FOR Muslims, the ninth month of the Hijri calendar, Ramadan, is a holy month because this is when the Qu’ran was originally revealed to the prophet Mohammed.
Every year during the holy month of Ramadan, Muslims fast from dawn until sunset. This fasting is one of the five pillars of Islam and all Muslims are expected to observe the fasting as long as they are medically well enough. If someone is too unwell, the Islamic Shariah allows for either partial fasting or for the person to abstain from fasting.
There are different interpretations of exactly when the fast should be broken (Iftar) until starting to fast again (Sehri or Suhoor). Some interpretations suggest that this year people will need to fast for 19-to-20 hours, leaving four-to-five hours when food, water and medicines can be taken, along with prayers and some sleep.
But how do we define who is well enough to fast? Where does a medical condition become serious enough that fasting would not be advised? What constitutes breaking the fast? Can someone use an inhaler and still be considered to be fasting? In this piece I hope to answer these and other related questions.
As a word of caution, I am not Muslim and do not claim to be any sort of expert in this area. I have developed my knowledge over the past 10 years working closely with patients and the wider communities around branches of Green Light Pharmacy. There may be points for debate and people who disagree with elements of this article. I welcome all feedback about it and am happy to learn and increase my own knowledge on this topic. I hope this can help other people who have a limited understanding of the issues around fasting in Ramadan and medicines’ correct and safe use or who would like to know more about it.
I have discussed these points with Muslim colleagues who have been working with Islamic scholars and the team from Written Medicine and Medical Information for Ethnic Minorities (MIEM) to produce videos in various languages such as English, Bengali, Urdu, Somali and Arabic. We hope these resources will help patients understand the issues themselves, especially where English is not their first language, and it may be useful to signpost interested people to the videos so they can reflect on the information and return to the pharmacy, their GP or someone for religious advice with further questions they may have.
In short, there is no simple answer and we cannot apply one set of fixed guidelines to every person, medication or disease. The Arabic word fiqh means understanding or interpretation and is used here because we need to adapt our advice to each individual. The Shariah, or Islamic law, needs to be interpreted in the correct way to meet the needs of the person you are speaking to and their circumstances. This isn’t normally taught in most schools of pharmacy
In deciding how best to proceed, we need to understand a patient’s health beliefs with regard to their condition(s) and treatment, their religious beliefs, and the cultural context of how these are put into practice. The latter may be influenced by family or local community interpretation. The interpretation for a medicine or disease may differ between separate people based on their circumstances and needs.
In healthcare, we have become accustomed to working in a multidisciplinary team. At the centre of discussions is the patient. Around the patient are various doctors, nurses, pharmacists, key workers, physiotherapists, and many others. Some people may be used to the idea of including social care in the multidisciplinary team. Increasingly, the spiritual and religious needs of a patient are recognised and so a representative of the person’s faith can form a part of this multidisciplinary team. This is especially the case when it comes to interpreting issues directly affected by faith, such as fasting during the month of Ramadan. In reality, it may not be easy to have a direct communication with a patient’s Imam but the pharmacy team can signpost a patient, much in the same way that we would signpost to a GP or dentist.
So, keeping the patient at the centre of this process, we first need to encourage discussion and planning. It can be tempting as a healthcare professional to think we know what is best for a patient and start telling them what to do. This won’t work. It’s important to recognise the patient’s underlying right to autonomy in that they can choose or refuse a course of treatment. A healthcare professional’s duty is to ensure that this decision is made with sufficient and accurate information so that it is an informed choice. And we must then respect that choice if it has been made with the correct context.
A medicines use review (MUR) can be an excellent forum to have this sort of discussion in pharmacy. The patient is contemplating changing the way they use their medicines during the month of Ramadan and so there is an important role to encourage a good understanding of this. Pharmacy is particularly useful because our expertise is so accessible. People don’t normally need to make an appointment and we’re experts on medicines and their use. The pharmacy team can make recommendations for changes to dose timings and sometimes even suggest an alternative medicine or formulation (switching to slow-release tablets or another medicine that only needs to be taken once daily).
There is consensus amongst a range of scholars that it is permitted to take medicines rather than fasting if a patient’s clinical condition would get worse through not taking medicines. This also applies to situations where fasting itself would harm a patient because their physical condition which may be influenced by advancing age or medical conditions. This year in particular, it may be wise for some people to avoid fasting because of the long period between Sehri and Iftar. Once the month of Ramadan occurs at a time of the solar calendar when the days are shorter, it may be suitable for some people to consider fasting again if their condition allows it.
There are several requirements of Muslims in preparation for Ramadan, not just fasting. If someone’s physical abilities are compromised it may be difficult to maintain the consistency and intensity required for proper worship.
Various groups within Islam agree that the health of a patient comes first for people with serious medical conditions and on long-term medication. Defining what is serious is not simple. We should encourage people to discuss their condition and medication with people including a GP, nurse, a local scholar and a pharmacist, along with the patient’s family, if appropriate. Severe heart disease or kidney disease may need a delicate balance of fluid and electrolytes that is not possible to maintain while fasting.
With acute conditions, for example an infection, there may be a need for urgent treatment that cannot wait until after Ramadan. Where possible, it makes sense to use a product that can be taken once daily or applied topically (if this is acceptable to the patient and clinically appropriate). Sometimes, the correct antibiotic may need more frequent dosing which would constitute breaking the fast. As a pharmacist, it is important to help the patient understand why it is important to take the medicine(s) and why the dosing needs to be spread evenly through the day. The patient may still refuse to use the treatment. If this is the case we must accept that, whilst being confident of having given adequate information to allow the patient to reach that decision.
If somebody’s medical condition is stable and it is possible to keep dosing within the hours of fasting (whilst maintaining adequate therapeutic levels of drug within the body) then this person is likely to be able to fast with little effect to their treatment or condition. If somebody’s condition worsens during fasting, it is generally considered acceptable to stop fasting.
With some medicines, it is dangerous for people to stop taking them suddenly. Certain cardiovascular medicines and anticonvulsants used to prevent epilepsy would fall into this category. The pharmacist’s knowledge of medicine safety and correct medicine use is key here.
Other medicines with once-daily dosing can just be taken after Iftar, as though the patient were in a different time zone and had shifted the dose timing appropriately. Many medicines for blood pressure, cholesterol, and depression fall into this category. It is useful to reassure the patient that they can make these changes in order to maintain clinical effectiveness whilst observing their fasting duties. It may be possible to find modified-release versions of medicines that can be prescribed to cover the month of Ramadan or it may be necessary to switch to a totally different medicine temporarily, if appropriate.
For some medications, timing around food is very important. Whether this is to ensure correct absorption of the dose or because the medicine has a direct action on metabolic processes like blood sugar levels, fasting would have an impact on this. Someone who needs insulin would need to consider very carefully if it is appropriate to fast. If they change the amount of food eaten, does the dose of insulin need to be altered as well? Some insulins are given once daily so can these be continued, taking into account dosage adjustments and quantity of food eaten? This is a complex area which requires careful discussion between the patient and their clinicians. It is useful to remind a patient that they can have this discussion.
Different schools of thought within Islam have different interpretations on what constitutes breaking a fast. For the most part, scholars are agreed that eye drops, ear drops, creams, ointments and certain types of injection are allowed during fasting. There are differences of opinion and understanding regarding inhalers, nasal sprays, suppositories, pessaries and patches: the person’s own beliefs and the interpretation within the branch of Islam they follow will affect what a patient is happy to use. Taking oral medicines such tablets, capsules, suspensions, and elixirs is generally considered as breaking the fast.
Occasionally people look to their family, community and other peers for advice. This advice is often useful and supportive but it’s important that nobody just copies what somebody else does in terms of fasting of medicines use. Each person potentially has a different set of circumstances which need separate consideration.
Encourage the patient to speak to their local scholar in combination with healthcare professionals in order to establish what the right decision would be for them.
General public health and lifestyle advice for people fasting during Ramadan.
Ramadan is a useful time to reinforce other messages around healthy living.
Many Muslims take the opportunity to look at stopping smoking or using other forms of tobacco, as well as trying to lose weight. Using this time of intense motivation can be very helpful as the patient is ready for this type of behaviour change.
Some of the foods traditionally consumed and prepared as part of breaking the fast can be unhealthy due to high sugar or fat content. It is worth reinforcing healthy advice around food preparation, portion size and the balance of nutrients.
Ramadan is a very important month for observant Muslims. There are some challenges related to health and medicines that mean not everyone can fast but there are equally plenty of people who, with no or minimal changes to their treatment, can fast in the same way as others with no medical conditions.
Each person’s situation needs to be assessed individually to balance clinical and religious factors. It is a good opportunity to check general understanding around healthy lifestyles, medicines taking, and a person’s medical conditions.
Alistair Murray is the clinical lead at Greenlight Pharmacy Group
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Acknowledgements and thanks
Ashraf Zaman, Lead Pharmacist at Green Light Pharmacy in Stepney for discussion and contributing some content.