prolonged fast in the absence of
adequate insulin can lead to excessive
glycogen breakdown and increased
gluconeogenesis and ketogenesis leading to
hyperglycemia and ketoacidosis.
Patients with type 2 diabetes
• a prolonged fast may lead to hyperglycemia
depending on the extent of insulin resistance
and/or deficiency.
• ketoacidosis is uncommon.
RISKS ASSOCIATED WITH FASTING IN PATIENTS
WITH DIABETES
•
•
•
•
Hypoglycemia.
Hyperglycemia.
Diabetic ketoacidosis.
Dehydration and thrombosis.
Hypoglycemia
• (EPIDIAR) study showed a high rate of acute
complications.
• However, a few studies on this topic using
relatively small groups of patients suggest that
complication rates may not be significantly
increased.
• EPIDIAR study showed that fasting during
Ramadan increased the risk of severe
hypoglycemia (defined as hospitalization due to
hypoglycemia) some 4.7-fold in patients with
type 1 diabetes and 7.5-fold in patients with type
2 diabetes.
• Severe hypoglycemia was more frequent in
patients in whom the dosage of oral
hypoglycemic agents or insulin were changed and
in those who reported a significant change in
their lifestyle.
Hyperglycemia
• EPIDIAR study showed a 5x increase in the incidence of
severe hyperglycemia (requiring hospitalization) during
Ramadan in patients with type 2 diabetes.
• An approximate 3x increase in the incidence with or
without ketoacidosis in patients with type 1 diabetes.
• Hyperglycemia may have been due to excessive
reduction in dosages of medications to prevent
hypoglycemia.
• Increase in food and/or sugar intake had significantly
higher rates of severe hyperglycemia.
Diabetic ketoacidosis
• type 1 diabetes are at increased risk.
• Particularly if they are grossly hyperglycemic
before Ramadan.
• The risk increase if excessive reduction of
insulin dosages based on the assumption that
food intake is reduced during the month of
Ramadan.
Dehydration and thrombosis
•
•
•
•
In hot and humid climates
hard physical labor with excessive perspiration
Hyperglycemia can result in osmotic diuresis.
Orthostatic hypotension especially in patients
with preexisting autonomic neuropathy.
• Increase in syncope,falls, injuries, and bone
fractures.
• Hypercoagulable state due to an increase in
clotting factors, a decrease in endogenous
anticoagulants, and impaired fibrinolysis.
• Increased blood viscosity secondary to
dehydration may enhance the risk of thrombosis.
• Alghadyan AA from Saudi Arabia reported
increased incidence of retinal vein occlusion in
patients who fasted during Ramadan due to
dehydration.
• coronary events and stroke were not increased
during Ramadan
MANAGEMENT
• Patients need to be aware of the associated risks.
• Follow the recommendations of health care
providers.
• Frequent monitoring of glycemia
• Nutrition-healthy balanced diet, simple CHO and
avoid fatty high CHO food at sunset (Iftar) meal,
eat complex CHO at sohour and to be as late as
possible.
• Exercise- avoid excessive physical activity
particularly during the few hours before the
sunset meal .
• Tarawaih prayer is considered as part of the daily
exercise program.
• Breaking the fast
- must always end the fast if hypoglycemia blood
glucose of 60 mg/dl.
- if blood glucose reaches 70 mg/dl in the first few
hours after the start of the fast, especially if
insulin, sulfonylurea drugs, or meglitinide are
taken with sohour.
• if blood glucose exceeds 300 mg/dl.
Medical assessment –
- 1–2 months before Ramadan.
-control of their glycemia,blood pressure, and
lipids.
-necessary changes in their diet or medication
regimen should be made .
Ramadan-focused structured diabetes
education
• Many health care professionals are unable to
give the appropriate medical advice due to
lack of knowledge about the optimum
management of diabetes while fasting.
• often people with diabetes feel that there is
lack of harmony between the medical and the
religious advice they receive.
Ramadan educational program should ideally
include three components:
1. An awareness campaign aimed at people
with diabetes, health care professionals, the
religious and community leaders as well as
the general public.
2. Ramadan-focused structured education for
health care professionals
3. Ramadan-focused structured education for
people with diabetes.
• structured education program, was conducted
in 2007 in the U.K. for a group of 111 people
with type 2 diabetes.
• excluded people treated with insulin,
secretagogues were used in over 90% of the
people.
• Individualized medication dose adjustments
were suggested to all patients.
• Compared with a control group who did not participate
in the Ramadan-focused diabetes education
• Those who received education exhibited a nearly 50%
reduction in hypoglycemic event rates despite fasting,
whereas those in the control group had experienced a
4x increase in the rate of hypoglycemic events from
baseline during fasting.
• The group that received structured education lost a
small amount of weight compared to weight gain in the
control group .
Categories of risks in patients with type 1 or
type 2 diabetes who fast during Ramadan
Very high risk
•
•
•
•
•
•
•
•
•
•
•
Severe hypoglycemia within the last 3 months prior to Ramadan
Patient with a history of recurrent hypoglycemia
Patients with hypoglycemia unawareness
Patients with sustained poor glycemic control
Ketoacidosis within the last 3 months prior to Ramadan
Type 1 diabetes
Acute illness
Hyperosmolar hyperglycemic coma within the previous 3 months
Patients who perform intense physical labor
Pregnancy
Patients on chronic dialysis
High risk
• Patients with moderate hyperglycemia (average blood glucose
between 150 and 300 mg/dl
• A1C 7.5–9.0%)
• Patients with renal insufficiency
• Patients with advanced macrovascular complications
• People living alone that are treated with insulin or sulfonylureas
• Patients living alone
• Patients with comorbid conditions that present additional risk
factors
• Old age with ill health
• Drugs that may affect mentation
Moderate risk
• Well-controlled patients treated with shortacting insulin secretagogues such as
repaglinide or nateglinide
Low risk
• Well-controlled patients treated with diet
alone, metformin, or a thiazolidinedione who
are otherwise healthy
Management of patients with type 1
diabetes
• Fasting at Ramadan carries a very high risk .
• Especially in: poorly controlled patients ,those
with limited access to medical care,
hypoglycemic unawareness, unstable glycemic
control, or recurrent hospitalizations, patients
unwilling or unable to monitor their blood
glucose levels several times daily.
• Insulin regimens recommended represent the
collective clinical opinion and many observational
and/or interventional studies .
• Glycemic control at near-normal levels requires
- use of multiple daily insulin injections (three or
more) or
- continuous subcutaneous insulin infusion
through pump therapy.
• Close monitoring and frequent insulin dose
adjustments is required.
• the basal-bolus regimen is the preferred
protocol of management.
• It is safer, with fewer episodes of hyper- and
hypoglycemia.
• The use of once- or twice-daily injections of
intermediate or long-acting insulin along with
premeal rapid-acting insulin.
Suggested insulin regimen in patients with type
1 diabetes who wish to fast during the month
of Ramadan*
• glargine and aspart or lispro
70% of the pre-Ramadan insulin dose divided as :
60% - 1 glargine dose in the evening and 40% as
ultra-short-acting insulin (aspart or lispro) divided
in 2 doses, 1 at Suhour and 1 at Iftar.
Regular insulin should be used at Iftar instead of
an ultra-short-acting insulin if snack is to be taken
in the hours after the sunset meal.
* A. Kobeissy et al Clinical Therapeutics/Volume 30, Number 8,2008
• Ultralente and regular insulin
85% of the pre-Ramadan dose may be divided
as 70% Ultralente and 30% regular insulin,
both given in 2 doses, 1 at Suhour and 1 at
Iftar.
• 70/30 premixed insulin
100% of the pre-Ramadan morning dose may
be given at Iftar and 50% of the usual evening
dose at Suhour
• NPH insulin may be associated with
hypoglycemic events during prolonged fasting,
as its peak effect usually occurs between 6
and 10 hours after the time of injection.
• a long-acting insulin (eg, insulin glargine) that
lacks the peak effect would be more
appropriate
Patients on insulin infusion (pump)
• observational study - 49 patients type 1
diabetes patients on insulin pumps during
Ramadan 2008 (29 days).
• All patients were stable on their insulin pump
and were deemed to be fully educated in
insulin pump self-management and
carbohydrate counting for adjusting their
bolus insulin.
• 30 patients (61.2%) fasted the whole month with no
problems
• 19 (38.7%) fasted between 23 and 28 days .
• Nearly half of the patients decreased their basal insulin
rate by 5-50%
• Seventeen patients had hypoglycemia necessitating
breaking their fast
• Fasting was broken on 55 out of 1,450 potential fasting
days (3.8%).
• Unusual hyperglycemia was reported in nine patients
(18%)
• Hypoglycemia can be aborted, reduced,
prevented, and even more readily treated in
pump-treated patients by timely downward
adjustments or even totally stopping of insulin
delivery from the pump.
• Most will need to reduce their basal infusion
rate whilst increasing the bolus doses to cover
the sohour and Iftar meals.
Management of patients with type 2
diabetes
Diet-controlled patients
• Distributing calories over two to three smaller
meals during the nonfasting interval may help
prevent excessive postprandial hyperglycemia.
Patients treated with oral agents.
• agents that act by increasing insulin sensitivity
are associated with a significantly lower risk of
hypoglycemia than compounds that act by
increasing insulin secretion.
Metformin.
• possibility of severe hypoglycemia is minimal.
• dose modefied - two-thirds of the total daily
dose with the Iftar meal and the other third
before the Sohour meal.
Glitazones
• require 2–4 weeks to exert antihyperglycemic
effects.
• cannot be quickly substituted for agents
associated with hypoglycemia during periods of
fasting.
Sulfonylureas.
• Severe or fatal hypoglycemia is a relatively
rare complication
• sulfonylureas glyburide (glibenclamide) and
gliclazide MR have played a central role in the
long-term outcome studies UKPDS and
ADVANCE
• both of which demonstrated microvascular
benefits and at least trends toward
improvements in cardiovascular disease
without evidence of excess mortality
• Zargar et al used gliclazide MR 60 mg as
monotherapy during the month of Ramadan
in 136 non-obese males.
• No alteration of previously well-controlled
diabetes, no weight gain and, importantly, few
hypoglycemic event.
• Three studies have shown glimepiride to be
effective and safe during Ramadan.
• Bakiner et al reported that meal-time
repaglinide three times a day plus single-dose
insulin glargine was safe (no hypoglycemia, no
change in glycemic control or weight gain) for
low-risk type 2 diabetic individuals who
insisted on fasting during Ramadan.
Incritins
Hormones secreted by enteroendocrine cells
postprandially to regulate glucose homeostasis
• Glucagon-like peptide-1 (GLP-1).
exenatide, liraglutide (GLP-1 memetics)
• Glucose-dependent insulinotropic polypeptide
sitagliptin, vildagliptin [dipeptidyl peptidase
(DPP-4, inhibitor).
GLP1 memetics
• No published reports on the use of these
agents during Ramadan
• LEAD-6 trial, liraglutide once a day provided
greater improvements in glycemic control
than did exenatide twice a day, and with less
incidence of hypoglycemia ,less nausea, better
glycemic control (1.8% reduction in HbA1c)
and weight loss of around 3 kg.
DPP-4 inhibitors
• Report from northwest London, Muslim diabetic
individuals on 2 g daily metformin during
Ramadan.
• randomized to the addition of either vildagliptin
50 mg daily (26 individuals) or gliclazide 160 mg
twice daily (26 individuals).
• one hypoglycemic event was recorded in 2
patients receiving vildagliptin and 16 patients
receiving gliclazide.
D. Devendra et al Int J Clin Pract, October 2009
• similar reductions in HbA1c and a small, but
insignificant, increase in weight.
• DPP-4 inhibitors provide a safe alternative
therapeutic option during Ramadan.
Conclusion
• Since over 400 million people fast each year during the
month of Ramadan
• Further scientific research on the medical and healthrelated aspects of Ramadan fasting is needed.
• Health personnel practicing in Muslim countries, as
well as those caring for Muslims in various parts of the
world need to be fully aware of the physiological
alterations occurring during Ramadan.
• The effects of Islamic fasting on various diseases and
the pharmacodynamics of different medications during
the month of Ramadan.
• Most patients with stable cardiac disease can fast.
There is no increase incidence of acute coronary events
or CHF hospitalisation
• Ther is no increase in the stroke incident compared to
other monthe of the year
• Patient with allograft renal transplant with normal or
mild renal impairment can fast Ramadan under
supervision
• Diabetic patient need to be aware of the associated
risks, and to follow the recommendations of health
care providers so that they a safe fasting.
‫نز َل ِفي ِه ْٱلقُ ْر ُ‬
‫اس‬
‫قال تعالى‪َ { :‬‬
‫ض َ‬
‫آن ُهدًى لّلنَّ ِ‬
‫ش ْه ُر َر َم َ‬
‫ان ٱلَّ ِذى أ ُ ِ‬
‫ش ِهدَ ِمن ُك ُم ال َّ‬
‫ص ْمهُ‬
‫َوبَ ِيّنَ ٰـ ٍ‬
‫ان فَ َمن َ‬
‫ش ْه َر فَ ْليَ ُ‬
‫ت ِ ّم َن ْٱل ُهدَ ٰى َو ْٱلفُ ْرقَ ِ‬
‫ٱّللُ ِب ُك ُم‬
‫َو َمن َك َ‬
‫سفَ ٍر فَ ِعدَّة ٌ ّم ْن أَي ٍَّام أُخ ََر يُ ِريدُ َّ‬
‫ان َم ِري ً‬
‫ضا أ َ ْو َ‬
‫علَ ٰى َ‬
‫ٱّلل َهدَا ُك ْم‬
‫ْٱليُ ْس َر َوالَ يُ ِريدُ ِب ُك ُم ْٱلعُ ْس َر َو ِلت ُ ْك ِملُواْ ْٱل ِعدَّة َ َو ِلت ُ َكب ُّرواْ ََّ‬
‫علَ ٰى َما‬
‫َولَعَلَّ ُك ْم ت َ ْش ُك ُر َ‬
‫ون} [البقرة‪َ ] 185 :‬‬