Drug intake during Ramadan
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7469.778 (Published 30 September 2004) Cite this as: BMJ 2004;329:778
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Dr Aadil and colleagues have provided a timely review of problems
faced by both Muslim patients and their doctors during the month of
fasting. However one gets the impression that most Muslim patients would
observe fasting irrespective of their illness.
Islam forbids any act that would be harmful to an individual. A person
who deliberately puts his health at risk by fasting against the advice of
his physician, contradicts this basic principle of Islam. Hence fasting
against doctor’s advice would contravene the basic principle of fasting.
For those who are unable to fast, Islam not only provides exemptions but
offers other alternatives.
Islamic scholars and Imams have a responsibility to educate patients
and communities. Doctors and nurses have a duty to point out the above
facts where their patient’s health may be at risk by fasting. Only in
circumstances where the patient intends to fast, despite clear warning
from their doctor, should advice be given to tailor therapy. Rearranging
the patient’s medications for fasting before a formal warning, will give
the wrong message and may encourage some patients to fast who should not
fast otherwise.
Competing interests:
None declared
Competing interests: No competing interests
Dr Aadil and colleagues very helpful review of the changes in drug
intake during Ramadan serves as a useful reminder to all health care
professionals looking after Muslim people during this time 1. An
interesting omission was the use of medication for both type 1 and type 2
diabetes during Ramadan. As a service looking after the largest
concentration of Muslim people in the UK, we are very much aware of the
major impact Ramadan can have on the management of diabetes, and have
developed a number of services aimed at supporting patients with diabetes
during Ramadan, including pre-Ramadan classes on diabetes management over
Ramadan, and a help-line for patients during Ramadan 2.
It should be emphasised to patients with diabetes that they are
exempt from fasting by almost all Muslim authorities. Nevertheless, in our
experience, most Muslim people with diabetes feel the spiritual need or
social pressure to fast, and surveys in our own department have shown that
many will ignore medical advice against fasting (unpublished data).
Changes to oral hypoglycaemic therapy during Ramadan are frequently
necessary. Whilst patients on metformin can frequently just omit their
lunchtime dose, care needs to be taken with sulphonylureas (SU) during
fasting. Avoidance of long acting SUs such as glibenclamide is necessary.
The dose of shorter acting SUs such as gliclazide, may have to be modified
during Ramadan, and we generally suggest halving the dose with the meal at
dawn, but continuing normal dose in the evening. Well controlled patients
on twice daily gliclazide may benefit from conversion to rapid acting
insulin secretagogues such as repaglinide or nateglinide. Patients on
insulin therapy should be strongly discouraged from fasting, but if
insistent, they should be offered support. Patients on twice daily mixed
insulin and reasonable glycaemic control should reduce the morning dose by
half, and continue the normal dose in the evening. Patients on basal bolus
regimens may be able to get away with just missing lunchtime insulin.
Of great importance is the advice to check blood tests frequently
during fasting. Some patients are under the misconception that blood
testing breaks the fast, and this myth should be strongly dispelled.
Management of diabetes over Ramadan is a challenge for patients and
health care professionals. With careful support and advice, along with
judicious changes in drug therapy, successful outcomes can be achieved.
Dr Tahseen A Chowdhury
Consultant in Diabetes
Dr David B Peterson
Consultant in Diabetes
Department of Diabetes and Metabolism
The Royal London Hospital
Whitechapel
London E1 1BB
E-mail:Tahseen.Chowdhury@bartsandthelondon.nhs.uk
References
1. Aadil N, Houti IE, Moussamih S. Drug intake during Ramadan. BMJ
2004; 329: 778-82
2. Chowdhury TA, Hussain HA, Hayes M. Models of good practice. An
education class on diabetes self-management during Ramadan. Practical
Diabetes 2003; 20: 306-7
Competing interests:
None declared
Competing interests: No competing interests
The people interviewed in this study did not consider that inserting
eye drops counted as breaking the fast. During a training course I ran
for bilingual health advocates in East London, I heard a story of a
patient with glaucoma who discontinued their eye drops during the hours of
daylight. The patient was said to have gone blind. Ironically, the drops
were available as a slow-release formulation.
As in any religion, there may be wide diversity in the individual
interpretation of prescribed rites and rituals. Whilst the patient in my
story may have been unusual, it surely does no harm to ask a person if
they PLAN to discontinue their 'topical' medication during a prolonged
fast, and be prepared to suggest alternatives if they do.
Competing interests:
None declared
Competing interests: No competing interests
Aadil et al observe that patients arbitrarily change intake times and
dosing for drugs without taking medical advice. Furthermore some people
with chronic diseases fast even though there is no religious imperative on
those who are sick to do so.
The British Heart Foundation (BHF) recognises that many Muslims who
are fasting are not seeking advice from their physicians and may endanger
their health. For this reason the BHF has started various programmes to
address this issue. In partnership with the Bradford University School of
Pharmacy we have been training mosque imams (priests) in prevention and
management of diabetes and coronary heart disease (CHD).
Imams have the potential to play a major role in disseminating
information as they hold a unique position of credibility in their local
communities. They are often approached for advice on personal and social
issues. During the month of Ramadan many more Muslims than usual visit
mosques for prayers and breaking their fasts and the potential of imams to
convey appropriate health messages is substantially increased. Such
messages can be tailored in terms of religious imperatives to look after
one’s health and the BHF’s initiatives have sought to highlight these.
Many Muslims use the month of Ramadan to make healthy changes to
their lifestyles. This is used by the BHF and partner organisations as an
opportunity to use relevant media in order to, for example, launch quit
smoking campaigns and to raise awareness of heart disease, its prevention
and management. Many first generation Asians only access ethnic language
media and we use them to hold discussion programmes and we invite scholars
and physicians to discuss these issues. We hope that with these programmes
we will be able to make a difference.
Of course the dialogue between patients and health service personnel
will be more meaningful if the latter are aware of the beliefs of their
patients. We also feel that there is a need to train physicians in the
cultural norms of minority communities, of whom there are a substantial
number in the UK (for example there are over 1.5 million Muslims).
In conclusion, it is clear there is a need for better awareness on
both sides – a need the BHF is striving to answer.
Competing interests:
None declared
Competing interests: No competing interests
EDITOR – Aadil et al approach some interesting ad important problems
which affect the healthcare community when patient adhering to Islam are
treated. The BMJ has traditionally given a lot of attention to the subject
and the problem is of increasing importance also in non-Islamic coutries,
e.g. Great Brittain with its large Pakistany/Indian population, France and
the Benelux countries with their rapidly increasing number of immigrants
from Northern Afrika and Germany with at least 3 millions of Turkish
people.
Besides cultural differences, missing knowledge about rules for
exeptions from fasting often the simple lack in the langauges of their
host-countries make cummunication between European physicians and Muslims
difficult. Furthermore, many Muslims understand illnesses differernt from
Europeans. Even if the Koran allows exemptions from fastig for patients
with acute or chronic illnesses, pregnancy, being on travel, etc it is
rather difficult to have access to food during daylight in an islamic
environment and the socio-cultural pressure to fast is increasing with a
more orthodox way of living. Many patients insist on fasting as it is one
of the main principles of Islam.
The authors state, that Ramadan can occur during all seasons, for the
comming years it will be 15.Oct – 13 Nov 2004, 05 Oct – 02. Nov 2005, 24.
Sept – 22 Oct 2006 and 13 Sept – 11 Oct.2007. As is clear vom these dates,
Radadan will be held each year two weeks earlier, for Europe in a few
years during summertime. This means, that the hours for food intake will
bekome shorter, the time of fasting will become longer and the climate
will be hotter. This is of great medical importance regarding dehydration
and it will affect in particular the elderly and females with a often low
intake of fluids, workers in the open, children and people with intensive
sport activities. It is known, that creatinine values rise significantly
during Ramadan1.
Another important aspect is the change in dietary patterns during
Ramadan. Unlike the fasting period of Christians before Eastern, where
food often is reduced in quantity and quality, and sweets and alcohol are
avoided, the food in the Muslim population is often better than outside
Ramadan, as it is a traditional habit, that the more wealthy relatives
invite the not so wealthy and the rich feed the poor. This results in an
increase of body weigt and BMI2.
Aadil and al discuss the need of larger and prospective studies, in
particular with respect to chronic deseases. Suprisingly, the have
forgotten to mention the lagest study on this topic3 and the consequences
for treatment during Ramadan. This prospective, randomised multicentre
study in 591 Moroccan diabetics over a period of three months could show
that the reversal of morning and evening doses, with the addition of any
midday dose to that taken in the evening is effective and the patients
diabetes remained as well controlled as that of patients who did not fast.
When we have data and know how it should be used, especially in a
review.
1 SH Chea, SL Ch’Ng, R Husain, MT Duncan. Effects of fasting during
Ramadan on urinary excretion in Malaysian Muslims. Br J Nutr 1990; 63: 329
-37
2 N Klöcker , J Belkhadir, H El Ghomari, A Mikou, M Naciri, M Sabri.
Ramadan and the influence of Body weight on metabolic parameters in
fasting NIDDM patient. Proceedings of the 1° International Congress on
Health and Ramadan, Casablanca 1994: 186-8
3 J Belkhadir J, H El Ghomari, N Klöcker, A Mikou, M Naciri, M
Sabri. Muslims with non-insulin dependent diabetes fasting during Ramadan:
treatment with glibenclamide. MBJ 1993, 307: 292-5
Competing interests:
None declared
Competing interests: No competing interests
This review highlights the importance of cultural understanding and
sensitivity when agreeing treatment plans with muslim patients, and of not
making assumptions about how muslim patients will or will not act in
relation to their medicines based on their religious conviction.
However, the issue of fasting during Ramadan is not the only one
which may have a bearing on culturally sensitive treatment for muslim
patients. Disregard for religious beliefs in relation to ingredients can
have a further important bearing on compliance with treatment, as
reflected, for example, in a UK study which found that 58% of British
Muslim patients indicated that they would stop taking prescribed
medications found to contain religiously prohibited ingredients (Bashir A,
Asif F, Lacey F, Marriorr J, Wilson K. Concordance in Muslim patients in
primary care Int J Pharm Pract 2001:9:R78).
Recent work carried out by a UK based expert group on this topic has
resulted in the publication in April 2004 of a BNF-sized booklet for
health professionals on drugs of porcine origin and their clinical
alternatives. The booklet not only provides a directory of drugs of
porcine origin and their alternatives, but also provides guidance on the
religious and cultural aspects of porcine derived products and explains
why and how patients of all faiths should be involved in decisions about
their medicines if the pitfalls of cultural misunderstanding are to be
avoided. It is available at http://www.medicines-partnership.org/our-
publications/drugs-of-porcine-origin
Competing interests:
None declared
Competing interests: No competing interests
In India, a large chunk of Muslim population observe fasting during
Ramadan. With the desire to appease their faith most people observe dusk
to dawn fast even if they are not in sound health. Physicians often try to
tailor the prescription to suit the convenience of the patient to help
them observe the fast which occasionally could be at the cost of optimum
control of the illness.
While any effort to make the treatment pattern to the patient's
convenience is appropriate, it is imperative that the physician puts the
patient's illness as well as his religious feelings in the right
perspective.
No religion insists on people who are ill to observe any type of
dietary restriction. Damaging one's own health in the name of religion is
damaging to the well-being of the family and consequently to society.
Therefore the physician should explain in clear terms the need to
take meals and medicines at proper times in the best interest of the
patient.
Competing interests:
None declared
Competing interests: No competing interests
An article by Aadil et al published in the recent issue of BMJ is
quite interesting and raises very practical issues.
I have faced similar problems in my practice during the months of
Ramadan in last several years while treating various skin problems. Two
conditions are worth mentioning where I have experienced a serious impact
in the patients' treatment.
One, while treating Herpes Zoster, a common drug used is Acyclovir
which needs to be given every five hours for atleast 5-7 days. The
schedule of this drug is highly unacceptable to most of the muslim
patients of mine. The alternative drug only recently available in the
Indian markets if Famciclovir, which needs to be given three times a day.
This drug also does not permit those patients fasting for Ramadan and do
not take anything by mouth from dawn to dusk. Consequently,there is
delayed recovery from the illness. Apart from the morbidity of the
disease,inadequate control of the neural inflammation might subject
especially the elderly population to a problem of post-herpetic neuralgia.
Not only that, inadequately spaced doses of the antiviral drug may run a
significant risk of drug resistance considering bioavailability of
acyclovir.
Second, while inducing remission in the cases of full-blown Pemphigus
Vulgaris, not an infrequent disease in the Asians. Here, we need to
administer the high doses of corticosteroids to suppress the
immunologically induced disease more frequently than could be given
avoiding the dusk-dawn pattern of the intake during the Ramadan months.
Thus it often leads to an inadequate control of the disease leading to
increased disease morbidity and may possibly invite complications of
disseminated infections through the denuded areas of skin lesions which
are good portal for bacterial sepsis.
Those patients who additionally have one or the other systemic
illness like hypertension, diabetes and acid peptic disease, such dosages
of drugs conforming the pattern of administration during the Ramadan month
may be additional burden on the patients for the fear of gastric
irritation due to polypharmacy for their original systemic disease plus
the skin illness.
Competing interests:
None declared
Competing interests: No competing interests
We believe that the BMJ has published a landmark paper. Every year
during the month of Ramadan, QUIT runs a major public health campaign
targeting some 1.6 million British Muslims on smoking and heart disease
through the ethnic media and the Imams (priests) of some 300 mosques.
In our experience, unpublished evaluation reports, this is the best
time to carry out a healthy lifestyle based campaign amongst the Muslim
communities in Britain as the civic mood and personal attitude of many
Muslims communities is ripe for behavioural change and health improvement.
Muslim Health Network, a voluntary organisation
(www.muslimhealthnetwork.org), has addressed the issue of patients on
medication by issuing the following caveat:
Through Koranic Verse, Hadiths (Sunna)and notable commentary made by
many Fiqhs (schools of law), the following are exempt from the obligation
of fasting:
1) Those who are ill-extended by modern scholars to include those on
medication and with mental health problems
2) Breast feeding mothers
3) People on a journey
Further, by using the portion of the verse 185 Surah 2 (Al Baqarah):
"Allah intends every facility for you; He does not want to put you in
difficulties.", we have supported patients in refraining from harming
themselves by adopting harsh and continuous fasting regimes.
We believe that it is important to understand and support the
patient's spiritual and physiological needs by advising and counselling
them in a culturally sensitive manner. This paper goes a long way to
establish the evidence base that we need to do this.
Competing interests:
None declared
Competing interests: No competing interests
Re: Physicians should put health in perspective during Ramadan
when the author wrote "most people observe dusk to dawn fast" I have
to assume this was a typographical error since it is the exact opposite
that the fast is from dawn to dusk.
Competing interests:
None declared
Competing interests: No competing interests