Document Detail

Thyroid diseases and Ramadan.
Jump to Full Text
MedLine Citation:
PMID:  22837909     Owner:  NLM     Status:  PubMed-not-MEDLINE    
In the month of Ramadan, patients with thyroid diseases, most of the time, do not need treatment adjustments and can fast safely without any health hazards. Patients with hypothyroidism taking thyroxine can take their tablets on an empty stomach at bedtime instead of half an hour before Sehr. Patients with hyperthyroidism, on methimazole/carbimazole can continue their dose in once or twice daily regimes, while those on propylthiouracil need to be switched. Hyperthyroid patients with severe symptoms should start treatment immediately and can avoid fast for few days after a consultation with their religious scholar.
Syed A Raza; Osama Ishtiaq; A G Unnikrishnan; A K Azad Khan; Jamal Ahmad; Mohammed A Ganie; Kishwar Azad; Manash Baruah; Md Faruque Pathan
Related Documents :
3794059 - The challenge of upper airway obstruction in pediatric intensive care.
2026239 - Quality assessment and predictors of survival in long-term domiciliary oxygen therapy. ...
2920079 - Tracheal obstruction presenting as new-onset wheezing.
823659 - Effect of long-term ionized air treatment on patients with bronchial asthma.
22837909 - Thyroid diseases and ramadan.
21564439 - Clinical significance of anaemia associated with prolactin-secreting pituitary tumours ...
9681609 - Identification of pathologic parathyroid glands in patients with primary hyperparathyro...
9036759 - Identification of the anaerobic threshold using double product in patients with coronar...
2511229 - Diamine oxidase plasma activities after treatment with heparin and jejunal morphometry ...
Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Indian journal of endocrinology and metabolism     Volume:  16     ISSN:  2230-9500     ISO Abbreviation:  Indian J Endocrinol Metab     Publication Date:  2012 Jul 
Date Detail:
Created Date:  2012-07-27     Completed Date:  2012-10-02     Revised Date:  2013-05-30    
Medline Journal Info:
Nlm Unique ID:  101555690     Medline TA:  Indian J Endocrinol Metab     Country:  India    
Other Details:
Languages:  eng     Pagination:  522-4     Citation Subset:  -    
Shaukhat Khanum Cancer Hospital and Research Center, Lahore, Pakistan.
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Indian J Endocrinol Metab
Journal ID (iso-abbrev): Indian J Endocrinol Metab
Journal ID (publisher-id): IJEM
ISSN: 2230-8210
ISSN: 2230-9500
Publisher: Medknow Publications & Media Pvt Ltd, India
Article Information
Copyright: © Indian Journal of Endocrinology and Metabolism
Print publication date: Season: Jul-Aug Year: 2012
Volume: 16 Issue: 4
First Page: 522 Last Page: 524
ID: 3401749
PubMed Id: 22837909
Publisher Id: IJEM-16-522
DOI: 10.4103/2230-8210.98001

Thyroid diseases and Ramadan
Syed A. Razaaff1
Osama Ishtiaq1
A. G. Unnikrishnan2
A. K. Azad Khan3
Jamal Ahmad4
Mohammed A. Ganie5
Kishwar Azad6
Manash Baruah7
Md Faruque Pathan6
Shaukhat Khanum Cancer Hospital and Research Center, Lahore, Pakistan
1Shifa International Hospital, Islamabad, Pakistan
2Department of Endocrinology, AIMS, Kochi, India
3President, Diabetic Association of Bangladesh, Bangladesh
4Rajiv Gandhi Centre for Diabetes and Endocrinology, J. N. Medical College, Aligarh Muslim University, Aligarh, India
5Department of Endocrinology, AIIMS, New Delhi, India
6BIRDEM and Ibrahim Medical College, Dhaka, Bangladesh
7Department of Endocrinology, Excel Hospitals, Guwahati, India
Correspondence: Corresponding Author: Syed A. Raza, Shaukhat Khanum Cancer Hospital and Research Center, Lahore, Pakistan. E-mail:


During the month of Ramadan, Muslims from all over the world abstain from food and fluid intake from dawn (Sehr) to sunset (Iftar) for 1 month. This prolonged fasting causes several minor metabolic and hormonal changes in the body.[1] which rarely cause any problem to a healthy individual. However, problems do arise in certain chronic diseases like diabetes mellitus, and thus, patients are advised to consult their physicians before planning to fast. In patients with thyroid diseases, so far there are minimal data suggesting any adjustment in the treatment during Ramadan. We have explored the available evidence and provide some guidelines in this regard.


In Ramadan, minimal changes are observed in the levels of T3, T4, and TSH in a normal person.[2] Few studies have shown that T4 decreases significantly during fasting in Ramadan in both genders, while TSH increases significantly in male subjects, although TSH and T4 levels stay within the normal ranges. There is a positive correlation between T4 changes and number of days of fasting in women. Most of these changes revert back to pre-Ramadan levels once fasting is over.[3, 4]

Options for thyroid hormone replacement and factors effecting absorption

Whether primary or secondary, thyroxine and its levo-isomer (levothyroxine) are the most widely available option for thyroid replacement. Thyroxine is taken usually orally (empty stomach) as recommended, as food/medications (cholestyramine resin, sucralphate, iron sulphate, calcium preparations, aluminum antacids, raloxifene, activated charcoal, various soya products, and food and herbal remedies) affect its absorption.[58] Also a fiber-enriched diet, the traditional South Asian diet, and coffee in early morning may also interfere with the absorption of levothyroxine.[9, 10] The amount absorbed decreases from 80% in the fasting state to 60% in the fed state.[11] So, when taken with food, the absorption of levothyroxine is incomplete, resulting in variable and higher TSH levels. Standard drug information resources recommend that levothyroxine should be taken half an hour before breakfast on an empty stomach, to prevent interference of its intestinal uptake by food or medication.[12] While taking thyroxine in between/with food might not be best, due to variable reasons,[13] taking it at bedtime is another option, as it has shown to have almost the same effect as when taken on an empty stomach.[14, 15]


During the month of Ramadan, changes in gastric motility (due to prolonged fasting), interference with heavy meals, possible alteration in the circadian rhythm and the effect of the deiodinase activity might alter the metabolism of the drug in the body. Based on the above information, it can be postulated that during Ramadan, the proper administration of thyroxine/levothyroxine is achieved if it is taken half an hour before Sehr. But most of the patients find it difficult to wake up that early and either miss the dose or take it with the meal. This problem can be easily managed, if levothyroxine is taken at bedtime, which too has an almost identical lowering effect (if not better) on TSH. The effect may be due to the better effect of factors such as gastric motility, heavy meals, circadian rhythms, and effect of deiodinase activity.[1619]


As people revert back to their usual routine/habits after Ramadan, it seems more logical to go back to their routine (as before Ramadan) after the Ramadan comes to an end. Based on our current knowledge of thyroid replacement regimens, it should not have any impact on the metabolic state of the individual.


There are essentially no data on the outcome of hyperthyroid patients during Ramadan. Warning signs in a newly diagnosed or untreated thyrotoxic patient include the development of polydipsia, dehydration, diarrhea, and tachycardia, which would further worsen in the case of prolonged fasting. Patients with mild symptoms of thyrotoxicosis usually have no trouble in fasting but, those with severe symptoms can land into troublesome dehydration and diarrhea. These patients can skip fasting for few days till their symptoms improve. Quran (the holy book of Muslims) has given clear exemption to the sick people from the fast during illness but they need to compensate for the missed days of Ramadan later. Patients can also be advised to discuss with a local religious scholar for such issues.

Early diagnosis and treatment of thyrotoxicosis is deemed an emergency. The use of thionamides like methimazole, carbimazole, and propylthiouracil (PTU) is effective in patients with hyperthyroidism. They are actively transported into the thyroid gland where they inhibit both the organification of iodine to tyrosine residues in thyroglobulin and the coupling of iodotyrosines.


Thyrotoxicosis includes hyperthyroidism (excessive hormone production by thyroid) as well as thyroiditis (inflammation of the thyroid gland). These two can be easily differentiated by a thyroid uptake study/thyroid scan. Approximately 5%–10% cases of thyrotoxicosis are due to thyroiditis. Differentiation is important as the treatment of these conditions could be entirely different. The mainstay of treatment for patients suffering from thyroiditis remains NSAIDs, steroids, or beta-blockers, and it remains a self-limiting condition. The management of this disorder during Ramadan depends on the severity of symptoms.

In the treatment of hyperthyroidism, thionamides are the used. Among thionamides, propylthiouracil has a limitation during Ramdan due to its required dosing of every 4–6 h. The other most commonly used antithyroid drug “methimazole” has a fairly long duration of action, and can be taken at any time of the day in a single or divided doses.[20] For that reason, in Ramadan, no treatment adjustment is needed in these patients and they can be monitored on the standard protocols. The carbimazole dose required to yield an equivalent dose of methimazole is approximately 40% higher. For example, a 10 or 20 mg dose of carbimazole yields roughly 6 and 15 mg of methimazole, respectively. This drug takes a week to show its maximum effect and thus it is added with beta-blockers for quick symptomatic control. Patients prefer to stay home and avoid frequent treatment adjustments. They can be followed easily after Ramadan. If the treating physician is considering alternate treatment options like radio-active iodine or surgery, these can be delayed till the completion of Ramadan for the said reasons.


Although there are essentially no data on the adjustment of treatment protocols of patients with thyroid diseases, we have proposed that hypothyroid patients can take their thyroxine at bedtime easily instead of half an hour before Sehr. For hyperthyroid patients, the preferred oral antithyroid treatment is methimazole, which can be taken once or twice daily in Ramadan easily. Patients with mild to moderate symptoms of hyperthyroidism can fast safely.


Source of Support: Nil

Conflict of Interest: None declared.

1. Ziaee V,Razaei M,Ahmadinejad Z,Shaikh H,Yousefi R,Yarmohammadi L,et al. The changes of metabolic profile and weight during Ramadan fastingSingapore Med JYear: 2006474091416645692
2. Mansi K,Masalmeh A. Impact of ramadan fasting on metabolism and on serum levels of some hormones among healthy Jordanian studentsJ Med SciYear: 2007775561
3. Ahmadinejad Z,Ziaee V,Rezaee M,Yarmohammadi L,Shaikh H,Bozorgi F,et al. The effect of ramadan fasting on thyroid hormone profile: A cohort studyPak J Biol SciYear: 2006919992002
4. Sajid KM,Akhtar M,Malik GQ. Ramadan fasting and thyroid hormone profileJ Pak Med AssocYear: 19914121361744968
5. Sherman SI,Tielens ET,Ladenson PW. Sucralfate causes malabsorption of L-thyroxineAm J MedYear: 19949653158017451
6. Singh N,Singh PN,Hershman JM. Effect of calcium carbonate on the absorption of levothyroxineJAMAYear: 20002832822510838651
7. Campbell NR,Hasinoff BB,Stalts H,Rao B,Wong NC. Ferrous sulfate reduces thyroxine efficacy in patients with hypothyroidismAnn Intern MedYear: 1992117101031443969
8. Siraj ES,Gupta MK,Reddy SS. Raloxifene causing malabsorption of levothyroxineArch Intern MedYear: 200316313677012796075
9. Liel Y,Harman-Boehm I,Shany S. Evidence for a clinically important adverse effect of fiber-enriched diet on the bioavailability of levothyroxine in adult hypo- thyroid patientsJ Clin Endocrinol MetabYear: 19968185778636317
10. Benvenga S,Bartolone L,Pappalardo MA,Russo A,Lapa D,Giorgianni G,et al. Altered intestinal absorption of L-thyroxine caused by coffeeThyroidYear: 20081829330118341376
11. Fish LH,Schwartz HL,Cavanaugh J,Steffes MW,Bantle JP,Oppenheimer JH. Replacement dose, metabolism, and bioavailability of Levothyroxine in the treatment of hypothyroidismN Engl J MedYear: 1987316764703821822
12. Bach-Huynh TG,Nayak B,Loh J,Soldin S,Jonklaas J. Timing of levothyroxine administration affects serum thyrotropin concentrationJ Clin Endocrinol MetabYear: 20099439051219584184
13. Huynh TG,Nayak B,Loh J,Soldin S,Jonklaas J. Timing of levothyroxine administration affects serum thyrotropin concentrationJ Clin Endocrinol MetabYear: 20099439051219584184
14. Bolk N,Visser TJ,Kalsbeek A,van Domburg RT,Berghout A. Effects of evening vs morning thyroxine ingestion on serum thyroid hormone profiles in hypothyroid patientsClin Endocrinol (Oxf)Year: 20076643817201800
15. Rajput R,Chatterjee S,Rajput M. Can levothyroxine be taken as evening dose? Comparative evaluation of morning versus evening dose of levothyroxine in treatment of hypothyroidismJ Thyroid ResYear: 2011201150523921785690
16. Wilson P,Perdikis G,Hinder RA,Redmond EJ,Anselmino M,Quigley EM. Prolonged ambulatory antroduodenal manometry in humansAm J GastroenterolYear: 1994891489958079926
17. Hays MT. Localization of human thyroxine absorptionThyroidYear: 1991124181824339
18. Stone E,Leiter LA,Lambert JR,Silverberg JD,Jeejeebhoy KN,Burrow GN. L-thyroxin absorption in patients with short bowelJ Clin Endocrinol MetabYear: 198459139416725518
19. Keck ES,Wolf CF,Pfeiffer EF. The influence of circulating thyroxine serum concentration on hepatic thyroxine deiodinating activity in ratsExp Clin EndocrinolYear: 199096269772083567
20. Okamura Y,Shigemasa C,Tatsuhara T. Pharmacokinetics of methimazole in normal subjects and hyperthyroid patientsEndocrinol JpnYear: 198633605153830069

Article Categories:
  • South Asian Guidelines for Management of Endocrine Disorders in Ramadan

Keywords: Hyperthyroidism, hypothyroidism, Ramadan, thyroid disease.

Previous Document:  Guidelines regarding management of adrenal insufficiency in the Holy month of Ramadan.
Next Document:  South Asian Consensus Guideline: Use of GLP-1 analogue therapy in diabetes during Ramadan.