Epilepsy & Behavior 111 (2020) 107117

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Epilepsy & Behavior

journal homepage: www.elsevier.com/locate/yebeh

Review

Managing epilepsy in Ramadan: Guidance for healthcare providers

and patients
Ammad Mahmood a, Hina Naz Abbasi a, Nazim Ghouri b, Ruzwan Mohammed c, John Paul Leach a,d,⁎
a
Department of Neurology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK
b
Department of Medicine, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK
c
SOLAS Foundation, 211 New City Road, Glasgow G4 9PA, UK
d
School of Medicine, Wolfson Medical School Building, University of Glasgow, Glasgow G12 8QQ, UK

a r t i c l e i n f o a b s t r a c t

Article history: Ramadan is a regularly recurring period of fasting that takes place in the ninth month of the Islamic calendar. For
Received 31 January 2020 this period, adult Muslims refrain from eating and drinking between dawn and sunset. The variation in summer
Revised 9 April 2020 daylight hours means that at temperate latitudes, fasting can last up to 20 h.
Accepted 11 April 2020
It is already recognized that epilepsy control can deteriorate during Ramadan, and this may be explained by
Available online xxxx
fasting-related changes to adherence to antiseizure drug regimes. This article provides specific advice to help
Keywords:
Muslim patients prepare for Ramadan and reduce chances of exacerbation in epilepsy. In addition to advice
Epilepsy around sleep hygiene, it explores the use of drugs or preparations of drugs that will demonstrate reduced varia-
Ramadan tion during periods of fasting.
Antiseizure drugs © 2020 Elsevier Inc. All rights reserved.
Fasting
Adherence

The worldwide prevalence of epilepsy is over 65 million with greater
prevalence in low-income countries where access to diagnosis and
management of epilepsy are limited [1]. Prevalence in the UK is approx-
imately 600,000 [2]. Specific prevalence of epilepsy among the global
Muslim population of 1.6 billion [3], 3.4 million in the UK [4], is not
known though the disease burden is likely significant given the high
prevalence in lower income countries where much of this population
reside. Among Western Muslim populations, factors such as inadequate
or delayed access to medical services for lower socioeconomic groups,
stigma surrounding epilepsy, consanguinity increasing genetic risk, in-
creased symptomatic causes of epilepsy among immigrants, and a
greater reliance on alternative or complementary therapies may all con-
tribute to challenges in the management of epilepsy [5].
Ramadan, the ninth month of the Islamic calendar, obliges adult
Muslims to refrain from eating, drinking, and conjugal relations from
dawn until sunset for up to 30 days consecutively. Muslims are accus-
tomed to a dramatic change of routine in this month involving an
early predawn meal (suhoor), a late postsunset meal (iftar), and daily
late-night prayers at the mosque or at home. The Islamic calendar shifts
by 11 days annually in relation to the Gregorian calendar. The variation
in summer daylight hours means that the fast can last up to 20 h in sum-
mer. Many Muslims see Ramadan as a time of heightened spiritual fer-
vor and community cohesion. Indeed, fasting is more likely to be
observed globally (93%) [6] and by Western Muslims (80% in USA) [7]
than other religious obligations.
Fasting in Ramadan presents a specific challenge for patients with
epilepsy. Studies [8,9] have demonstrated an increase in incidence of
seizures among patients with epilepsy during Ramadan. Relevant ad-
vice and recommendations for fasting with number of chronic health
conditions [10] are now available, such as in diabetes [11], with specific
advice pertaining to periods of long fasts [12] and activities with legal
implications such as driving [13]. Specific epilepsy advice is not readily
available. This article aimed to facilitate informed decision-making by
healthcare professionals working with Muslim patients during
Ramadhan.
1. Seizure risk during Ramadan
Various factors can contribute to increased seizure risk in Ramadan.
1.1. Medication regime changes

⁎ Corresponding author at: Department of Neurology, Institute of Neurological Sciences,
Queen Elizabeth University Hospital, Glasgow G51 4TF, UK.
E-mail addresses: Ammad.Mahmood@glasgow.ac.uk (A. Mahmood),
hina.abbasi@nhs.net (H.N. Abbasi), Nazim.Ghouri@glasgow.ac.uk (N. Ghouri),
ruzwan@isyllabus.org.uk (R. Mohammed), john.leach@glasgow.ac.uk (J.P. Leach).
Changes to antiseizure medication (ASM) regimens are commonly
required and may not always be led by the physician. Driven by their
zeal to participate in the religious customs, many Muslims with epilepsy
may take the risk of independently altering medication regimens [14].

https://doi.org/10.1016/j.yebeh.2020.107117
1525-5050/© 2020 Elsevier Inc. All rights reserved.
2 A. Mahmood et al. / Epilepsy & Behavior 111 (2020) 107117

Low risk High risk

•Normal MRI •Abnormal MRI
•Normal EEG •Abnormal EEG
•1 2 Seizures whole adult life •Frequent Seizures
•Maintained on single monotherapy •Maintained on combinaon medicaons
because of low seizure burden because of poorly controlled seizures in
•Moderate dose past
•Previous Status Epilepcus
•Comorbid condions like hypertension,
heart failure, malignancy, diabetes
•Elderly

Fig. 1. Risk stratification of patients with epilepsy and suitability of fasting in Ramadan.

Most often, this will result in default from usual twice daily (BD) dosing
in summer months, when all oral consumption is condensed into a short
period at night. Altering medication regimens in Ramadan is linked to a
higher risk of increases in seizure frequency [8,9]. Moreover, Muslim pa-
tients may avoid seeking the opinion of their healthcare professionals
because of an assumption that religious considerations will not be un-
derstood or validated [15]. Physicians also may feel ill equipped to pro-
vide culturally sensitive advice and may rely on preconceptions of the
patient's views rather than exploring the reasons for poor adherence
to medication [15].
1.2. Sleep disturbance
Participation in Ramadan can involve a significant change to rou-
tines and sleep patterns. Fasting Muslims will waken early for a pre-
dawn meal before the fast commences. Working hours may be
adjusted to account for this in Muslim majority countries, but this is
rarer in non-Muslim majority countries. Sleep disruption and fatigue
are well-recognized seizure triggers [16], and sleep structure is theoret-
ically aggravated further during periods of fasting, causing delayed sleep
onset and impaired rapid eye movement (REM) [17]. These changes
have been attributed to the changes in lifestyle rather than an innate ef-
fect of fasting itself [18]. Adequate advice around obtaining enough
sleep or adjusting sleeping patterns to incorporate daytime sleep should
be provided.
1.3. Metabolic changes
Dehydration and hypoglycemia may be concerns in periods of hot
weather or long fasts. Particular attention may need to be given to pa-
tients taking topiramate because of compounded risk of nephrolithiasis.
There are theoretical beneficial effects of fasting on seizure control. Re-
search suggests that severe restriction of daily carbohydrate consump-
tion (b 50 g/day) can induce significant ketosis after several days [19].
While Ramadan fasting in summer in temperate climates could theoret-
ically mimic this, which may help reduce seizure frequency, this has to
be balanced with the risk of dehydration from cumulative daily religious
fasting if fluid intake has been inadequate. Additionally, animal studies
of intermittent fasting have demonstrated enhanced neurotransmission
of inhibitory γ-aminobutyric acid (GABA) raising the possibility of a
protective effect [20].
2. Identifying at-risk patients
In preparation for Ramadan, it is vital that patients and their doctors
are able to form a plan for managing their seizure disorder and ASM re-
gimes. We have suggested a stratification of patients into high- or low-
risk depending on the tendency toward experiencing severe or
prolonged seizures. In general, fasting will be safe for most people
with epilepsy if they follow medical advice. Fig. 1 above provides gen-
eral guidance on risk stratifying patients and advice on fasting status;

Table 1
Antiepileptic drug (AED) attributes to consider in Ramadan prescribing.
Adapted from ‘Choosing antiepileptic drugs’ Doyle, Alick [21] and ‘Drug withdrawal in the epilepsy monitoring
unit – The Patsalos table’ Kirby et al. [22].

Medicaon name Typical maintenance dose Half-life (h) Method of clearance

Pregabalin 200–600 mg in 2–3 divided doses 5–7 Renal
Leveracetam 750–1500 mg BD or OD if MR 6–8 Renal
Lacosamide 100–200 mg BD 13 Renal
Carbamazepine Up to 2.4g/day, TDS if IR, BD if MR 8–20 Hepac
Clobazam 20 mg in 2 divided doses 36–42 Hepac
Topiramate 125–200 mg in 2 divided doses 20–30 Hepac + renal
Lamotrigine 75–200 mg BD or OD if MR 15–35 Hepac
Sodium valproate 60 mg/kg/day, BD/TDS if IR, OD if 12–16 Hepac
MR
Clonazepam Up to 4–8 mg OD if stable dose 17–56 Hepac
Eslicarbazepine 800–1600 mg OD 20–24 Renal
Zonisamide 400–600 mg OD 50–70 Renal
Phenytoin 200–500 mg, OD or 2 divided doses 30–100 Hepac
Perampanel 4–12 mg OD 51–129 Hepac

ASMs suitable for once daily dosing are highlighted in dark blue. OD = once daily. BD = twice daily. IR = imme-
diate release. MR = modified release.
 A. Mahmood et al. / Epilepsy & Behavior 111 (2020) 107117 3

Table 2 less than 6 h apart may not be advisable. In such cases, medications
Options for those exempted from fasting due to illness. with longer half-lives (e.g., perampanel, eslicarbazepine,
Circumstance Example in epilepsy Resolution zonisamide, and clonazepam) which can be given once daily (OD)
Acute monophasic Single seizure in an otherwise Fasts made up at a later
may be more suitable. It may be possible to prescribe shorter half-
illness low-risk well-controlled date once recovered life medications OD at a higher dose, preferably if modified release
epilepsy preparations are used such as with levetiracetam, lamotrigine, or
Longer fasts are high ASMs must be maintained in a Fasts are made up at topiramate. Again, this is dependent upon factors such as side effects
risk but shorter fasts regime necessitating doses another time of year
and nature of seizures. Patients receiving renally excreted medica-
are feasible during the fast
No safe option for High-risk patient on multiple Charitable donations tions such as levetiracetam, lacosamide, zonisamide, and topiramate
future fasting ASMs termed ‘fidyah’ take the should be counseled about the pharmacokinetic risks of dehydration,
place of fasting as well as an increased risk of nephrolithiasis with topiramate.
Table 1 highlights attributes of ASMs which can aid in decision-mak-
ing around prescribing in Ramadan.
patients should be considered on an individualized basis. We would rec-
ommend that people hoping to fast in Ramadan would consult with
their treating physician or epilepsy specialist nurse at least 3 months 4. Islamic rulings regarding Ramadhan and exemptions from fasting
prior to the commencement of Ramadan.
A degree of difficulty as a means of encouraging virtues such as pa-
3. Medications tience is expected in Ramadan for those partaking in it. However,
there is preemption of potential harm to health and well-being and ex-
Attributes of specific ASMs such as half-life, adverse effects, and emptions or alternatives in place of the usual rituals where there is a risk
method of clearance will affect their suitability for use in patients of harm. Exceptions to the obligation of fasting exist for the elderly, trav-
fasting during Ramadan. These considerations should be made in ellers, pregnant women where there is a known or potential risk to
light of the time of year – fasts can vary widely in duration in temper- mother or fetus, and those with significant mental health illness [23].
ate climates. Commonly prescribed ASMs such as lamotrigine, leveti- Those with preexisting or current illness exacerbated by fasting are per-
racetam, and carbamazepine require BD dosing which can be mitted to not fast. Such judgments may be based on previous experi-
difficult to implement in summer months when nights are especially ence of illness or the opinion of a qualified physician in conjunction
short. It may be possible to extend the interval between doses to with one with knowledge of the relevant religious rulings. If an individ-
comply with fasting but maintain BD dosing. The minimum accept- ual is deemed at risk of harm from fasting as per the criteria laid out in
able time period in between doses will vary depending on the med- Fig. 1, this exempts them from the obligation to fast. It should be noted,
ication, side effect profile, and nature of seizure disorder, but dosing however, that seizure disorders which present no threat to quality of life

Fig. 2. Decision-making aid.

4 A. Mahmood et al. / Epilepsy & Behavior 111 (2020) 107117
such as focal seizures with no impairment of awareness would not be
considered a sufficient threat to life or well-being.
Consideration should also be given to the potential impact of sei-
zures or medication changes on driving status. Breakthrough seizures
or medication substitutions/reductions would result in revocation of
driving privileges in the UK for patients with group 1 licenses [24]. Sub-
sequent impact on patients' ability to continue employment or on public
safety should be carefully considered when judging an individual's suit-
ability for fasting.
Those exempted from fasting at a particular time point have several
options dependent on their circumstances summarized in Table 2 [13].
Although some routes of administration of medicines may be per-
mitted during the fast by Islamic scholars, all agree that oral administra-
tion of medicines is not consistent with the fast [14,23].
It should be recognized that there is a breadth of opinion on a variety
of issues, and healthcare providers may encounter Muslims with differ-
ing viewpoints on these. Furthermore, Muslim patients may not have an
indepth knowledge of some of the concepts discussed above. A
layperson's level of familiarity may be present, both of the medical
and religious issues at hand. A significant number of people who have
been advised not to fast by their health care professional will still choose
to do so [25]. A more detailed exposition pertaining to the religious ob-
ligation of fasting and considerations in relation to health and illness has
been published elsewhere by authors of this review [13].
5. Decision-making in the clinic
Fig. 2 proposes a flowchart that can be used as a decision-making aid,
bringing together the issues to demonstrate potential approaches in the
clinic. Factors considered are the inherent seizure risk of the patient, the
length of the intended fast, and the patient's dosing regimen. Other fac-
tors may include occupation, driving status, risk of dehydration, and
sleep patterns. Pregnant women with epilepsy should likely be advised
not to fast unless the length of the fast is short and seizure risk is known
to be low.
The benefits of shared decision-making in the epilepsy clinic are
known [26] and are especially applicable in this case. Exploring individ-
ualized factors such as the importance of fasting to the individual, per-
sonal challenges around employment and sleep, concerns around
medication changes and side effects, and the impact of any break-
through seizures should all be considered. The potential for patients to
dismiss medical advice particularly if it is seen to be rigid and uncom-
promising is high. Education regarding the risks of poor compliance
with medication and increased seizure risk during Ramadan may be im-
portant in helping the patient make a balanced and informed decision
on whether to fast. Low- or moderate-risk patients who are aware of
the risks can be supported in their decision to fast with the necessary
medical and practical precautions in place. Conversely, high-risk pa-
tients who are determined to fast can be directed to seek further guid-
ance from reliable religious sources on the possibility of exemption
from fasting to protect life and well-being enshrined in Islamic law.
6. Conclusion
A large number of Muslims with epilepsy will choose to fast during
the month of Ramadan. Seizure risk is increased during periods of
fasting, and usual medication regimens often require alteration during
Ramadan. Specific advice relating to epilepsy and fasting for healthcare
professionals and patients is scarce. We propose stratifying patients by
low- and high-risk features based on nature of epilepsy and likelihood
of seizure recurrence. The possibility of exemption from fasting should
be discussed. Planned alteration of medication regimens may be possi-
ble, either switching to OD dosing or maintaining BD dosing with short-
ened gap between doses. Shared decision-making can help in
acknowledging the patient's medical and spiritual needs. Enhancing ed-
ucation among healthcare professionals and their Muslim patients is re-
quired. Further future research into seizure risk during fasting will allow
development of specific guidelines to direct clinical practice.
Declaration of competing interest
The authors declare that none of the authors of this paper have any
competing financial interests or personal relationships that they would
wish to declare.
References
[1] Thurman DJ, Beghi E, Begley CE, Berg AT, Buchhalter JR, Ding D, et al. Standards for
epidemiologic studies and surveillance of epilepsy. Epilepsia 2011;52(Suppl. 7):
2–26.
[2] What is epilepsy?|Epilepsy action. https://www.epilepsy.org.uk/info/what-is-
epilepsy; 2019.
[3] Center PR. World's Muslim population more widespread than you might think.
http://www.pewresearch.org/fact-tank/2017/01/31/worlds-muslim-population-
more-widespread-than-you-might-think/; 2019.
[4] Muslim population in the UK. Office for National Statistics; 2019. https://www.ons.
gov.uk/aboutus/transparencyandgovernance/freedomofinformationfoi/
muslimpopulationintheuk/.
[5] Bartolini E, Bell GS, Sander JW. Multicultural challenges in epilepsy. Epilepsy Behav
2011;20(3):428–34.
[6] Center PR. Most Muslims say they fast during Ramadan. http://www.pewresearch.
org/fact-tank/2013/07/09/global-median-of-93-of-muslims-say-they-fast-during-
ramadan/; 2019.
[7] Center PR. American Muslims' religious beliefs and practices. http://www.
pewforum.org/2017/07/26/religious-beliefs-and-practices/; 2019.
[8] Gomceli YB, Kutlu G, Cavdar L, Inan LE. Does the seizure frequency increase in Ram-
adan? Seizure 2008;17(8):671–6.
[9] Ashraf Abdou AEF, Allah Horya Sad, Elhakeem Naglaa Abd. Effect of Ramadan fasting
on seizure control in epileptic patients. http://n.neurology.org/content/84/14_
Supplement/P6.296; 2015.
[10] Beshyah Salem A, Ibrahim Wanis H, Deeb Asma, El-Ghul Ashraf M, Bel'eed Akkari
Khalid, Tawil Ashref A, et al. The year in ramadan fasting research (2017): a narra-
tive review. IJMBS 2018;10(2):39–53.
[11] Hassanein M, Al-Arouj M, Hamdy O, Bebakar WMW, Jabbar A, Al-Madani A, et al. Di-
abetes and Ramadan: practical guidelines. Diabetes Res Clin Pract 2017;126:303–16.
[12] Ghouri N, Gatrad R, Sattar N, Dhami S, Sheikh A. Summer-winter switching of the
Ramadan fasts in people with diabetes living in temperate regions. Diabet Med
2012;29(6):696–7.
[13] Ghouri N, Hussain S, Mohammed R, Beshyah SA, Chowdhury TA, Sattar N, et al. Di-
abetes, driving and fasting during Ramadan: the interplay between secular and reli-
gious law; 2018.
[14] Aadil N, Houti IE, Moussamih S. Drug intake during Ramadan. BMJ 2004:778–82.
[15] Mir G, Sheikh A. ‘Fasting and prayer don't concern the doctors … they don't even
know what it is’: communication, decision-making and perceived social relations
of Pakistani Muslim patients with long-term illnesses. http://dxdoiorg/101080/
13557851003624273; 2010.
[16] Nakken KO, Solaas MH, Kjeldsen MJ, Friis ML, Pellock JM, Corey LA. Which seizure-
precipitating factors do patients with epilepsy most frequently report? Epilepsy
Behav 2005;6(1):85–9.
[17] Roky R, Chapotot F, Hakkou F, Benchekroun MT, Buguet A. Sleep during Ramadan in-
termittent fasting. J Sleep Res 2001;10(4):319–27.
[18] Qasrawi SO, Pandi-Perumal SR, BaHammam AS. The effect of intermittent fasting
during Ramadan on sleep, sleepiness, cognitive function, and circadian rhythm.
Sleep Breath 2017;21(3):577–86.
[19] Pinckaers PJM, Churchward-Venne TA, Bailey D, van Loon LJC. Ketone bodies and ex-
ercise performance: the next magic bullet or merely hype? Sports Med 2017:
383–91.
[20] Liu Y, Cheng A, Li YJ, Yang Y, Kishimoto Y, Zhang S, et al. SIRT3 mediates hippocam-
pal synaptic adaptations to intermittent fasting and ameliorates deficits in APP mu-
tant mice. Nat Commun 2019.
[21] Doyle A, Alick S. Choosing antiepileptic drugs. Pract Neurol Oct 2018:41–5.
[22] Kirby J, Leach VM, Brockington A, Patsalos P, Reuber M, Leach JP. Drug withdrawal in
the epilepsy monitoring unit – the patsalos table. Seizure 2020;75:75–81.
[23] Al-Shurunbulali Al-I. Ascent to felicity. . 1st ed.London: White Thread Press; 2010.
[24] DVLA. Assessing fitness to drive: a guide for medical professionals. https://www.gov.
uk/guidance/assessing-fitness-to-drive-a-guide-for-medical-professionals; 2019.
[25] Babineaux SM, Toaima D, Boye KS, Zagar A, Tahbaz A, Jabbar A, et al. Multi-country
retrospective observational study of the management and outcomes of patients with
type 2 diabetes during Ramadan in 2010 (CREED). Diabet Med 2015;32(6):819–28.
[26] Pickrell WO, Elwyn G, Smith PEM. Shared decision-making in epilepsy management.
Epilepsy Behav 2015;47:78–82.