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Information for healthcare professionals on fasting and medicines during Ramadan Introduction Ramadan is one of the most holy months in the Muslim calendar. During this period Muslims fast for 30 days during daylight hours. The first fast is subject to the sighting of the new moon. This year it is expected to be around June 17. Fasting commences at dawn and ends at sunset. Each fasting day will be getting later as the month progresses. Please refer to the Unified Islamic Prayer Timetable for London which can be found here. The East London Mosque Ramadan timetable can be found here. Until recently little was known of medication compliance during Ramadan. A project was undertaken, at Barts Health, to determine medication usage in the Tower Hamlets Muslim population during Ramadan. The results were quite alarming. It was found that 23% of patients did not take their medication at all during the holy month, and a further 48% doubled their evening dose to compensate for medicines normally taken twice a day. Doubling the dose of twice-daily medication or omitting a dose altogether could in some cases cause severe adverse effects and is an important point to consider when prescribing or counselling this group of patients especially when acute therapy is prescribed during this time. Action: As healthcare professionals we can advise patients on whether it is safe to fast in the first instance and advise on safe ways to fast, The general Islamic ruling is, if a person‟s health is at risk due to a medical condition they should not fast or they can break their fast. Below are some specific rulings Figure 1: The following persons are exempt from fasting: Children under the age of puberty. Persons incapable of fasting due to: a) old age b) incurable disease i.e. cancer / HIV infection ? c) chronic disease e.g. diabetes, COPD, cardiovascular disease d) Severe diseases e.g. cancer, kidney disease, Menstruating women or women with post partum bleeding should not fast. Any food or medicine used as a substitute for food that reaches the body by mouth or any other means will invalidate fasting. 1 There is no restriction on having or using the following items during Ramadan: Having a blood test. Having an injection (which is not a substitute for food). Using eye drops Taking tablets invalidates the fast. According to the Islamic ruling (Shariah) you can take Insulin while fasting on the basis that it is purely for medical use and does not constitute nutritional consumption. With the use of inhaler, the Islamic ruling excuses one from fasting in this instance, but must make it up when health permits otherwise pay a charitable contribution (fidyah).The other Islamic rulings allows the use of the inhaler in this instance. The table below gives guidance on the safety of fasting by patients with medical conditions. Further information is available on the Faith in Health website, which can be found on East London Mosque website. Direct link to the website http://www.faithinhealth.com Dietary Advice: There are three stages to the fast during Ramadan. Firstly there is the pre-dawn breakfast, which should consist of a light meal and water. The fasting period runs from sunrise to sunset. At sunset the fast is broken with a small snack and dinner is eaten in the evening. There is no need for excess. All patients must maintain a balanced diet consisting of items from the following five groups, that is, meat or bean, bread or cereal, milk, vegetable and fruit. The following advice is particularly useful: Encourage fluids especially water to prevent dehydration. (Break the fast with fruit and water). Consume sufficient vegetables at mealtimes. Avoid caffeine-containing beverages such as tea, coffee and cola etc. (Reduce the quantity consumed before Ramadan to prevent headache, irritability and mood swings) Avoid intake of refined sugar (table sugar, sucrose) in food such as sweets or other forms. Avoid spicy foods. Ramadan is a good time to quit smoking. It provides a great opportunity to change unhealthy habits such as smoking NHS Choices has information about a „Healthy Ramadan‟ which can be found here: http://www.nhs.uk/livewell/healthyramadan/Pages/healthyramadanhome.aspx 2 References 1. Ramadan health guide; a guide to healthy fasting; http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/document s/digitalasset/dh_078408.pdf 2. Athar, S. “Health Concerns for Believers; contemporary issues.” http://www.islam-usa.com/h8.htm 3. Nomani, M.Z.A. “Diet during Ramadan http://www.islamicity.com/articles/articles.asp?ref=RR0210-1775 4. Azizi, F. and Behnam, S. “Ramadan fasting and diabetes mellitus.” (1998) Int. Journ. Ramadan. Fasting Res. 2:8-17. http://www/labs.net/ains/j98ar2.htm 5. Athar, S. “Medical aspects of Islamic fasting.” http://www.islam-usa.com/im15.html 6. 5. Aprilawati, L. (translated by Green, C.) “Fasting for Muslims with AIDS” (1998) PROCARE. http://www.essentialdrugs.org/programs/provcaarehma/procare.199801/msg00000.html 3 Information on Fasting and Medicines during Ramadan Disease state: Type 1&2-Insulin Dependent Diabetes Type 2-Non-Insulin Dependent Diabetes Diet controlled Oral medication Chronic respiratory disease COPD, emphysema, bronchitis Asthma Advice Safe way to fast Type 1 and Type 2 insulin dependent Patients must maintain their normal diet, i.e. low fat and diabetic patients should not fast, especially low sugar diet, when breaking the fast and maintain their if less than 20 years or pregnant. normal daily activity. Patients must also drink sufficient water in the hours Diet controlled diabetic patients can fast before and after the fasting period to prevent dehydration. safely. It may be possible make changes to their medication in Patients taking oral hypoglycaemic agents order to help them take tablets outside the times of fasting. should not fast unless their diabetes is Recommend to discuss with health care staff. controlled. All patients must be counselled of the warning signs of dehydration and hypoglycaemia. If either occurs they must break the fast immediately. Patients should only fast if the diabetes is controlled. It is not safe to fast and patients who fast may experience severe illness. Chronic heart disease Coronary artery disease Severe uncontrolled hypertension It is not safe to fast and patients who fast may experience severe illness Chronic renal disease Renal dialysis Renal transplant Nephrotic syndrome It is not safe to fast. Unsafe Mild or moderate asthmatic patients can fast providing they continue all regular medication. Inhalers can be used during the fasting period Asthma UK information can be found here Unsafe In controlled hypertension with no other coexisting cardiovascular disease patients can fast, but must continue all regular medication. It may be a good opportunity to review current treatment and medicines adherence Discuss with health care staff if any concerns Patients should maintain their normal diet and fluid intake Patients should continue taking their medicines as prescribed and attend appointments as planned Information on Fasting and Medicines during Ramadan Disease state: Immunocompromised On immunosuppressants including: steroids, ciclosporin, mycophenolate, azathioprine, tacrolimus HIV/AIDS infection Aged over 65 years Advice It is safe to fast providing the patient is generally well. Most medicines are taken once or twice daily. Doses can be adjusted to suit the meal times i.e. sunset and sunrise meals It is not safe to fast if the patient is unwell, or has reduced weight or poor hepatic or renal function. Refer patients with HIV to their HIV centre who can give more individualised advice on the treatment regime. It is not safe to fast if taking saquinavir (must be taken after food), or zalcitabine, which must be taken three times a day. It is safe to fast providing the patient is of good health generally. Safe way to fast The steroid dose must be taken with food and is best taken in the morning (the pre-dawn meal) to mimic the body‟s normal release. Ensure adequate fluid intake between the fasting periods to prevent dehydration and to aid clearance of the medication. Safe to fast if not taking any anti-retroviral or only taking prophylactic anti-infective agents i.e. anti-fungal, antituberculous or anti-PCP (pneumocystis carinii pneumonia) medication. Refer patients taking antiretrovirals to their HIV centre. A balanced diet comprising all nutrients. Break the fast with fruits and water. Ensure sufficient water is taken between the fasting periods. Menstruating women Post partum bleeding Pregnant and nursing mothers Exempt from fasting. Women can make up the days missed at an alternative time. They have the provision to break their fast if However the woman will need to make up those fasts needed. later. Epilepsy Patients with epilepsy are more likely to have seizures during Ramadan Taking your medications at the same time and every day can help to prevent seizures If you require further advice please call the Barts Health epilepsy team on 0203 594 0701 or [email protected] or speak with your nurse, doctor or pharmacist. 5 Get enough sleep, as tiredness can provoke seizures 6