Courtesy of Green Light Pharmacy, Euston
According to the UK census, there are around 2.7 million Muslims in the UK[1]
and a significant proportion will be observing fasts during Ramadan.
Ramadan is the ninth month of the Islamic lunar calendar. In 2016, Ramadan will begin on Tuesday 7 June and will end in the first week of July (see ‘Box 1: Dates Ramadan begins in the UK, 2017–2020).
Box 1: Dates Ramadan begins in the UK, 2017–2020
2017 – Saturday 27 May
2018 – Wednesday 16 May
2019 – Monday 6 May
2020 – Friday 24 April
Islam has five fundamental pillars, which are an integral aspect of the religion. Fasting during Ramadan is the third pillar of Islam and is one of the ritual acts that Muslims are obliged to undertake. Fasting promotes subservience, sacrifice and putting God before an individual’s worldly needs.
Muslims fast from dawn until dusk and therefore consume meals just before dawn and after dusk (called suhoor and iftar, respectively)[2]
. In the UK, depending on which month Ramadan falls in, fasts can range from between 10 hours and 19 hours.
Eating, drinking (including water), sexual activity, smoking and administration of medicines orally and intravenously are prohibited during this time. However, these activities can continue at dusk until the next fast resumes at dawn.
It is important for healthcare professionals to recognise the changes that can occur in the body during fasting (see ‘Box 2: Changes to the body during fasting’). This can provide a better understanding of patients’ medical needs and limitations, allowing them to make suitable adaptations to medicine regimens in line with the demands of Ramadan.
Box 2: Changes to the body during fasting
During a fast, the body generates its own energy by burning stored excess fats, carbohydrates and sugars to produce energy. Metabolically, early fasting is characterised by a high rate of gluconeogenesis with amino acids as the primary substrates. As fasting continues, progressive ketosis develops because of the mobilisation and oxidation of fatty acids[3]
.
Several hormonal changes occur during fasting, including a fall in insulin and T3 levels and a rise in glucagon and reverse T3 levels[3]
.
Blood sugar levels may fall and can reduce the ability to think clearly. This can cause the patient to be irritable, forgetful and confused. Other changes to the body during fasting include a slight decrease in core body temperature because of a decline in metabolic rate[4]
.
Who is exempt from fasting?
Fasting during Ramadan is obligatory for almost all Muslims. However, the Qur’an states that those who are exempt from fasting include:
- Children;
- Women who are menstruating;
- Elderly or frail patients;
- Those suffering with a severe mental illness or condition;
- Those suffering with a chronic illness, where fasting can cause detriment to health.
Patients can be advised to discuss their medication, including types of medical devices and medicines that retain the validity of the fast, with an appropriately qualified Islamic scholar. However, this discussion should take place in conjunction with their healthcare professional who is the most qualified to determine the significance of the medication and the possible impact on the health of the patient.
The Islamic scholar, after discussion with the healthcare professional, can confirm whether the patient’s fast is valid, requires being made up later, or that the fidyah (charity in lieu of a fast) be offered. For an Islamic scholar’s perspective on the ethos of fasting in Ramadan and the ruling around use of medicines during fasting, see ‘Box 3: An Islamic scholar’s perspective’.
Box 3: An Islamic scholar’s perspective
Shaykh Muhammad Nizami, co-director of the think tank Averroes and visiting scholar to Kingston Mosque
When the Qur’an and prophetic traditions address believers, there is explicit recognition that not all adherents can fast for the entire month of Ramadan because of old age, illness or other medical conditions[5]
.
The Qur’an specifically exempts patients with severe or acute medical conditions who are either at risk of getting worse from fasting or where fasting will directly impede them getting better. This also applies to patients with infections that require the immediate use of antibiotics[5]
. A patient’s health takes precedence over fasting, but patients can make up missed fasts when their condition becomes more stable.
There is consensus among classical and contemporary scholars that fasting is not only not obligatory for patients with severe medical conditions but it is deemed an offence if they participate in fasting knowing that it will be detrimental to their health. This also applies for people on a long-term medication regimen, the disruption of which might lead to further harm[5]
.
Taking non-essential medicines during fasting is an area of debate and there are legitimate differences of opinion in the areas of medicine, so patients would be required to consult Islamic legal specialists who have the relevant insight into the field[5]
. For example, the use of ear drops, creams, ointments and certain types of eye drops and injections are thought to break a fast by some schools of thought.
In the context of fasting, healthcare professionals need to be considerate to patients who are eager to fast. If modifications can be made to a patient’s treatment regime, they can be counselled about these. If it is not possible to make any changes, and if by fasting the patient puts their health at significant risk, then healthcare professionals need to clearly communicate the risks and advise the patient to seek the advice of the local scholars and Imams. For information on managing medical conditions during Ramadan from a Muslim doctor’s perspective, see ‘Box 4: A Muslim doctor’s perspective’.
Box 4: A Muslim doctor’s perspective
Ali Sameer Mallick, ear, nose and throat surgical registrar at Queen’s Medical Centre, Nottingham
The most obvious medical condition clinicians become concerned about during Ramadan is diabetes and the dangerous sequelae of erratic blood sugar control[6]
.
Patients with diabetes should be advised to seek advice from their healthcare professional before they begin their fasts. During consultations, it is important to allow patients the opportunity to discuss how fasting is for them.
Many options are available to assist a diabetic patient during Ramadan. For example, changes can be made to insulin regimes or patients can be switched to longer acting formulations. However, if the healthcare professional believes that the patient will be putting their life at risk while fasting, this needs to be explicitly explained to the patient[6]
.
All options should be discussed with patients suffering from long-term conditions that require them to take regular medicines (e.g. cardiac conditions and respiratory conditions).
As a healthcare professional, it is essential to ensure that the patient’s autonomy is maintained. Patients should be given all the available information in order for them to make an informed decision. Healthcare professionals need to be sensitive of the fact that, by not fasting, not only do people feel disappointed that they cannot take part in a significant religious ritual, but they can also feel excluded from their community and family life[6]
.
Healthcare professionals should work together with patients to see if changes can be made to their medication regime or to titrate doses according to the fasting routine, however, this may not be possible in all cases. In these situations, the healthcare professional must provide the patient with all the facts and advise them to consult an Islamic scholar[6]
.
It is important that healthcare professionals in primary care create links with local scholars prior to Ramadan. This way, the local scholars (as well as the local Imam) will be aware that patients may be directed to them for guidance[6]
.
Advice for consultations with patients fasting during Ramadan
Patient consultation is fundamental when preparing patients for Ramadan. Patients should be advised to plan ahead of fasting by visiting their local pharmacy to discuss their medicines and health. They can also be reminded that pharmacists are accessible (an appointment is not needed) and pharmacies are open long hours throughout the week, including weekends. Important counselling points for patients on taking their medicines in Ramadan include:
- Pharmacists can offer professional advice on the management of medicines and can speak with the patient’s GP to make any necessary changes to their medicines regime in preparation for Ramadan.
- Patients should not stop or alter any prescribed medicines without consulting their pharmacist or GP.
- Patients with long-term conditions, such as diabetes, asthma, chronic obstructive pulmonary disease, high blood pressure or heart disease, need to seek medical advice from their pharmacist and GP.
- Patients with long-term medical conditions who are taking multiple medicines can continue to fast, as long as their condition is stable. However, this may require the alteration of some of the patient’s medicines to a different formulation or revised dose timings to fit around fasting[7]
. - Patients with acute medical conditions, such as chest infection, migraine and toothache, can continue to fast, providing they are able to control their symptoms with their medicines outside of the fasting time and with the prior knowledge of their pharmacist and GP.
- Medicines come in various pharmaceutical forms and can have different routes of administration. Many oral medicines come in other forms, including injections, patches, suppositories, pessaries and inhalers. Not all the different drug formulations are prohibited from use during fasting according to many classical and contemporary scholars.
- Many drugs prescribed for various conditions are available as immediate-release, medium-release and sustained-release. This means that certain types of medicines can remain and be effective in the body for longer periods of time, reducing the need to take medicines multiple times during the day.
- Patients with unstable medical conditions should avoid fasting if it is likely to make their condition worse in the short or long term. This may also apply to patients who are on specific medicines, such as insulin for diabetes or certain types of antibiotics for serious infections.
- If the existing medical condition gets worse during a fast or if a patient becomes unwell while fasting, they have the option of breaking their fast; it may be obligatory to break the fast if the condition worsens.
- Each patient is different and responds to medicines in different ways. Patients should be advised not to blindly follow someone with a similar condition to them. Each case requires patient specific management of both the condition and the medicines.
Additional resources
The following resources may also be useful when advising patients during Ramadan:
- ‘Medicines management during Ramadan’ article from The Pharmaceutical Journal;
- ‘Towards a healthy Ramadan’ from Muslim Health Network;
- ‘Information for healthcare professionals on fasting and medicines during Ramadan’ from Tower Hamlets Clinical Commissioning Group;
- ‘Ramadan health FAQs’ from NHS Choices.
Nadia Bukhari is senior teaching fellow in pharmacy practice and preregistration coordinator at the University College London School of Pharmacy.
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References
[1] Office for National Statistics. 2011 Census data. Available at: https://www.ons.gov.uk/census/2011census/2011censusdata (accessed June 2016).
[2] Azizi F. Islamic fasting and health. Ann Nutr Metab 2010;56:273–282. doi: 10.1159/000295848
[3] Kerndt PR, Naughton JL, Driscoll CE et al. Fasting: The history, pathophysiology and complications (Medical Progress). West J Med 1982;137:379–399. PMCID: PMC1274154
[4] Meo SA & Hassan A. Physiological changes during fasting in Ramadan. J Pak Med Assoc 2015;65:S6–S14. PMID: 26013791
[5] Shaykh Muhammad Nizami. Co-director Averroes and visiting scholar to Kingston Mosque. Personal communication, 10 May 2016.
[6] Ali Sameer Mallick. ENT Surgical Registrar. Personal communication, 15 May 2016.
[7] Ibrahim M, Abu Al Magd M, Annabi FA et al. Recommendations for management of diabetes during Ramadan: update 2015. BMJ Open Diab Res Care 2015;3:e000108. doi: 10.1136/bmjdrc-2015-000108
