Effects of Ramadan Fasting in Patients with Chronic Myeloid Leukemia in Chronic Phase
Authors: Yassin Mohamed A , Ghasoub Rola S , Aldapt Mahmood B , Abdulla Mohammad Abdul-Jaber , Chandra Prem , Shwaylia Hawraa M , Nashwan Abdulqadir Jeprel , Kassem Nancy , Akiki Susanna Jane 
Published: November 2019

Background
Chronic myeloid leukemia (CML), is a clonal bone marrow stem cell disorder that accounts for 10% of all leukemias.
Generally, CML is one of the best examples of effective targeted therapy. Today, the overall survival of patients with CML treated by using tyrosine kinase inhibitors (TKIs) is very close to that of the healthy population. However, little is known about the effect of certain measures such as fasting especially during Ramadan period.
In Islam, Ramadan fasting represents one of the five pillars of creed and considered as a mandatory religious duty, although in some instances among which, patients are exempted from observing this duty. The day fasting hours in Ramadan varies according to the geographical location of countries from 11 to 22 hours.
To the best of our knowledge, this is the first quantatative study evaluating the effects of Ramadan fasting on patients with CML on TKIs.
Objectives
The main objective of this study was to evaluate the effect of fasting on CML patients receiving TKIs by evaluating their clinical course, hematological parameters, and BCR-ABL levels.
Patients & Methods
A retrospective study was conducted by reviewing medical records for adult Muslim patients with CML in the state of Qatar, who fasted Ramadan month during the period of 2016, 2017 and 2018, therefore we evaluated:
1) Complete Blood Count before, during, and after Ramadan.
2) BCR /ABL level before, during, and after Ramadan.
3) Any loss of hematological response or clinical evidence of disease progression like increase in spleen size during Ramadan.
Patients were retrospectively asked and confirmed that they're fasting during Ramadan period by a telephone call made by the study team.
Results
A total of 49 patients fulfilled the criteria of the study, with median age of 46 years (range from 22-86), of these 36 (73.5%) were males and 13 (26.5%) were females, with ratio of 2.8 : 1.
27 (55.1%) patients are middle eastern, while 16 (32.7%) patients came from the Indian subcontinent, and 6 (12.25) patients were black.
Multiple TKIs were used, imatinib was the most common TKI; used in 25 patients (51%), nilotinib in 15 patients (30.6%), dasatinib in 8 patients (16.3%) and ponatinib used only in one patient.
Repeated measure analysis of variance (ANOVA) statistical analysis showed that the mean White blood count, neutrophils and BCR-ABL was found to be reduced after Ramadan period compared to before and during Ramadan period, however their difference was statistically insignificant (P>0.05). Mean platelet, hemoglobin, basophils and eosinophils values appeared to have similar trend before, during and after Ramadan periods.
Unpaired t test revealed that the mean values of the most of the hematological parameters among male was found to be higher compared to females.
Age was found to be negatively correlated (low to moderate correlation) with all hematological parameters and BCR-ABL levels (Pearson correlation (r) ranges from -0.10 to -0.46).
Conclusion
TKIs use during fasting in Ramadan period is poorly studied with scarce data. The use of TKIs during fasting in Ramadan period did not result in significant changes in hematological indices nor in BCR-ABL levels in our study. Patients who wish to fast during Ramadan period may be reassured in this regard, yet physicians can adopt the safe trial approach, where they allow the patients to fast, but with instructions as when to break fasting. On the other hand, further research is needed to reach a definite conclusion.
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Disclosures
No relevant conflicts of interest to declare.