Managing Parkinson's Disease During Ramadan

January 10, 2017

How to manage Muslim patients with Parkinson's disease (PD) during the month of Ramadan, when fasting is advocated between dawn and dusk — including abstinence from medications — is the subject of a new review paper.

In the paper, published online in JAMA Neurology on December 27, Philippe Damier, MD, Centre Hospitalier Universitaire Nantes, France, and Jasem Al-Hashel, MD, University of Kuwait, Al-Khaldiya, explain that depending on the season in which Ramadan occurs, the fasting period varies from 11 to 18 hours a day. This causes problems for patients with PD, most of whom use levodopa, a drug with a very short half-life, as their mainstay therapy.

They note that levodopa is dosed at least three times a day, and at the stage of motor fluctuation, the daily number of levodopa intakes can increase to be more than 10 in some patients. A delay in drug administration often leads to the reappearance of motor symptoms as well as nonmotor symptoms, such as pain, anxiety, depressive mood, sweating, or dyspnea.

In the most severe cases, the patient might be frozen, hardly able to move with generalized muscle rigidity, which can lead to dehydration, fever, and rhabdomyolysis. Finally, any sudden withdrawal of dopamine replacement drugs is associated with the risk for a life-threatening malignant hyperthermia syndrome.

The authors say that a patient at the early stage of the disease with a once-daily administration of antiparkinsonian medication should be able to follow the fasting period without major difficulties and risks.

Patients with mild to moderate fluctuations can also be managed if they are treated with a daily levodopa equivalent dosage lower than 300 mg and are able to tolerate dopamine agonists, which have a longer-duration effect, they suggest.

They advise switching such patients to an equivalent dosage of an extended-release dopamine agonist administered once daily or by transdermal patch. This can be supplemented with a controlled-release levodopa formulation with one intake at dawn before the fasting starts and one intake at dusk when the fast is broken.

They recommend starting the changes to treatment at least 2 weeks before Ramadan to leave room for any adjustments.

In more severe cases, they say treatment is difficult and presents a risk to the health of the patient. The patient should be reminded that the religious texts clearly state that patients with a chronic disease do not need to fast, they write. But if the patient still wants to fast, the same combination of extended-release dopamine agonist and levodopa formulations can be used as in milder patients. However, it is essential to progressively reduce the amount of dopamine replacement drug before Ramadan starts to prevent the risk for malignant hyperthermia, they warn.

They suggest that adding a once-daily monoamine oxidase B inhibitor dose during the nonfasting time could help by extending the symptomatic relief, and the use of amantadine might be useful in the case of dyskinesia.

After the Ramadan period, the antiparkinsonian treatment needs to be adjusted back gradually, the authors conclude.

They add that in the absence of specific studies on this topic, many questions remain about the best way to adapt Parkinson's treatment during Ramadan fasting and the effect of that period on the short-term and long-term control of the disease.

Dr Damier reports he has received lecture fees from Medtronic, Teva Pharmaceuticals, and Novartis. The other authors have disclosed no relevant financial relationships.

JAMA Neurol. Published online December 27, 2016. Abstract

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