Impact of Lifestyle Changes During Ramadan on Thyroid Function Tests in Hypothyroid Patients Taking Levothyroxine

El-Kaissi, Samer; Dajani, Ruba; John, Terrence J. Lee-St.; Santarina, Sherry Ann; Makia, Fiona; AlTakruri, Malak; Ahmed, Y. Abshir

doi:10.4158/ep-2019-0505

Cited by 11 publications

(18 citation statements)

References 14 publications

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“…In a secondary multivariable regression analysis, only baseline TSH was a predictor for loss of control during Ramadan, whereas age, sex, baseline fT4, levothyroxine dose, and interfering medications were not found to affect thyroid control in our cohort. This is in contrast to recent study from El-Kaissi et al who suggested that males and older adults are more prone to loss of control post-Ramadan ( 20 ). However, as also acknowledged by the authors, this retrospective study included only 10 male participants and yielded statistically insignificant results.…”

Section: Discussioncontrasting

confidence: 99%

Ramadan Fasting and Changes in Thyroid Function in Hypothyroidism: Identifying Patients at Risk

Alkaf

Siddiqui

Ali

et al. 2022

Thyroid

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Background: Ramadan fasting (RF) is associated with major changes in meal times. This can affect thyroxine absorption and thyroid function (TF) in patients with hypothyroidism. We aimed to examine the short- and long-term impact of RF on TF in patients with primary hypothyroidism on levothyroxine. Methods: TF tests in patients with primary hypothyroidism attending an endocrine center in the United Arab Emirates were retrospectively analyzed. The impact of RF on TF, namely serum thyrotropin (TSH) TSH, free thyroxine (fT4) and free triiodothyronine (fT3), was investigated in 481 patients within 3 months before Ramadan (BR), 1–2 weeks (PR1), and 3–6 months (PR2) post-Ramadan. Controlled TF was defined as TSH between 0.45 and 4.5 μIU/mL. Inadequate control was defined as TSH >4.5 μIU/mL. Loss of control was defined as having controlled TF at BR and inadequate control at PR1. Multivariable regression analyses were used to assess the association of baseline TSH, baseline levothyroxine dose, and medication use with loss of thyroid control in Ramadan. Results: TSH increased significantly from a median of 2.0 (0.8–3.7) μIU/mL at BR to 2.9 (1.4–5.6) μIU/mL at PR1 ( p < 0.001). This was accompanied by a fall in fT4 and fT3 at PR1 ( p < 0.001). 25.5% of patients with previously controlled TF at BR had deterioration in TF at PR1. Sixty-one percent of patients with previously uncontrolled TF at BR remained uncontrolled at PR1. Baseline TSH was significantly associated with loss of thyroid control in Ramadan with an odds ratio (95% confidence interval) of 1.5 (1.17–1.92) ( p < 0.001), whereas other variables, including medications known to affect levothyroxine absorption were not associated with loss of control. TSH, fT4, and fT3 levels returned to normal at PR2. Conclusions: RF can negatively affect TF of patients on levothyroxine replacement. Although this effect is modest and transitory in most patients, a significant minority exhibit more pronounced, and clinically relevant changes. The latter includes those with higher TSH BR, and a smaller group whose thyroid disease appears to be particularly affected by the mealtime and lifestyle changes of Ramadan.

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Section: Discussioncontrasting

confidence: 99%

Ramadan Fasting and Changes in Thyroid Function in Hypothyroidism: Identifying Patients at Risk

Alkaf

Siddiqui

Ali

et al. 2022

Thyroid

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“…Four published studies reported the impact of fasting Ramadan in previously well controlled hypothyroid patients with numbers of included patients ranging from 47 patients by Karoli et reported that 32% of their patients were dysthyroid after Ramadan, whereas only 20.2% of the patients in the present study were dysthyroid [13].…”

Section: Discussionmentioning

confidence: 62%

Impact of fasting on thyrotropin and thyroid status during Ramadan in 292 previously well controlled hypothyroid patients. IFTAR study

Elsherbiny

2022

Endocrine

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Purpose Fasting during Ramadan affects thyrotropin both in healthy subjects and hypothyroid patients on adequate levothyroxine replacement. Few studies have addressed this effect in hypothyroid patients with pre-Ramadan euthyroidism. This study aims to report the impact of fasting in a relatively large cohort. Methods This was a prospective study including hypothyroid patients who fasted Ramadan during the years 2018, 2019, and 2020 in Alexandria, Egypt. All patients were euthyroid. Patients chosen one of three levothyroxine regimens during Ramadan, regimen 1: 60 min before Iftar, regimen 2: 3–4 h after Iftar, 60 min before Suhor, regimen 3: before the start of next fast, 3–4 h after an early Suhor. Thyroid status was assessed in pre-Ramadan visit and reassessed in post-Ramadan visit within 6 weeks from the end of Ramadan. Results The study included 292 hypothyroid patients. Most patients were adherent, 249 patients (85.3%), one sixth of patients were non-adherent, 43 patients (14.7%). Post-Ramadan TSH was 2.13 ± 1.88 mIU/L versus 1.60 ± 0.96 mIU/L pre-Ramadan [P = 0.001]. Most patients were still euthyroid post-Ramadan, 233 patients (79.8%), while 59 patients (20.2%) were dysthyroid. Post-Ramadan TSH significantly correlated to pre-Ramadan TSH [P < 0.001]. Post-Ramadan TSH was significantly higher in non-adherent patients, 3.57 ± 3.11 mIU/L compared to adherent patients, 1.88 ± 1.44 mIU/L [P < 0.001]. Conclusion Fasting Ramadan in well controlled hypothyroid patients resulted in a significant increase in post-Ramadan TSH, yet 80% the patients remain euthyroid after Ramadan. Post-Ramadan TSH and euthyroidism are related to adherence and pre-Ramadan TSH.

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“…We have previously shown in a retrospective analysis [5] that plasma TSH increases post-Ramadan irrespective of levothyroxine administration time, and that the increase was greater in older patients and in males. However, in our current prospective study, the increase in plasma TSH in groups 2 and 3 were not related to age or gender.…”

Section: Discussionmentioning

confidence: 90%

“…The altered eating habits during Ramadan, in addition to time constraints during the nonfasting period, present a challenge for levothyroxine-treated patients and may lead to reduced compliance with the instructions of taking levothyroxine on an empty stomach and at least 30 min before eating and drinking, which in turn may lead to an increase in plasma thyroid-stimulating hormone (TSH) post-Ramadan, as demonstrated in a number of prospective studies [1][2][3][4] and by our group in a retrospective analysis [5]. However, it is unknown if the change in thyroid function in Ramadan is associated with worsening symptoms of hypothyroidism.…”

Section: Introductionmentioning

confidence: 99%

Levothyroxine Administration during Ramadan: A Prospective Randomized Controlled Trial

El-Kaissi¹,

AbdelWareth²,

Dajani³

et al. 2021

Eur Thyroid J

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Background and Aim: We have previously shown in a retrospective analysis that the plasma thyroid-stimulating hormone (TSH) rises significantly post-Ramadan in levothyroxine-treated hypothyroid patients, possibly as a result of lifestyle alterations and time restrictions during the nonfasting period from dusk until dawn. The aim of this study is to determine the best time to instruct patients to take levothyroxine during Ramadan so as to minimize changes in thyroid function tests during this period. Methods: In a randomized prospective design, hypothyroid patients taking levothyroxine were randomized to receive instructions to take levothyroxine at one of the following 3 times during Ramadan: (group 1) at dusk 30-min before Iftar meal, (group 2) 3 or more hours after Iftar meal, or (group 3) at dawn 30-min before Suhur meal. Thyroid function tests were performed within 3 months before Ramadan and within 6 weeks post-Ramadan. Data from patients with at least 1 blood test before or after Ramadan were analyzed using mixed-effects regression models. Results: Plasma TSH levels were available at one or more time points for 148 patients, group 1 (n = 50), group 2 (n = 46), and group 3 (n = 52). A statistically significant within-patient increase in plasma TSH was seen in patients at the 25th percentile pre-Ramadan in groups 2 and 3 (p values <0.001), but not in group 1. A statistically significant within-patient decrease in plasma TSH was found in patients at the 75th percentile in group 1 only. For patients at the 50th percentile pre-Ramadan, no statically significant within-patient changes were found, though descriptively, increases in plasma TSH were observed for groups 2 and 3, while a decrease was observed in group 1. Conclusions: Our data suggest that instructing patients to take levothyroxine at the time of breaking the fast 30 min before the Iftar meal minimizes unfavorable changes in plasma TSH post-Ramadan. In contrast, instructing patients to take levothyroxine 3 h post-Iftar or 30 min before Suhur led to a greater rise in post-Ramadan TSH.

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Impact of Lifestyle Changes During Ramadan on Thyroid Function Tests in Hypothyroid Patients Taking Levothyroxine

Cited by 11 publications

References 14 publications

Ramadan Fasting and Changes in Thyroid Function in Hypothyroidism: Identifying Patients at Risk

Ramadan Fasting and Changes in Thyroid Function in Hypothyroidism: Identifying Patients at Risk

Impact of fasting on thyrotropin and thyroid status during Ramadan in 292 previously well controlled hypothyroid patients. IFTAR study

Levothyroxine Administration during Ramadan: A Prospective Randomized Controlled Trial

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