CC BY-NC-ND 4.0 · Journal of Diabetes and Endocrine Practice 2023; 06(01): 017-024
DOI: 10.1055/s-0043-176327
Original Article

Thyroxine Replacement Therapy during Ramadan Fasting: Physicians' and Patients' Perceptions and Practices

1   Department of Medicine, Yas Clinic Khalifa City, Khalifa City, Abu Dhabi, United Arab Emirates
2   Department of Medicine, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates
3   Department of Medicine, Dubai Medical College for Girls, Dubai, United Arab Emirates
4   Imperial College London Diabetes Center, Abu Dhabi, United Arab Emirates
Anas S. Beshyah
5   Department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
Mahmoud M. Benbarka
5   Department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
Ibrahim H. Sherif
5   Department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
› Author Affiliations
Funding and Sponsorship None.


Objective Thyroxine (T4) therapy is taken on an empty stomach and no food is taken for a short period. During Ramadan fasting (RF), Muslim patients may face difficulties taking levothyroxine as recommended.

Materials and Methods We performed a mixed methods study of an online survey of 218 physicians to explore their perceptions and practices. Also, we interviewed a sample of 172 hypothyroid patients to establish their practices and source of information. Their median age was 46 (17–90) years; they had hypothyroidism for a median of 5 years and took a median thyroxine dose of 100 µg daily. Furthermore, we attempted to explore the effects of RF on available thyroid function tests.

Results Consultants were 58.4%, and the most represented specialty was endocrinology, 46.1%. Regarding the impact of RF on T4 therapy, 52.3% thought the RF was not clinically relevant in most patients on T4 replacement. However, 27.5% thought RF affects T4 replacement therapy in a clinically relevant manner. About 77.1% of respondents reported giving advice routinely to all patients on T4 replacement during RF. One hundred sixty-four respondents were split between recommending taking the medications with Iftar, Suhour, or other times. Most respondents (73.9%) do not repeat measurements of thyroid hormone levels after Ramadan unless needed during their scheduled clinic visit. On the other hand, 50.3% of the patients confirmed that their physician advised them to take their thyroxine during Ramadan, whereas 40.4% could not recall receiving any advice. About 59.9% of the patients took thyroxine with Iftar, 23.8% with Suhour, and 16.3% at different times. In those patients where thyroid function tests were available before and after RF, serum thyroid-stimulating hormone and serum-free T4 did not show a specific pattern in the group as a whole and with subgroups.

Conclusion There is variation in the advice that hypothyroid patients receive on taking thyroxine during Ramadan and in their practices. Further studies are needed to determine the best timing for thyroxine replacement.

Authors' Contributions

S.A.B. adapted the questionnaire and managed the online and patients survey. A.S.B. managed the data collection and analysis. All other authors reviewed the data and contributed to the data analysis and interpretation, drafting, and revising the manuscript and approving its final version.

Compliance with Ethical Principles

The physician survey was approved by the IRB of Sheikh Khalifa Medical City, and all physicians provided informed consent digitally before they could answer the survey questions. The patient section was conducted as a quality improvement exercise; patients provided informed verbal consent for their data to be included in the audit. All data were analyzed anonymously.

Publication History

Article published online:
03 March 2023

© 2023. Gulf Association of Endocrinology and Diabetes (GAED). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (

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