Thursday, June 26, 2014

Ramadan and Emergency Medicine: An Inside Look

I am generally pretty good about not letting my personal life affect my work environment. As we all know, the combination is not usually a great one, especially if things occurring your personal life impact your approach to work, your attitude with others that you are working with, and the work being produced.

However, once a year, without fail, the creep of my personal life into my work and professional life occurs. No matter how hard I try, it inevitably happens. However, after a couple of days, as I adjust to the change, I am able to cope and get back into the swing of things without any untoward effects or long-term issues.

Now, you may be asking: Why? Well, the short answer is that once a year, Ramadan happens.


So, what is Ramadan? It is the ninth month of the Muslim lunar calendar, and it is considered to be the holy month of the year for those practicing within the Islamic faith (some 1.6 billion people, or 23% of the world's population, according to the Pew Research Center). During this month of 29 or 30 days, Muslims are expected to fast from sunrise to sunset. Some of you may have encountered someone engaging in this fast at one point or another, and you may recall that the fasting occurred during the fall or winter months. Since Muslims follow the lunar calendar, the start and end of the month of Ramadan actually shifts backwards about ten days each year, and this year, the month starts this coming weekend.

Fasting during Ramadan is an obligation for all Muslims. Not only are Muslims expected to not eat or drink during the hours between sunrise and sunset (yes, that includes water), but they also refrain from smoking and engaging in sexual activity. Depending on where you are living in the world, the daily fast can be as short as six hours to as long as 18 hours. In doing so, fasting teaches Muslims discipline and restraint from selfish indulgences as well as empathy for those who are impoverished and suffer from lack of basic human necessities on a daily basis.

Once sunset settles in, Muslims are able to break their fast and eat and drink through the sunrise of the next morning. In addition, it is encouraged for those who are fasting to have a pre-dawn meal (or "suhoor" in Arabic) to facilitate the ability to get through the upcoming day of fasting.

Although fasting is a tenet of the Muslim faith, there are certain populations of individuals who are exempt from fasting. These populations include prepubescent children and adolescents, the elderly, the ill, those with their monthly menses, pregnancy, lactating mothers, diabetics, and those who are traveling. Although these populations are not obligated to fast, some people do so on their own volition, which can have its consequences, both good and bad.

In anticipation of Ramadan this year, I wondered if there was any literature published regarding the impact Ramadan can have in patients who present to the emergency department. Remarkably, and to my surprise, I came across more than a few articles about this topic.

In a study conducted in the mid-1990s, investigators observed that there was a significant increase in the general number of visits to the emergency department in Ramadan compared to periods outside of Ramadan (1). However, the results of this study have not been reproduced in recent observational studies. Investigators of one study evaluated the chief complaints and diagnoses of fasting patients who presented to the emergency department, and although there was a slight increase in the number of presenting patients during the month of Ramadan, the demographics and clinical characteristics of patients were not any different than those who presented outside of the month of Ramadan (2). However, investigators of another study evaluated a similar outcome, and found that during the month of Ramadan, there were more frequent visits for uncomplicated headache and hypertension that in periods outside of the month of Ramadan (3). In addition, they also observed that patients who presented with diabetic complications to the emergency department were much younger than those patients in the control group, although the frequency of visits related to this condition was not found to be significantly different. In a couple of studies, there were no differences in the incidence or risk factors related to both ischemic and hemorrhagic stroke during Ramadan (4-5).

On the other hand, the incidence and complications of peptic ulcer disease has been observed to occur with greater frequency during Ramadan in a number of studies (6-9). Patients with underlying risk factors should be advised regarding the risks of fasting, as they may be excused from fasting altogether to prevent any exacerbation of preexisting injury.

A common acute ailment related to emergency medicine observed in fasting patients during the month of Ramadan is migraine headache, and one study found that the although the duration of the headache was three times as prolonged and associated with aura relative to the control group, the frequency of the migraine headache was actually lower (10). The authors note that for those engaging in the practice of fasting, prevention of migraine headache is key and can certainly improve the patient's quality of life during Ramadan. Encouraging patients to drink plenty of fluids during suhoor, and difficult as it may be, forgoing consumption of caffeine during off-fasting hours to minimize the incidence of withdrawal headaches as well as dehydration may be options. Patients with chronic migraine headache may need to have their medications adjusted, and the authors suggest the use of long-acting prophylactic agents that do not require a prolonged titration schedule to be prescribed to patients during this month such as naratriptan and valproic acid. Other agents such as tricyclic antidepressants, topiramate, beta-blockers may be poor choices due to the potential for dehydration and hypotension as adverse events. Interestingly enough, based on a study conducted in patients fasting during Yom Kippur (11), investigators performed a study evaluating the use of etoricoxib as prophylactic therapy for the "first of Ramadan" headache in fasting patients, which demonstrated good results in reducing the incidence of headache by over 50% and decreasing the severity of the headache over the first five days of the month of Ramadan (12). However, this COX-2 inhibitor is not available in United States.

Hopefully, you are equipped with some helpful information related to conditions to have a heightened awareness for as you approach your next fasting patient in the ED this coming month. Make sure to provide wishes for a happy and healthy Ramadan (your fellow colleagues would certainly appreciate the greeting, too). Or, if you are so inclined to state the salutation in Arabic: "Ramadan Kareem."

References:

  1. Langford EJ, Ishaque MA, Fothergill J, et al. The effect of the fast of Ramadan on accident and emergency attendances. J R Soc Med 1994; 87:517-518.
  2. Pekdemir M, Ersel M, Yilmaz S, et al. No significant alteration in admissions to emergency departments during Ramadan. J Emerg Med 2010; 38:253-256.
  3. Topacoglu H, Karcioglu O, Yuruktumen A, et al. Impact of Ramadan on demographics and frequencies of disease-related visits in the emergency department. Int J Clin Pract 2005; 59:900-905.
  4. Bener A, Hamad A, Fares A, et al. Is there any effect of Ramadan fasting on stroke incidence? Singapore Med J 2006; 47:404-408.
  5. Akhan G, Kutluhan S, Koyuncuoglu HR. Is there any change of stroke incidence during Ramadan? Acta Neurol Scand 2000; 101:259-261.
  6. Bener A, Derbala MF, Al-Kaabi S, et al. Frequency of peptic ulcer disease during and after Ramadan in a United Arab Emirates hospital. East Mediterr Health J 2006; 12:105-111.
  7. Gokakin AK, Kurt A, Akgol G, et al. Effects of Ramadan fasting on peptic ulcer disease as diagnosed by upper gastrointestinal endoscopy. Arab J Gastroenterol 2012; 13:180-183.
  8. Gökakın AK, Kurt A, Atabey M, et al. The impact of Ramadan on peptic ulcer perforation. Ulus Travma Acil Cerrahi Derg 2012; 18:339-343.
  9. Amine el M, Kaoutar S, Ihssane M, et al. Effect of Ramadan fasting on acute upper gastrointestinal bleeding. J Res Med Sci 2013; 18:230-233.
  10. Abu-salameh I, Plakht Y, Ifergane G. Migraine exacerbation during Ramadan fasting. J Headache Pain 2010; 11:513-517.
  11. Drescher MJ, Alpert EA, Zalut T, et al. Prophylactic etoricoxib is effective in preventing Yom Kippur headache: a placebo-controlled double-blind and randomized trial of prophylaxis for ritual fasting headache. Headache 2010; 50:1328-1334.
  12. Drescher MJ, Wimpfheimer Z, Abu Khalef S, et al. Prophylactic etoricoxib is effective in preventing "first of Ramadan" headache: a placebo-controlled double-blind and randomized trial of prophylactic etoricoxib for ritual fasting headache. Headache 2012; 52:573-581.