By Amira Shaikh, Deputy Senior Clinical Pharmacist; NHS 111 pharmacist advisor; Royal Pharmaceutical Society Ambassador
Providing tools and resources related to understanding different cultures is essential for pharmacists’ competency to provide optimal care. While serving Muslim patients who observe fasting during the holy month of Ramadan, patient autonomy should be taken into account. Where the patient chooses to continue to fast despite contrary advice they must be given the support and tools to retain their engagement in case of an emergency.
In order to advise patients and counsel clinicians on healthcare management during the month, it is very important to understand the basic physiological changes the body goes through. Understanding these changes at their most basic level will aid in better understanding on the pharmacological impact medicines may or may not have.
Early fasting is characterised by a high breakdown of blood glucose. As fasting continues, progressive ketosis develops because of the mobilisation and oxidation of fatty acids. Several hormonal changes occur during fasting, including a fall in insulin and changes in thyroid levels. Other changes to the body during fasting include a slight decrease in core body temperature.
Categorising a patient’s underlying health
1 – Stable Long Term Condition (LTC)
The advice given to patients needs to be specific to their chronic LTC and how a fasting regime may or may not have an effect. The following are common LTC’s encountered in primary care (which by no means is an exhaustive list). Clinical judgement should always be exercised to ensure that the information given relates to the patient and their condition.
Diabetes – The most obvious medical condition clinicians become concerned about during Ramadan is diabetes and the dangerous issue of erratic blood sugar control and risk of constant high blood glucose levels. The advice for diabetic patients will vary depending on whether they are taking insulin or taking hypoglycaemic drugs such as sulphonylureas. If they are taking insulin, the following should be considered:
. Regular check of their blood sugar levels to preempt action before entering into a full hypoglyceamic state
.To use less insulin before starting fast
. Possibly change the type of insulin being used as pre-mixed insulin are not recommended
. To break their fast with healthy option meals that are slow releasing, high energy meals and drink plenty of fluids
Diabetes UK have plenty of material to share with patients that can be useful to help consolidate the message.
Heart Failure (HF)- Patients have a limited daily intake of fluid to less than two litres and sodium to less than 2500 mg. Medications include angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), beta blockers, diuretics and digoxin. Research has started to emerge supporting HF patients fasting as long as adhere to fluid and salt restrictions and ensure compliance with their medication schedule. For those who are two daily dose, would be advised to take each dose during their non fasting hours with as big a gap as possible. Where possible, to change the drug to modified release preparations. However, due to the narrow gap we will experience this year, it must be discussed with relevant consultant physicians.
Chronic Kidney Disease – For patients with kidney disease, discussions should always be sought with their consultants. There have been several studies that have confirmed safety in fasting for CKD patients, however, limitation with these studies is that they have been carried out in Ramadan during the cold seasons. As Ramadan is in the summer season with longer fasting hours, management will be deemed more complex.
Asthma/COPD There is limited evidence available for a direct link between fasting and asthma exacerbation. There is however, physiological evidence that dehydration, can lead to drying up of airways which may induce acute exacerbations. The ruling of asthma inhaler use is mixed amongst scholars, which makes it difficult to direct patients. However, patients need to be made aware that they need to use their relievers during acute periods in order to avoid deterioration or hospital admissions.
2 – Unstable Long Term Condition
General advice may be provided to patients or clinicians. However, due to complexity of certain drug regimens for unstable patients generally, the safer advice would be to 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 where they are on multiple dosing (due to small gap between fasting and non-fasting hours) it would not manage their condition or increase risk.
3 – Acute illnesses
The Shariah (Islamic ruling) does allow exemption from fasting for patients with severe or acute medical conditions who are either at risk of getting worse or if fasting would directly impede their health in any way. This is particularly important for patients who require immediate antibiotics for acute infections.
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. Patients should be advised to consult with their local imams to confirm their theological standing especially for patients suffering from asthma.
- Nicola Luigi Bragazzi. Ramadan fasting and chronic kidney disease: A systematic review. [PMCID]
- Kelly Grindrod, BScPharm, ACPR, PharmD, MSc and Wasem Alsabbagh, BScPharm, PhD. Managing medications during Ramadan fasting. [PMCID]
- Fasting and asthma [online] Available at: https://www.asthma.org.uk/advice/living-with-asthma/fasting/ [Accessed April 2019]
- Berbari AE, Daouk NA, Mallat SG, Jurjus AR. Ramadan fasting in health and disease. In: Berbari AE, Mancia G, editors. Special Issues in Hypertension. Milan, Italy: Springer-Verlag; 2012.