Corporate Pharmacy Department Disease Drug/category Specification Recommendation Atorvastatin and OD Take after Iftar or Suhoor

Rosuvastatin (Long Drug Information Center acting)

Simvastatin and OD Take before bedtime Pravastatin (short Medication Management During Ramadan acting) Muslims are obliged to participate in an intermittent fasting and refrain from eating from dawn to sunset for a Fibrates During fasting, risk of Take after Iftar 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. Hyperlipidemia 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) 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. Epilepsy 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: 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 Asthma 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 after Suhoor, 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 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 diabetics Repaglinide Reduce TID dose to BID than 6 months. Pregnant and breastfeeding women are advised to take a healthy diet, to keep hydrated and to seek - 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

Oral Anti Oral 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

on 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. Diabetes 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 Long- or intermediate- OD Take at Iftar. ACEs & ARBs OD - Monitor for postural Take after Ishaa praying

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

Insulins* Rapid- or short-acting Take normal dose at Iftar

and diltiazem effect of the drug 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 on Reduce Suhoor dose by 25–50% Premixed insulin OD Take normal dose at Iftar

Hypertension hypotension e.g. dizziness 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 Diabetes 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 Antiplatelet e.g. BID After Iftar and Suhoor last meal and 30 minutes before the thyroid next meal. ticagrelor Interval between doses should not be less than 8 hours Hyper- Methimazole OD Take with main Iftar meal or Suhoor Contrast media after Increase risk of contrast induced Advise not to fast BID Take with main Iftar meal and Suhoor 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; Disease 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 - All above recommendations are based on the available literature and are subjected to physician approval. Coronary Artery Isosorbide dinitrate Option 2: Take after Iftar & Suhoor

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: Drug Information Center, Pharmacy Executive Office Dr. Mohamed Bashir, Consultant, disturbance Designed and edited by: Endocrinology department 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 Dr. Boulenouar Mesraoua, Sr. Consultant, Flecainide BID Take after Iftar and Suhoor Approved by: Neurology department Sotalol Interval between doses should not be Dr. Palli Valapila Abdulrouf, Assist. Director Dr. Abdelnasser Elzouki, Sr. Consultant, less than 8 hours Dr. Moza Al Hail, Executive Director HMC Pharmacy Arrhythmia Medicine department Oral electrolyte OD Preferred after Suhoor 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 significant dehydration and electrolyte Drug Information Center (DIC)

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

Heart Failure 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 II. Maintain and update shared drug information database Rivaroxaban OD Take after full Iftar meal Mrs. Yolande Hanssens, Co-Head of DIC III. Coordinate adverse drug reaction monitoring with Dr. Binny Thomas, DIC Coordinator Medication safety office Dabigatran BID - Might increase GI Take after full Iftar and Suhoor Mr. Shaban Mohammed, DI specialist IV. Support and review HMC formulary and guidelines disturbance with the Iftar dose Interval should be ≥ 8 hours Mr. Mahmoud Mohamed, DI pharmacist V. Support medical research center by reviewing research Mr. Haseebur Rahman Mohammed, DI pharmacist

disorders proposals Apixaban BID Take after full Iftar and Suhoor Ms. Dina Abushanab, DI pharmacist Coagulation Interval should be ≥ 8 hours VI. Support continuous education and training