A multicenter mixed-methods study on the effects of intermittent fasting in patients with immune thrombocytopenia receiving thrombopoietin receptor agonists

IntroductionIn recent years, significant advances have been made in the treatment of immune thrombocytopenia (ITP) with the development of thrombopoietin receptor agonists (TPO-RAs). TPO-RAs are often used following the failure of prior therapies or when bleeding episodes persist despite glucocorticoid use. In Muslim countries, where religious observance includes 16/8 intermittent fasting, the timing of medication administration may be affected. This study is the first to evaluate the impact of Ramadan fasting on patients receiving different TPO-RAs.MethodsA multicenter mixed-design study was performed in which Muslim patients who fasted during Ramadan while receiving TPO-RAs were interviewed between 2015 and 2023. Patient responses before, during, and after Ramadan were evaluated retrospectively. The bleeding tendency was assessed as (1) no bleeding, (2) minor cutaneous/mucosal bleeding, or (3) severe bleeding that involves major organs.ResultsThe present study included 100 patients from three Muslim countries, including Qatar, Kuwait, and Saudi Arabia, across four tertiary centers. A complete response was observed in 63% of patients on ROM, 46% on ELT and 37% on AVA. For AVA, the mean platelet (PLT) count before Ramadan was estimated at [146.11 ± 111.76], while during Ramadan, it dropped to [131.7 ± 107.6]. For patients on ELT, the mean PLT count before Ramadan was estimated at [120.02 ± 59.7], while during Ramadan, it dropped to [100.8 ± 68.16] (p = 0.016). For patients on ROM, the mean platelet count before Ramadan was estimated at [122.68 ± 80.57], while during Ramadan, it was [130.94 ± 84.96]. Only 3% (3 patients on ELT) experienced bleeding episodes.ConclusionThis study supports the feasibility of Ramadan fasting for ITP patients receiving TPO-RAs. Further studies with a larger sample size are recommended to investigate the impact of other types of fasting on the efficacy and safety of TPO-RAs.