ORIGINAL ARTICLE

The Impact of Ramadan Fast on Patients With Gout George Habib, MD, MPH,*†‡ Samih Badarny, MD,†§ Maroun Khreish, MD,║ Fadi Khazin, MD,¶ Vivian Shehadeh, RD,# Geries Hakim, MD,** and Suheil Artul, MD†† Backgrounds: Ramadan fast is a religious custom in Islam. Increased serum uric acid level during this month had been reported in past studies of nongout patients. Objectives: The objective of this study was to assess the impact of Ramadan fast on patients with gout. Methods: All Moslem patients with gout from the registry of Nazareth Hospital, who intended to fast during Ramadan, were asked to participate in our study (group 1). Data regarding age, gender, income, education, duration of gout, meds, adherence to low-purine diet, and gouty attacks were documented. Age- and gender matched Moslem patients from the same registry, but who did not intend to fast during Ramadan, were asked to participate as a control group (group 2). Just prior to and at the end of Ramadan, blood for uric acid, creatinine, and urea levels were obtained as well as body mass index, from all the patients. During Ramadan, patients were monitored for gouty arthritis or renal calculi attacks, as well as low-purine diet and medicine adherence. Results: Twenty-one and 22 patients from groups 1 and 2, respectively, completed the study. Mean serum uric acid, urea, creatinine, and body mass index levels at the end of Ramadan fasts in group 1 patients were 8.11 mg/dL, 26.38 mmol/L, 0.87 mg/dL, and 31.0 kg/m2, respectively, as compared with 7.92 mg/dL (P = 0.707), 24.54 mmol/L (P = 0.769), 0.84 mg/dL (P = 0.180), and 30.5 kg/m2 (P = 0.907) respectively, obtained just prior to the fast. No significant change in any parameter was seen also in group 2 patients. There also was no significant change between the 2 groups in arthritis or renal calculi attacks and also in medication and low-purine diet adherence, during Ramadan. Conclusions: There was no risk for a significant increase in gouty arthritic/renal calculi attacks or serum uric acid in patients with gout during Ramadan fast. Key Words: Ramadan fast, gout, uric acid (J Clin Rheumatol 2014;20: 353–356)

R

amadan fast is an old tradition in Islamic faith. During this holy month, millions of Moslems all over the world fast from dawn until sunset with no food or fluid intake at all. Following fast break, eating and drinking are permitted until the dawn of the next day. It must be remembered that the holy month of Ramadan (lunar calendar) rotates during the Gregorian calendar, and sometimes it occurs in summer where the fast during hot weather, as seen in the Middle East, may be associated with dehydration.1

From the *Department of Medicine, Carmel Medical Center; and †Faculty of Medicine, Technion, Israel Institute of Technology, Haifa; and ‡Rheumatology Clinic, Nazareth Hospital, Nazareth; §Department of Neurology, ║Department of Medicine, Carmel Medical Center, and ¶Department of Orthopedics, Carmel Medical Center, Haifa; #Diet Unit, Carmel Medical Center; and Departments of **Orthopedics and ††Radiology, Nazareth Hospital, Nazareth, Bar-Ilan Medical School, Tzfat, Israel. The authors declare no conflict of interest. Correspondence: George Habib, MD, MPH, Department of Medicine, Carmel Medical Center, Haifa 34362, Israel. E-mail: [email protected]. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 1076-1608 DOI: 10.1097/RHU.0000000000000172

Hyperuricemia is the most important risk factor for the development of gout.2 There are many acquired causes for the rise of serum uric acid including environmental ones such as purinerich diet and dehydration.3,4 Many studies in the literature had shown a significant increase in serum uric acid during Ramadan fast.5–7 All of these studies were done either in normal people or in patients with diabetes. With the improvement of the standard of living during the years in many Islamic countries, relatively large quantities of food, especially meat, are consumed following fast break, and there are studies showing weight gain, rather than weight loss during Ramadan.8 Potentially, Ramadan fast could be a risk factor for the development of gouty attacks in patients with gout. There are no studies in the literature addressing the impact of Ramadan fast on patients with gout.

PATIENTS AND METHODS All Moslem patients from the registry of the rheumatology clinic at Nazareth Hospital with the diagnosis of gout9 and who intended to fast Ramadan were asked to participate in our study (group 1). Age- and gender matched group of patients with gout from the same registry but who did not intend to fast Ramadan were asked to participate as a control group (group 2). Demographics and clinical and laboratory parameters were documented including age, gender, income, years of study, duration of gout, date of last arthritic gouty attack, renal colic, arthritic gouty attacks during the previous year, adherence to low-purine diet, treatment with colchicine and dose, and treatment with allopurinol and dose. Adherence to low-purine diet was graded to 3 levels: grades 3, 2, and 1mean that greater than 70%, 40% to 70%, and less than 40%, respectively, of the patient intake of calorie was composed of low-purine diet, respectively. Just prior to the start of Ramadan (within 3 days), serum uric acid, serum creatinine, and blood urea in addition to body mass index (BMI) were obtained from all the patients at 9:00 AM. The same parameters were obtained again at the same time from all the patients who completed the study, during the last 2 days of Ramadan. The inclusion criteria included patients older than 18 years and patients able to sign a consent form. The exclusion criteria were as follows: patients who changed dose or started or stopped any medication that may affect the level of uric acid such as uricosuric agents, xanthine oxidase inhibitors, or diuretics, during the previous 3 months prior to the Ramadan fast. Also patients who changed their diet during the previous month prior to Ramadan fast and patients with renal failure were also excluded. Patients from both groups were given contact phone number of the first author in order to call immediately in case they develop arthritic attack or a clinical picture similar to renal colic. All the patients were also called by phone by the mid and end of Ramadan fast and asked about the number of tabs of allopurinol or colchicine they took during Ramadan and also other medicines such as diuretics that may affect uric acid and kidney function levels. They were also asked about adherence

JCR: Journal of Clinical Rheumatology • Volume 20, Number 7, October 2014

www.jclinrheum.com

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

353

JCR: Journal of Clinical Rheumatology • Volume 20, Number 7, October 2014

Habib et al

TABLE 1. Baseline Demographic, Clinical, and Laboratory Parameters of the Patients in Groups 1 and 2 Group 1

Group 2

P

20:1 52.5 ± 13.7, 32–82 20 (95) 9.7 ± .4, 0–16 9.7 ± 4.8, 0–18 13 (62) 1 (5) 7.7 ± 7.6, 0.6–17 3.0 ± 2.7, 0.3–30 1.9 ± 2.5, 0–8 2.05 ± 0.59, 1–3 11 (52) 0.75 ± 0.55, 0–1 17 (81) 194 ± 90, 100–300 0 (0)

21:1 49.8 ± 12.2, 34–80 18 (82) 10.2 ± 5.2, 2–15 8.8 ± 3.2, 0–16 11 (50) 0 (0) 6.8 ± 6.4, 0.8–16 4.2 ± 2.6, 0.4–24 1.6 ± 1.8, 0–6 2.14 ± 0.52, 1–3 14 (64) 0.80 ± 0.48, 0–1 16 (73) 176 ± 92, 50–300 1 (5)

0.999 0.602 0.606 0.246 0.072 0.454 >0.999 0.691 0.145 0.144 0.586 0.582 0.696 0.784 0.521 0.999

Parameter Gender, male:female, n Agea Married Years of studya Incomea,b CHF/HTN Diuretics Duration of gout, ya Time since last arthritic attack, moa No. arthritic attacks in last yeara Low-purine diet adherencea Patients with colchicine treatment Dose of colchicine, mga Patients with allopurinol treatment Dose of allopurinol, mga Patients with renal calculi a

Mean ± SD, range. Thousand new Israeli Shekel. CHF indicates congestive heart failure; HTN, hypertension. b

to low-purine diet during Ramadan fast. Patients who started any medication during Ramadan that could affect uric acid levels such as diuretics or could affect gout in general such as nonsteroidal anti-inflammatory drugs or steroids for reasons not related to gout would be excluded from further analysis. For statistical analysis, Mann-Whitney U and χ2/Fisher exact sign tests were used to compare between the continuous and categorical parameters, respectively, of both groups at baseline, during, and at the end of Ramadan fast (Tables 1 and 3). Wilcoxon signed rank test was used to compare the continuous parameters within each group prior to and at the end of fast (Tables 2 and 3). The study was approved by the local ethics committee of Nazareth Hospital, and all the patients had signed a consent form.

RESULTS Thirty-one Moslem patients with gout intended to fast Ramadan, and 25 of them were enrolled (qualified the criteria) (group 1). Similar number of age- and gender matched Moslem

patients with gout who did not intend to fast Ramadan was enrolled as a control group (group 2). Twenty-one patients from group 1 and 22 from group 2 completed the study. Those who did not complete the study were not available for repeated blood tests by the end of Ramadan. Ramadan fast started on July 10, 2013, and lasted for 30 days. Table 1 summarizes the demographic, clinical, and laboratory parameters of the 2 groups at enrollment. There was no significant difference in any parameter of either group. Table 2 summarizes the laboratory parameters of the 2 groups in addition to BMI levels. There was no significant change in serum uric acid, kidney functions, and BMI levels at the end of the fast compared with levels at baseline in either group. Table 3 summarizes the number of gouty arthritis or renal colic in patients from groups 1 and 2 and also purine diet, allopurinol, and colchicine adherence. There was no significant difference in any parameter between the 2 groups and also within each group during Ramadan compared with baseline. One

TABLE 2. Laboratory and BMI Parameters Just Prior and at the End of Ramadan in Groups 1 and 2 Parameter a

SUA, mg/dL Urea, mg/dLa Creatinine, mg/dLa BMI, kg/m2a SUA, mg/dLa Urea, mg/dLa Creatinine, mg/dLa BMI, kg/m2a

Group

Prior to Ramadan

At the End of Ramadan

P

1 1 1 1 2 2 2 2

7.92 ± 1.69, 4.7–10.5 24.54 ± 8.49, 11–38 0.84 ± 0.19, 0.58–1.3 30.5 ± 5.75, 23.9–49.4 7.6 ± 1.6, 5.0–9.1 22.2 ± 7.6, 10–35 0.82 ± 0.21, 0.5–1.4 29.8 ± 4.8, 24–44.8

8.11 ± 1.84, 4.8–10.9 26.38 ± 9.18, 12–38 0.87 ± 0.14, 0.64–1.07 31.0 ± 5.6, 25.4–48.5 7.4 ± 1.8, 4.6–9.2 23.6 ± 6.8, 11.34 0.84 ± 0.18, 0.52–1.34 30.2 ± 5.2, 23.9–45.2

0.707 0.769 0.180 0.907 0.594 0.615 0.486 0.717

a

Mean ± SD, range. SUA indicates serum uric acid.

354

www.jclinrheum.com

© 2014 Lippincott Williams & Wilkins

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

JCR: Journal of Clinical Rheumatology • Volume 20, Number 7, October 2014

Ramadan and Gout

TABLE 3. Diet and Medication Adherence for Gout, Gouty Arthritic, and Renal Calculi Attacks During Ramadan in Groups 1 and 2 Group 1

Group 2

P

2.05 ± 0.59, 1–3 1.89 ± 0.62, 1–3 0.827 0.75 ± 0.55, 0–1 0.73 ± 0.56, 0–1 0.934 194 ± 90, 100–300 182 ± 78, 100–300 0.528 1 0

2.14 ± 0.52, 1–3 2.12 ± 0.54, 1–3 0.871 0.80 ± 0.48, 0–1 0.82 ± 0.46, 0–1 0.855 176 ± 92, 50–300 168 ± 82, 50–300 0.621 0 0

0.586 0.551

Parameter a

Low-purine diet adherence prior to Ramadan Low-purine diet adherence during Ramadana P Colchicine dose prior to Ramadan, mga Colchicine dose during Ramadan, mga P Allopurinol dose prior to Ramadan, mga Allopurinol dose during Ramadan, mga P Gouty arthritic attacks Renal colic

0.557 0.396 0.921 0.824 0.999 0.999

a

Mean ± SD, range.

patient from group 1 had a gouty arthritic attack at the right ankle responding to nonsteroidal anti-inflammatory drugs. This patient had 4 gouty arthritic attacks during the previous year.

DISCUSSION The most important finding in our study is the lack of significant change in serum uric acid at the end of Ramadan fast compared with levels just prior to the fast in both groups 1 and 2 patients. The lack of change in kidney functions at the end of Ramadan fast supports the fact that there was no evidence of dehydration, an important component in the mechanism of serum uric acid rise during Ramadan. Usually, during Ramadan fast in Israel, many workers leave the work early for home, and also employers ease work conditions of the Moslem workers. Many of the studies that showed significant increase in serum uric acid during Ramadan came from Arab countries,6,7 where the weather conditions are harsher than in Israel, and the standard of living is lower. In such circumstances, people from Arab countries who fast Ramadan could have lost more fluids during daytime and had less rehydration after fast break. The lack of significant change in BMI and no significant change in adherence to low-purine diet and to allopurinol treatment had certainly contributed to the lack of significant change in serum uric acid during Ramadan fast. The second most important finding in our study is the lack of significant difference in the number of gouty arthritic attacks or renal calculi attacks during Ramadan fast (1 arthritic attack in group1 compared with none in group 2, P = 0.999). This fact is supported by our first conclusion of the lack of significant change in serum uric acid in our patients during Ramadan fast. This indicates that Ramadan fast by itself is not a risk factor for the development of gouty attacks. It seems that following fast break at sunset there was no significant or rapid increase in serum uric acid level in patients with gout. This could result from gradual ingestion of food, where usually people spend hours in such a social gathering of fast break, along with rehydration. Also, the preventive therapy for gout that these patients kept taking during Ramadan protected them from developing such attacks. As mentioned earlier, there are no data in the literature regarding the impact of Ramadan fast on patients with gout in terms of gouty attacks. So our study is a unique one in this sense, and patients with gout and no serious medical problems could fast the holy month of Ramadan without a significant risk for the development of gouty attacks or jeopardizing renal function. © 2014 Lippincott Williams & Wilkins

Regarding renal colic, there also was no difference between the 2 groups. This is probably associated with the lack of difference between the levels of uric acid and renal function at the end of Ramadan compared with those levels, respectively, just prior to the fast. There was 1 study in the literature about the risk of renal colic in general during Ramadan, and such a risk was not increased compared with the risk at regular time.10 Surprisingly, there was no significant change in the level of adherence to low-purine diet during Ramadan. This fact could be related to the availability of diverse food after fast break, enabling the patients to choose also or mainly from the food they were accustomed to. Also, women who usually prepare the food were familiar with the type of foods that their husbands or sons are accustomed to. These facts were also supported by the lack of significant change in serum uric acid and weight. In the literature, there are no data about adherence to low-purine diet during Ramadan fast. Because Ramadan fast lasts every day from dawn to sunset, medications at best can be taken twice a day. Because allopurinol is taken once a day and colchicine twice a day, there should be no problem with compliance of these 2 types of medication during Ramadan. In both groups 1 and 2, there was no significant difference in medication adherence, and at least for allopurinol it is supported by the lack of significant difference in serum uric acid at the end of Ramadan. As in diet, there are no data about adherence to preventive therapy for gout with either colchicine or allopurinol during Ramadan. One limitation of our study is the relatively small number of our patients. However, in the face of total lack of data in the literature on this topic, religious leaders and physicians could have a reference, when asked by patients with gout about the risk of fasting Ramadan. In any case, repeated studies are needed, hopefully with larger number of patients, to support or refute our results. REFERENCES 1. Bates GP, Miller VS, Joubert DM. Hydration status of expatriate manual workers during summer in the Middle East. Ann Occup Hyg. 2010;54: 137–143. 2. Punzi L, So A. Serum uric acid and gout: from the past to molecular biology. Curr Med Res Opin. 2013;29(suppl 3):3–8. 3. Choi HK, Liu S, Curhan G. Intake of purine-rich foods, protein, and dairy products and relationship to serum uric acid: the Third National Health and Nutrition Examination Survey. Arthritis Rheum. 2005;52:283–289.

www.jclinrheum.com

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

355

JCR: Journal of Clinical Rheumatology • Volume 20, Number 7, October 2014

Habib et al

4. Huang LL, Huang CT, Chen ML, et al. Effects of profuse sweating induced by exercise on urinary acid excretion in a hot environment. Chin J Physiol. 2010;53:254–261. 5. Gumaa KA, Mustafa KY, Mahmoud NA, et al. The effect of fasting in Ramadan. Serum uric acid and lipid concentration. Br J Nutr. 1978;40:573–581. 6. Schmahl FW, Metzler B. The health risk of occupational stress in Islamic industrial workers during the Ramadan fasting period. Pol J Occup Med Environ Health. 1991;4:219–228. 7. Al Khader AF, Abu Farsakh NA, Khatib SY, et al. The effects of Ramadan fasting on certain biochemical markers in normal

356

www.jclinrheum.com

subjects and in type 2 diabetic patients. Ann Saudi Med. 1994; 14:139–141. 8. Bakhotma BA. The puzzle of self-reported weight in a month of fasting (Ramadan) among a cohort of Saudi families in Jeddah, Western Saudi Arrabia. Nutr J. 2011;10:84. 9. Rakieh C, Conaghan PG. Diagnosis and treatment of gout in primary care. Practitioner. 2011;255:17–20. 10. Miladipour AH, Shakhsallim N, Parvin M, et al. Effect of Ramadan fasting on urinary risk factors for calculus formation. Iran J Kidney Dis. 2012;6:33–38.

© 2014 Lippincott Williams & Wilkins

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

The impact of Ramadan fast on patients with gout.

Ramadan fast is a religious custom in Islam. Increased serum uric acid level during this month had been reported in past studies of nongout patients...
177KB Sizes 1 Downloads 3 Views