Patient-guided modifications of oral anticoagulant drug intake during Ramadan fasting: a multicenter cross-sectional study

Journal of Thrombosis and Thrombolysis https://doi.org/10.1007/s11239-020-02218-0 Patient‑guided modifications of oral anticoagulant drug intake during Ramadan fasting: a multicenter cross‑sectional study AbdulAziz Batarfi1 · Haitham Alenezi2 · Abdulrahman Alshehri3 · Saud Balelah4 · Hameedullah Kazim5 · Mohammed Algthami6 · Mariam M. Hussain7 · Nada Alshehri8 · Rahaf Alsharif9 · Hadeel Ashour10 · Mutaz Althobaiti10 · Shomokh Alotaibi11 · Helmuth Steinmetz1 · Christian Foerch1 © The Author(s) 2020 Abstract Fasting Ramadan is known to influence patients’ medication adherence. Data on patients’ behavior to oral anticoagulant (OAC) drug intake during Ramadan is missing. We aimed to determine patient-guided modifications of OAC medication regimen during Ramadan and to evaluate its consequences. A multicenter cross-sectional study conducted in Saudi Arabia. Data were collected shortly after Ramadan 2019. Participants were patients who fasted Ramadan and who were on long-term anticoagulation. Patient-guided medication changes during Ramadan in comparison to the regular intake schedule before Ramadan were recorded. Modification behavior was compared between twice daily (BID) and once daily (QD) treatment regimens. Rates of hospital admission during Ramadan were determined. We included 808 patients. During Ramadan, 53.1% modified their intake schedule (31.1% adjusted intake time, 13.2% skipped intakes, 2.2% took double dosing). A higher frequency of patient-guided modification was observed in patients on BID regimen compared to QD regimen. During Ramadan, 11.3% of patients were admitted to hospital. Patient-guided modification was a strong predictor for hospital admission. Patient-guided modification of OAC intake during Ramadan is common, particularly in patients on BID regimen. It increases the risk of hospital admission during Ramadan. Planning of OAC intake during Ramadan and patient education on the risk of low adherence are advisable. Keywords Oral anticoagulation · Ramadan · Fasting · Saudi Arabia · Adherence · Education Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11239-020-02218-0) contains supplementary material, which is available to authorized users. 6 Department of Internal Medicine, Al Hada Armed Forces Hospital, Taif, Saudi Arabia 7 College of Medicine, King Saud Bin AbdulAziz University, Riyadh, Saudi Arabia 8 Department of Cardiology, King AbdulAziz Medical City Complex, Riyadh, Saudi Arabia College of Medicine, King Khaled University, Abha, Saudi Arabia 9 Department of Internal Medicine, Aseer Central Hospital, Abha, Saudi Arabia College of Medicine, Taibah University, Madinah, Saudi Arabia 10 College of Medicine, Taif University, Taif, Saudi Arabia 11 College of Medicine, King AbdulAziz University, Jeddah, Saudi Arabia * AbdulAziz Batarfi 1 2 3 Department of Neurology, University Hospital of Frankfurt, Goethe-University, Schleusenweg 2‑16, 60528 Frankfurt am Main, Germany 4 Department of Internal Medicine, King Fahad General Hospital, Madinah, Saudi Arabia 5 Department of Cardiology, Al Hada Armed Forces Hospital, Taif, Saudi Arabia 13 Vol.:(0123456789) A. Batarfi et al. Highlights • Patient-guided modification of OAC regimen is common during Ramadan. • Fasting patients on BID regimen face a conflict in taking the morning dose as prescribed to them, and therefore, Patient-guided modification are more in this group. • The chance of hospital admission during Ramadan triples in patients who modify their regimen. • Patient education and modifying the intake of OAC prior to Ramadan to suit fasting times is of an essence. Introduction One of the most important events in the Islamic calendar is the act of fasting during Ramadan. Around 1.6 billion Muslims practice this community celebration. All adult Muslims are required to refrain from taking food and beverages between the beginning of the morning twilight (Fajr) and sunset. This includes the oral intake of medications [1, 2]. Exceptions are granted to pregnant and lactating women, sick people, and elderly who cannot tolerate the fasting [3]. A conflict, however, exists for patients with chronic diseases and for individuals who are on regular prophylactic drug treatment [4–7]. Patient-guided modification of medication regimen during Ramadan is common. Aslam et. al. found that only 42% of the surveyed 81 Asian Muslim patients were adherent to their usual treatment schedule during Ramadan. The remaining changed their intake pattern and skipped doses or took them at different timings [8]. In another survey conducted in Kuwait, 64% of the patients were found to alter their treatment schemes during Ramadan, many of them taking their tablets as a single dose instead of divided (i.e. double dosing). Particularly in elderly patients, this led to potentially serious side-effects [9]. The clinical importance of patient-guided modification during Ramadan was reported in other studies as well [10, 11]. For oral anticoagulant drug (OAC) treatment, the patient-guided modification of medication regimen appears to be particularly critical, both in terms of thrombotic and bleeding complications. However, a prospective evaluation of this behavior in the context of OAC (including warfarin and direct oral anticoagulants [DOAC]) during Ramadan has never been performed. What is known from a real world systematic review comprising 1.6 million patients with atrial fibrillation is that overall adherence to DOAC (irrespective of Ramadan) is relatively low. Moreover, the study highlighted suboptimal adherence to DOAC as a risk factor affecting clinical outcomes, 13 with higher rate of non-adherent patients having bleeding events [12]. In the current study we aimed to characterize patientguided modification of OAC intake during Ramadan. We hypothesized that OAC medication that has to be taken twice daily (BID) is associated with higher rates of selfguided modification than once daily (QD) medication. We also determined the risk of complications resulting from patient-guided modification of treatment regimen. Methods We designed a multi-center cross-sectional study targeted to examine the behavior of fasting Muslims to OAC intake during Ramadan. A questionnaire was created for the purpose of data collection. The data collection was obtained through face-to-face interviews from trained medical personnel at regular patient visits in different outpatient clinics (neurology, hematology, cardiology departments, and anticoagulation clinics) in six centers distributed around Saudi Arabia (King Abdulaziz University Hospital, Jeddah; King Fahad General Hospital, Madinah; King Faisal Medical Center, Taif; Al Hada Military Hospital, Taif; Aseer Central Hospital, Abha; and King Abdulaziz Medical City Complex, Riyadh). In 2019, Ramadan lasted from May 6th to June 4th. The data were collected in July and August 2019 to ensure full representation of data through the wh (...truncated)