Surgical meshes containing animal products should be labelled
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4625 (Published 27 July 2011) Cite this as: BMJ 2011;343:d4625All rapid responses
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I agree with Mr Shiwani that the biological constituents of medical
devices need to be explicitly stated.(1) I would extend this affirmation
to also include all medicinal preparations. For example, succinylated
gelatin solutions are a frequently used form of colloid resuscitation
fluid. The gelatin source is bovine,(2) although this provenance is not
explicitly stated in the British National Formulary (or the Summary of
Product Characteristics for at least one product [Source: Medusa]).(4)
Would strict Hindu patients or strict vegans consider this an appropriate
medication? I would be interested to hear the consensus.
1. Shiwani MH. Surgical meshes containing animal products should be
labelled. BMJ 2011 343:d4625doi:10.1136/bmj.d4625
2. Braun [Online]. Basics of IV Therapy. Cited: 2nd August 2011.
Available from: http://www.iv-
partner.com/index.cfm?2A450D1AB7B24C098978DB9F6D6602DB
3. Plasma and Plasma Substitutes In: Joint Formulary Committee.
British National Formulary [Online], [61] Ed., London: British Medical
Association and Royal Pharmaceutical Society of Great Britain; [March
2011]. Cited: 4th August 2011. Available from: http://www.bnf.org
4. Medusa [Online]. Cited: 2nd August 2011. Available from:
http://medusa.wales.nhs.uk
Competing interests: No competing interests
We read your article with interest. We believe there is an onus on
the surgeon to be conversant with the base components of the biological
implants in use in their department, most of which are listed in their
accompanying literature. If in doubt, company representatives are usually
helpful. It is worth noting that not only surgical meshes but also
numerous haemostatic agents contain animal derivatives.
In our practice, with informed consent, we have been able to implant
collagen matrix mesh of porcine origin into patients of different
religious and cultural backgrounds, including those of the Muslim faith.
Ideally, the decision to use a biological implant should be pre-emptive.
This allows patients time to discuss these decisions with their family and
seek religious guidance where required.
Competing interests: No competing interests
Hernia repair remains to be a demanding procedure and using different
meshes is a very interesting topic that stimulates further evaluation;
many thanks for the author view.
It is an interesting personal view on surgical meshes; however would it be of relevant significant to use different biological meshes. I think further prospective randomized studies are required to assess the clinical as well as the cost effectiveness of each biological mesh. Regards.
Competing interests: No competing interests
The author states that the use of porcine material in medication and
prosthetic implants is controversial.
Is he aware of the statement on "The Judicially Prohibited and Impure
Substances in Foodstuff and Drugs"?
Permission to reproduce this statement is included in the statement
itself and is reproduced at:
http://www.ganfyd.org/index.php?title=Islam_unclean_substances_in_medicines
Competing interests: Contributor to ganfyd.org
M Shiwani reminds us that patients are not always aware that surgical
implants may originate from animal tissue[1]. He is right to advocate that
we seek informed consent for use of such devices, as patients might have
ethical objections to their implantation. It should be simple and
practical to incorporate this information in to the written consent that
is routinely obtained prior to such surgery.
Doctors may also be unaware fact that they are prescribing
medications that have animal-derived excipients[2].
As an example, many oral vitamin D or calcium supplements contain
porcine or bovine products[3]. This is a potential prescribing hazard,
especially considering that vitamin D supplements are often used to treat
deficiencies arising from cultural or dietary abstension[4, 5]
The British National Formulary (BNF) does not list gelatin as an
excipient of vitamin supplements[6]. Its presence can be confirmed within
the summary of product characteristics of the various types of
preparations.
In addition to clearer labelling of implanted devices, we would
welcome clearer excipient labelling in formularies, to aid prescribers, as
it is clear that patients would prefer to be informed if their medication
contained animal derivatives[2].
1. Shiwani MH. Surgical meshes containing animal products should be
labelled. British Medical Journal 2011;343:d4625.
2. Sattar SP. Patient and Physician Attitudes to Using Medications
with Religiously Forbidden Ingredients. Annals of Pharmacotherapy
2004;38(11):1830-35.
3. http://emc.medicines.org.uk. The Electronic Medicines Compendium
2009.
4. Glerup H, Mikkelsen K, Poulsen L, Hass E, Overbeck S, Thomsen J,
et al. Commonly recommended daily intake of vitamin D is not sufficient if
sunlight exposure is limited. Journal of Internal Medicine 2000;247(2):260
-68.
5. Holick M. Vitamin D Deficiency. New England Journal of Medicine
2007.
6. British National Formulary. 61st ed: BMJ Publishing Group, 2011.
Competing interests: No competing interests
A little knowledge......
Unfortunatelly, Mr Shiwani seems to have confused issues of (a)
mainstream religious belief (eg. Islam & Hinduism), (b) firmly-based
personal practices (eg. vegetarian, vegan, animal rights), and (c) loosely
-based practices/beliefs that have arisen as a result of misinterpretation
of a religion.
The idea that medicinal use of porcine products is "controversial" among
Muslims is unfounded, because all the Schools of Islamic jurisprudence
have been consistently unequivocal in stating the contrary. A detailed
statement to this effect has been issued under the auspices on the World
Health Organisation and Al-Azhar University, Cairo (http://scienceblogs.com/insolence/upload/2007/06/Islamicposition.pdf).
As with all matters, a little knowledge can be a dangerous thing!
Competing interests: No competing interests