Thread by @muddasir_ayazMD

MEGA 🧵‼️

#Ramadan and #IBD: Should folks with IBD fast?

This one is a 5-part tweetorial because it deserves due diligence

A data desert 🌵 so I’ll do my best & apologies in advance for what I forget or omit

Let’s dive in! @southasianIBD @ibdtweets @ibddoctor

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One way to try and understand the relationship between Ramadan fasting & IBD is by subgroups:

1️⃣ patients with IBD in remission
2️⃣ hospitalized with active disease
3️⃣ undifferentiated IBD patients
4️⃣ animal models of fasting & IBD
5️⃣ extrapolations from rheumatology

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1️⃣ #IBD PATIENTS IN REMISSION

⬇️

Available data from 🇮🇷 suggests
🥁🥁🥁

this group is NOT at risk of ⬆️ symptom burden while fasting ‼️🤷🏽

shorturl.at/GSU48

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1️⃣ cohort study over 2 years published in 2008
✴️ pre- and post- ☪️
✴️all pts allowed to fast as they saw fit
✴️immunomods and steroid use was ok ✅

Excluded:
⛔️history of perf
⛔️ comorbidity (🫘, 🫀, DMII)
⛔️ mod to severe dz at induction 🧐

Outcomes: quality of life
4/

1️⃣ authors followed 60 patients over the month
✴️ CDAI lower after fasting
✴️majority of those who fasted were < 40 yo
⛔️no objective endpoints

Conclusion? “IBD patients who insist on fasting who are in remission and on maintenance therapy with no comorbidities may fast”

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1️⃣ caveats

✅ provides some data that the psychosocial disease component improves with fasting in self-selecting group

⛔️patients were not on biologics
⛔️ how much can this group be extrapolated? Hard to know

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2️⃣ HOSPITALIZED #IBD PATIENTS

✴️ a lack of benefit from this 🇰🇷 study looking at effect of fasting while admitted
⛔️ fasting period not defined
⛔️ not reflective of Ramadan fasting (💧permitted)

➡️No difference in Mayo Score, symptoms 🧐

shorturl.at/hnoCL
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2️⃣ study concludes that during flares, fasting does not offer benefit but harm signal is unclear

no ⬆️ risk of harm in short term however this did not look at prolonged fasting so hard to extrapolate to Ramadan fasting

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3️⃣ EFFECT OF RAMADAN ON OBJECTIVE #IBD MARKERS OF INFLAMMATION

‼️‼️ MOST important study in the series from 🇪🇬 measured all comers with IBD pre/post ☪️ fasting with stable disease to look at changes in objective measurements of inflammation

shorturl.at/orAC4

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3️⃣
➕ 80 patients with IBD
➕fecal calprotectin and CRP used as objective marker of activity
➕includes patients on biologics!

Exclusion criteria:
⛔️history of perf
⛔️ comorbidity (🫘, 🫀, DMII)
⛔️previous harms noted from fasting

Duration of fast: 15 hr/day‼️

10/

3️⃣ results
✴️ 50% of enrolled patients on biologics
✴️ Calprotectin ⬆️ in fasting patients but not statistically significant (163 v. 218)
✴️ 2/80 patients self discontinued fasting
✴️ no major difference in CRP (0.53 v 0.50)
✴️ Mayo score ⬆️ 1.7 v 2.3

11/

3️⃣ results continued:
Slight increases in Mayo score and while it seems statistically significant, I’m not sure that there’s clinical significance in such small changes 🤷🏽

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3️⃣
Subgroup analysis shows calprotectin ⬆️ in:
🔥older patients (>65)
🔥patients with higher calprotectin to start with

No data on if fasting alone could explain ⬆️ in calpro (never been studied AFAIK)

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3️⃣ THE CHALLENGES
Here’s the problem:
This is the ONLY available data (published in English) looking at objective measurement of disease activity in IBD patients who fast during Ramadan - its not enough data to make sufficient recommendations but it’s ALL we have

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4️⃣ THE MOUSE 🐁 MODELS 🤷🏽

there’s a mouse model that shows that fasting ⬇️ inflammatory markers

shorturl.at/estKS

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4️⃣ THE 🐁 MODELS
There’s 3️⃣ on mice (here’s the other two, the first is ⬆️)

The argument is the same in all three papers: Fasting works in mice and might improve colitis so maybe fasting will help with flares in humans

shorturl.at/ipCPU

shorturl.at/klxA0

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4️⃣
I find the mouse models to be not very helpful on this topic but it’s there if you’re interested in reading it

Finally on to the last category

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5️⃣ EXTRAPOLATIONS FROM RHEUMATOLOGY
🧐Why did I include this part?
➡️safety data for new biologics in IBD often uses rheum data so the underlying autoimmune association can be useful to 👀

First, Ramadan fasting and Hidradenitis Suppurativa (HS)

shorturl.at/mD368

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5️⃣
55 patients with HS in maintenance phase (interestingly, patients with comorbid IBD were excluded) were examined pre/post ☪️ fasting
✴️most had a draining abscess prior to fasting
✴️ 41% on stelara or Humira
✴️ majority of patients were mild to moderate dz severity

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5️⃣
68% had ⬇️ in abscess formation and 38% with ⬇️ in fistula output, with most improvement in patients NOT on biologics
Conclusion: ☪️ fasting not detrimental in this group‼️

Second paper from 🇹🇳 found ⬇️ ESR in fasting RA patients

shorturl.at/hlsGL

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SUMMARY

Lots of caveats and data is VERY limited, but my take on it is

If people with mild to moderate #IBD in remission choose to fast, there is no evidence of harm

I would favor some form of noninvasive monitoring in these patients to guide decision making

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If you made it this far congratulations! #GITwitter lmk what you think! @IBDimmunology @ibdesis @IBD_Afzali @MondayNightIBD @QariYousef @DrMohdZein @AmerGastroAssn @ASGEendoscopy @AmCollegeGastro @SultanMahmoodMD @OmerShahabMD @laura_targownik @GI_Pearls @drkeithsiau

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@DCharabaty @mqkMD @IrisWangMD @DrMohdZein @ReezwanaCMD @RashidLui @RobertBechara @AsadurRahman87 @mtahirMD @helpatologist @BilalMohammadMD @nsenussiMD @AhmadBazarbashi @MarkPochapin @ibdgijami

(And for anyone keeping track that’s 7 papers read for ☪️ days #5-#11 😂)

FIN/