Ramadan is a holy month during which adherents of Islam fast from dawn until sunset. All Muslims are expected to observe the fasting as long as they are medically well enough. If someone is too unwell, the Islamic Sharia allows for either partial fasting or for the person to abstain from fasting.
This year, because of when the lunar month falls within the solar calendar, the length of day for fasting is long. 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.
If you’re currently fasting, you may have questions about medication management during Ramadan. Who is well enough to fast? Which medical conditions are too serious so fasting would not be advised? What constitutes breaking the fast? In this guide, we hope to answer these as well as other related questions.
We have discussed these points with Muslim colleagues who have been working with Islamic scholars and the team from Written Medicine and MIEM (Medical Information for Ethnic Minorities) to produce videos in various languages such as English, Bengali, Urdu, Somali and Arabic. These videos can be accessed here.
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.
Patient- (or even better, person-)centred care and discussions
In short, it’s not easy to apply one set of fixed guidelines to every person, medication or disease. 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.
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 it’s important to respect an informed choice.
A medicines use review (MUR) can be an excellent forum to have this sort of discussion in pharmacy. 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).
A patient’s underlying health
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. 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 like an infection, there may be a need for urgent treatment that cannot wait until after Ramadan. Sometimes, the correct antibiotic may need more frequent dosing which would constitute breaking the fast. As a pharmacist, it is important to discuss with the patient and understand if it is clinically 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.
The medicines being taken
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.
There are different interpretations of what constitutes breaking the fast. Creams, ointments, and eye drops are permitted by many people, although there are differences of opinion and understanding regarding inhalers and nose sprays. Oral tablets, capsules, or liquids are almost always considered to be breaking the fast.
General public health and lifestyle advice for people fasting during Ramadan
Ramadan is a useful time to reinforce other messages around healthy living - from stopping smoking and losing weight to choosing healthier meal options when breaking the fast.
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.
With Echo, you’ll be able to change the timing of your set medication reminders to reflect the new timings during Ramadan 2018. Download the app here.
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