Effects of Ramadan Fasting on Patients with Immune Thrombocytopenia (ITP) Receiving Eltrombopag
Authors: Yassin Mohamed A , Alasmar Aya , Chandra Prem , Ismail Omer , Nashwan Abdulqadir Jeprel , Sideeg Deena , Ghori Firdous , Hamad Anas , Ghasoub Rola 
Published: November 2020

Introduction:
The thrombopoietin receptor agonists (TPO-RA) such as eltrombopag (ELT) have, in recent years, changed immune thrombocytopenia (ITP) treatment, showing that there is both increased platelet destruction and suboptimal platelet production in ITP. ELT is an oral drug and studies have shown that absorption can be affected by meals. Thus, for optimum absorption, patients are counseled to take the ELT on empty stomach at least 1 hour before or 2 hours after a meal and at least 2 hours before and 4 hours after calcium containing meals. However, in the Muslim world, the holy month of Ramadan, where Muslims have to fast since dawn till sunset the scheduling of drug consumption can be affected.
Objective:
The aim of this study is to evaluate the effect of fasting on patients with ITP receiving Eltrombopag.
Methods:
A mixed design study was performed in which we retrospectively analyzed and interviewed all Muslim patients (n=29) who are 18 years and older in Qatar and fasted Ramadan while receiving Eltrombopag treatment between the years of 2015 and 2019 recording clinical and biological parameters and using a standardized patient form. Fasting status was confirmed by a telephone call to each patient. Patients' responses were retrospectively evaluated before, during and after Ramadan. A significant drop in platelets was defined by either drop in platelets to &lt; 30 000 /L or drop to ≥ half from baseline. Bleeding tendency was also evaluated as either no bleeding, minor cutaneuos and mucosal bleeding or life threatening bleeding involving major organs (i.e. central nervous system, gastrointestinal or genitourinary).
Results:
Twenty-nine patients were identified who matched our inclusion criteria for this study. Majority of which were Arabs (~83%) whereas the rest were of the sub-continent of India. Platelet responses were statistically significantly impacted (P-Valua: 0.005) by the fasting of the holy month of Ramadan, the mean platelet count before Ramadan was estimated at 87.78±67.75 while during Ramadan it dropped to 46.57±36.50. Wheras when compared Platelet beofr and after Ramadan showed insignificant difference (116.4±68.2 vs 132.9±91.3; P=0.389).
Only 10% (3 patients) of the patients fasting Ramadan experienced bleeding episodes. 1 of which experienced minor bleeding (ecchymosis) and 2 had major bleeding episodes during Ramadan (CNS and GU bleeds).
Conclusion:
ELT is generally well tolerated and effectively achieves target platelet counts in adult ITP patients. However, the absorption of ELT is highly effected by food consumption and thus it is critical to adhere to the instruction given on how ELT should be consumed on an empty stomach. As has been shown due to the mis-scheduling of ELT consumption during the holy month of Ramadan. Health care providers must pay more attention to this period and provide a better tailored plan for patients in order to prevent platelet drop and pouts of bleeding that patients might experience

Disclosures
No relevant conflicts of interest to declare.