Best Time for Levothyroxine Intake in Ramadan (THYRAM): Basrah Experience

Abstract

Background: Fasting the month of Ramadan should be achieved by every pubescent Muslim unless they have an excuse. Fasting involves complete abstinence of oral intake throughout daytime. Patients who have hypothyroidism usually require levothyroxine (L-thyroxine) replacement, which is typically given on an empty stomach away from meals. Taking L-thyroxine replacement without feeding is challenging during the nighttime of Ramadan, in addition to being prohibited during daytime.Objectives: This study aimed to determine the best time of L-thyroxine intake during Ramadan. Methods: Fifty patients who were taking L-thyroxine treatment for primary hypothyroidism were involved in this prospective study for three months including the fasting and pre-fasting months. The patients were divided into three groups with different times of L-thyroxine intake. In the group one (pre-iftar), the patients were asked to take L-thyroxine at the time of iftar (the sunset meal) but to delay any oral intake for at least 30 minutes. In the group two (post-iftar), the patients were asked to take L-thyroxine two hours after iftar. The patients in the last group (pre-suhoor) were asked not to eat in the last two hours before suhoor (the predawn meal) and to take L-thyroxine tablet one hour prior to suhoor.Results: When thyroid stimulating hormone (TSH) levels were compared before and after Ramadan, there were no significant differences neither within each group nor among all the study groups. Moreover, the frequencies of the TSH control after Ramadan showed no significant differences within each of the study groups (P = 0.18, 0.75, 1.0 for pre-suhoor, pre-iftar, and post-iftar respectively). Similarly, comparison among the groups of the study showed no significant differences regardless of whether the patients had controlled or uncontrolled TSH prior to Ramadan (P = 0.75 and 0.67, respectively). In the patients with controlled TSH before Ramadan, 8 out of 10 (pre-suhoor), 8 out of 12 (pre-iftar), and 4 out of 6 (post-iftar) maintained their control after Ramadan. While in the patients with uncontrolled TSH before Ramadan, 7 out of 10 (pre-suhoor), 6 out of 8 (pre-iftar), and 2 out of 4 (post-iftar) achieved controlled TSH after Ramadan.Conclusions: No significant differences in TSH control were observed in patients taking L-thyroxine at pre-iftar, post-iftar, or presuhoor time in Ramadan.

Preference, Adherence, and Maintenance of Euthyroidism Using 3 Different Regimens of Levothyroxine Intake during the Fasting Month of Ramadan

“…[14][15][16]. No recommendations exist for optimal L-T4 timing during the fasting month of Ramadan [17][18][19][20][21]. Only few studies explored the effect of fasting Ramadan on thyroid status in euthyroid and hypothyroid individuals [23][24][25].…”

“…The included patients range from 47 to 97 patients. Four studies had a prospective design, while the fifth study was a retrospective one [17][18][19][20][21].…”

“…The tested timings for L-T4 administration during Ramadan are as follows: 2 h after meal at bedtime [17], 2 h after meal and 30 min before the next meal [18], a comparison between 30 min before iftar versus 30 min before suhor [19], a comparison between 30 min before iftar versus 2 h after iftar versus 1 h before suhor after 1 h of empty stomach [20], and finally, a comparison between at iftar versus at suhor [21]. None of these regimens follow the principles of the ATA or ETA evidence-based recommendations.…”

“…None of these regimens follow the principles of the ATA or ETA evidence-based recommendations. We may conclude that the choice of these regimens or timings was based mainly on what is convenient, feasible, or accepted by the patients, rather than what is physiologic or recommended based on the available literature [17][18][19][20][21].…”

“…Based on these observations, both the American Thyroid Association (ATA) and the European Thyroid Association (ETA) recommend that L-T4 be taken after awakening from sleep -on empty stomach by defaultand 60 min before breakfast, or for those who have an early evening meal, at least 3-4 h after the last meal and before going to sleep [14][15][16]. Few studies with a limited number of patients have reported the effect of fasting during Ramadan on thyroid function in Muslim hypothyroid patients treated with L-T4 following L-T4 intake regimens that do not comply with the current recommendations by the ATA and ETA and do not guarantee optimal L-T4 absorption [17][18][19][20][21]. The present study aimed to evaluate preference, adherence, and maintenance -or attainment -of euthyroidism using 3 different regimens of administering L-T4, regimens that fulfill the 2 conditions recommended by the ATA: first, to take the L-T4 tablet at least 3-4 h after the last meal and second, to take the tablet 60 min before the next meal or beverages, during the holy month of Ramadan in fasting hypothyroid patients in Egypt.…”