Background: Fasting during Ramadan, the ninth month of Islamic calendar, requires the abstinence from food and drink from sunrise to sunset [1]. Muslims are allowed to consume two major meals per day, one shortly before dawn (Suhoor) and the other immediately after sunset (Iftar). Although some previous investigations have reported a beneficent impact of fasting on rheumatic diseases’ activity [1,2], very few studies have dealt with the possible impact of intermittent fasting on chronic medications intake.

Objectives: The objective of this study was to assess the impact of Ramadan intermittent fasting on adherence and tolerance of Disease-Modifying Anti-Rheumatic Drugs (DMARDs) in patients with rheumatoid arthritis (RA).

Methods: This is a prospective monocentric study including patients with rheumatoid arthritis (RA) who fasted Ramadan 2019. Each patient was evaluated during 2 visits: 6 months before starting Ramadan fasting and after fasting at least 7 days. The following parameters were assessed: compliance with treatments, tolerability and timing of intake (Iftar meal, evening, Suhoor meal).

Results: Thirty-six patients were enrolled: 7 men and 29 women. The average age of patients was 57.5 years ± 10.9 [39-79] and the mean disease duration was 6.7 years ± 3.3 [1-13]. Biological agents, methotrexate (MTX), Salazopyrin (SLZ) and Leflunomide (LFN) were respectively prescribed in 8, 22, 4 and 4 patients.

Ramadan fasting did not affect either compliance with biological agents or tolerance. No additional side effects have been reported during this period.

The compliance to MTX was comparable before and during fasting in 68.4% of cases. It was impaired by fasting in the rest with a full stop in 26.3% of patients. MTX was taken away from meals (as recommended) by 42.8% of patients. The timing of drug intake was the Iftar meal in 21.4% of patients, the Suhoor meal in 14.3% of patients and the evening in 64.3% of patients.

Except 1 patient, adherence to SLZ was adequate during Ramadan fasting. It was taken with the 2 major meals in 50% of cases and during the evening in 50% of cases.

Patients under LFN did not report any discontinuation.

The reported reasons of discontinuations of Conventional Synthetic Disease-Modifying Anti-Rheumatic Drugs (csDMARDs) were: objective adverse effects (25%), apprehension of gastrointestinal adverse effects (25%) and lack of time between the two major meals (50%) (since they were advised to take MTX away from meals).

Regarding the tolerance, gastrointestinal side effects of MTX were reported to be more frequent during Ramadan by 20% of patients, fewer by 13.3% of patients and unchanged by the rest of the patients. The gastrointestinal tolerance of SLZ and LFN was similar before and during Ramadan fasting.

Conclusion: Even if the tolerability of chronic medications was not impaired by Ramadan fasting in the majority of patients, adherence to conventional DMARDs was reported to be reduced by more than a quarter of patients, mainly because of a lack of time between the two major meals. Physicians should be aware of the impact of Ramadan fasting on chronic drugs intake because they have a crucial role in helping patients with RA adjust medications safely.

References: [1]Adawi M, Damiani G, Bragazzi NL, et al (2019) The Impact of Intermittent Fasting (Ramadan Fasting) on Psoriatic Arthritis Disease Activity, Enthesitis, and Dactylitis: A Multicentre Study. Nutrients 11

[2]Bragazzi NL, Watad A (2017) The Impact of Fasting on Rheumatic Diseases. Isr Med Assoc J IMAJ 19:378–379

Disclosure of Interests: None declared