Corporate Pharmacy Department Disease Drug/category Specification Recommendation

Atorvastatin and OD Take after Iftar or Suhoor

Drug Information Center Rosuvastatin (Long

Hyperlipidemia
acting)
Simvastatin and OD Take before bedtime

Medication Management During Ramadan Pravastatin (short

acting)
Fibrates During fasting, risk of Take after Iftar
Muslims are obliged to participate in an intermittent fasting and refrain from eating from dawn to sunset for a
month, unless they are advised not to fast. In Qatar, fasting duration ranges between 9 and 15 hours. The first meal rhabdomyolysis might increase if Monitor muscle pain
in the day is just before the dawn (Suhoor), while the second meal is immediately after the sunset (Iftar). Fasting used in combination with statins
Muslims are expected to take their medication between Iftar and Suhoor. Healthcare Providers (HCPs) should be due to dehydration and
aware about the effect of the drug modification on the disease management. dehydration during fasting
Ezetimibe OD Take after full Iftar or Suhoor
Physiological and pharmacokinetic changes:
Carbamazepine (IR) Should be taken at least twice daily Option 1: convert to CR formula
Gastro-intestinal tract: Option 2: Redistribute total daily dose
During fasting, the gastric pH significantly decreases up to 1, resulting in an increased gastro-intestinal into BID dose and take after food
disturbance of drugs that are taken on an empty stomach. Such drugs are advised to be taken before Suhoor. Drugs Carbamazepine (MR) Initiation OD Take after iftar or Suhoor
that are taken after food are advised to be taken 1 hour after the main meal (Iftar), allowing normalization of the pH. Initiation BID Take after iftar and Suhoor
Urinary excretion: Maintenance BID
Drug excretion is not expected to be altered in patients with normal renal function, including patients with renal Benzodiazepines OD or PRN doses Take after Iftar (preferred after Ishaa
transplant. However, patients with chronic kidney disease are more likely to have adverse outcomes secondary to pray)

Epilepsy
dehydration and decreased drug excretion. Sodium Valproate Regular formulation - BID Take after Iftar and Suhoor
Chrono – OD or BID Take after Iftar and/or Suhoor
Liver and Cytochrome P 450 (CYP 450): Oxcarbazepine BID Take after Iftar and Suhoor
Short-term fasting alter CYP450-mediated drug metabolism, which might lead to altered (increased/decreased)
Topiramate
hepatic metabolism during Ramadan. However, these findings are inconclusive and further research is needed.
Pregabalin
Therefore, patients with hepatic impairment are managed on individual bases (clinical judgment).
Levetiracetam
Lamotrigine (IR) Initiation OD or BID Clinical judgment. Take after Iftar
Challenges faced by HCPs during Ramadan
and/or suhoor
High risk patients:
Maintenance BID Take after iftar and suhoor
High risk patients, such as type 1 diabetes and heart failure patients, who insist to fast, pose a great challenge to
the HCPs in the management of their disease. Structured education and pre-Ramadan medication management Lamotrigine (MR) OD Take after Iftar or Suhoor
planning is crucial. Phenytoin BID Take after iftar and suhoor
TID Clinical judgment
Fasting without HCPs awareness: Inhalers Advise to avoid food that can No dose change, Does NOT invalidate
Patients arbitrarily change their drug regimen without seeking medical advice, e.g. they:

Asthma
trigger asthma symptoms such as the fast, Stay hydrated
 stop their medications peanuts, milk, eggs, and wheat
 modify the timing of administration/intake Vaporizers PRN No dose change, invalidate fasting
 change the frequency change the total daily dosage
Capsule e.g. tiotropium
 take their total daily dose in one intake.
Metformin (IR) OD: Daily dose remains unchanged Take after Iftar
Knowledge about patient practices regarding their medication use in Ramadan is paramount. Such modifications
BID: Daily dose remains unchanged Take after Iftar and Suhoor
may result in significant drug-drug or drug-food interactions and abnormal drug levels, and may results in serious
TID: Daily dose remains unchanged Morning dose afterSuhoor, combine
adverse outcomes. Patients may not disclose this issue if not discussed. Therefore, HCPs are advised to be proactive
afternoon & evening dose at Iftar
and initiate this conversation with their patient to ensure a proper medication Ramadan management plan.
Metformin (MR) MR - Daily dose remains Take after Iftar

Diabetes on Oral Anti-diabetics

Special population unchanged
Pregnant and breastfeeding women Acarbose No dose modifications
Pregnant and breastfeeding women are allowed to fast if they are healthy, unless they are advised not to fast Pioglitazone, No dose modifications. Dose can be
such as pregnancy with diabetes, hypertension, or anemia and mothers with exclusively breastfed babies aged less Rosiglitazone taken with Iftar or Suhoor
than 6 months. Pregnant and breastfeeding women are advised to take a healthy diet, to keep hydrated and to seek Repaglinide Reduce TID dose to BID
medical opinion if they experienced any of the following symptoms: dizziness, palpitations, severe headache, fever, Exenatide & Maintenance No dose modification is needed
nausea or start vomiting, vision disorders, weakness, decreased fetal movement while fasting. Liraglutide
Sitagliptin, Vildagliptin, No dose modification is needed
Elderly patients and Saxagliptin
Elderly patients are prone to dehydration during long fasting hours that might affect their kidney function. Also, Sulfonyl Ureas e.g. OD Take at Iftar
they are likely to have a polypharmacy. Pre-Ramadan planning and careful distribution of their medication is Glibenclamide*, *Glibenclamide should be avoided Dose may be reduced in patients with
important. Gliclazide, and Switch to newer SU (Gliclazide, good glycemic control
Glimepiride Glimepiride) where possible.
Pediatrics BID Take at Iftar and Suhoor
Fasting becomes obligatory for pediatrics at puberty. Children are trained to fast gradually at an earlier age. *Glibenclamide should be avoided
Iftar dose remains unchanged
Because of increased metabolic needs and water loss due to large surface area, it is advised to keep hydrated (drink Switch to newer SU (Gliclazide,
Suhoor dose may be reduced in patients
30 ml/kg of water) during fasting break hours. On the other hand, they should not fast if they use chronic Glimepiride) where possible
with good glycemic control
medications as it might negatively affect their disease status. Dapagliflozin, and Take with Iftar
Canagliflozin No dose modifications
Disease Drug/category Specification Recommendation Keep hydrated. Avoid in the elderly with
BB: e.g. Bisoprolol OD Take after Suhoor renal impairment, hypotensive
BB: e.g. Metoprolol BID Take after Iftar and Suhoor individuals or patient taking diuretics
ACEs & ARBs OD - Monitor for postural Take after Ishaa praying Long- or intermediate- OD Take at Iftar.
Diabetes on Insulins*

hypotension e.g. dizziness acting basal insulin Reduce dose by 15–30%

Hypertension

CCBs Dihydropyridine e.g. amlodipine or Take after Iftar or Suhoor e.g. BID Take usual morning dose at Iftar
nifedipine NPH/Detemir/Glargine Reduce evening dose by 50% and take
Non–dihydropyridine e.g. verapamil Take after Suhoor due to the circadian at Suhoor
and diltiazem effect of the drug Rapid- or short-acting Take normal dose at Iftar
Thiazide diuretics OD - might cause dehydration Take after Ishaa prayer prandial/bolus insulin Omit lunch time dose
Alpha blocker OD - Monitor for postural Take after Ishaa praying Reduce Suhoor dose by 25–50%
hypotension e.g. dizziness Premixed insulin OD Take normal dose at Iftar
Hydralazine Every 6 or 8 hours Option 1: Take the total dose in two BID Take usual morning dose at Iftar
divided doses, monitor blood pressure Reduce evening dose by 25–50% and
Option 2: Change the drug take at Suhoor
Antiplatelet e.g. OD - Aspirin and clopidogrel take after the full Iftar meal (to avoid TID Omit afternoon dose
aspirin, clopidogrel and Increased resistance in diabetic the stomach irritation) Adjust Iftar and Suhoor doses
prasugrel patients during fasting Strict adherence is recommended Hypo- Levothyroxine OD Should be taken 2 hours before the
Coronary Artery

Antiplatelet e.g. BID After Iftar and Suhoor last meal and 30 minutes before the
ticagrelor Interval between doses should not be thyroid next meal.
Methimazole OD Take with main Iftar meal or Suhoor
Disease

less than 8 hours Hyper- BID Take with main Iftar meal and Suhoor
Contrast media after Increase risk of contrast induced Advise not to fast
angioplasty nephropathy due to dehydration thyroid Propylthiouracil Clinical judgment
Nitrates (MR) e.g. Monitor for postural hypotension Take after Ishaa praying or after Acronyms: ACEs: Angiotensin converting enzyme inhibitors; ARBs: Angiotensin receptor inhibitors; OD: once daily;
Isosorbide dinitrate Suhoor BID: Twice daily; BB: Beta blockers; GI: gastrointestinal; IR: Immediate release; MR: Modified release PRN: as needed;
Nitrates (IR) e.g. BID Option 1: Convert to long acting TID: three times daily. *Insulin dose modification is case dependent
Isosorbide dinitrate Option 2: Take after Iftar & Suhoor - All above recommendations are based on the available literature and are subjected to physician approval.
Nitrates (IR) e.g. TID Distribute the total dose in to BID
Isosorbide dinitrate
Amiodarone Patient are sensitive to electrolyte Take after full Iftar meal. Prepared by: Reviewed by:
disturbance Drug Information Center, Pharmacy Executive Office Dr. Mohamed Bashir, Consultant,
Endocrinology department
Arrhythmia

Designed and edited by:

Mexiletine TID - Patient are sensitive to Fasting is not recommended Mr. Ahmed Moursi, Pharmacy supervisor, Pharmacy Executive Dr. Fahad Al Kindi, Consultant,
electrolyte disturbance e.g. K & Mg Office Interventional Cardiology department
Flecainide BID Take after Iftar and Suhoor Dr. Boulenouar Mesraoua, Sr. Consultant,
Approved by:
Interval between doses should not be Neurology department
Sotalol Dr. Palli Valapila Abdulrouf, Assist. Director
less than 8 hours Dr. Abdelnasser Elzouki, Sr. Consultant,
Dr. Moza Al Hail, Executive Director HMC Pharmacy
Oral electrolyte OD Preferred after Suhoor Medicine department
Corporate Pharmacy Services
replacement BID Take after iftar & suhoor
* A special thank you to Dr. Ahmed Ragab, clinical pharmacist, Al-Khor Hospital for his contributions
Loop Diuretics alone Take after Ishaa prayer
Combined with thiazides Advise not to fast. Monitor for
Drug Information Center (DIC)
Failure
Heart

significant dehydration and electrolyte

disturbance Drug information center at HMC was established in April 2018 under the direction of Dr. Moza Al Hail, Executive
Spironolactone Take after Iftar or Suhoor Director Pharmacy, to promote the use of evidenced-based medicine, improve medication safety, and enhance
Digoxin Monitor for toxicity secondary to Take after Suhoor patient-centered pharmaceutical care at HMC through practice, research and teaching.
hypokalemia and dehydration
Warfarin OD - Take the dose in the same Take after main Iftar Drug Information Center staff: Drug Information Center services:
time every day Monitor INR frequently I. Provide specialist information to health care providers
Dr. Palli Valapila Abdulrouf, Head of DIC
Coagulation

Rivaroxaban OD Take after full Iftar meal II. Maintain and update shared drug information database
disorders

Mrs. Yolande Hanssens, Co-Head of DIC

III. Coordinate adverse drug reaction monitoring with
Dr. Binny Thomas, DIC Coordinator
Dabigatran BID - Might increase GI Take after full Iftar and Suhoor Medication safety office
Mr. Shaban Mohammed, DI specialist
disturbance with the Iftar dose Interval should be ≥ 8 hours IV. Support and review HMC formulary and guidelines
Mr. Mahmoud Mohamed, DI pharmacist
V. Support medical research center by reviewing research
Mr. Haseebur Rahman Mohammed, DI pharmacist
Apixaban BID Take after full Iftar and Suhoor proposals
Ms. Dina Abushanab, DI pharmacist
Interval should be ≥ 8 hours VI. Support continuous education and training