Ramadan and medication
There are over 2.7 million Muslims in the UK and a significant number of these will fast during the month of Ramadan.
What is Ramadan?
Ramadan is the ninth month of the Islamic calendar. The month consists of 29 or 30 days, with Muslims fasting from dawn until dusk. Depending on the time of year that Ramadan falls, this can be anywhere between 10 and 19 hours a day. Since the calendar is lunar-based, it consists of 354 days a year, and so the month of Ramadan falls 10 to 11 days earlier every year.
The month of Ramadan allows people to appreciate what they have and increase their participation in prayer to form a closer relationship with God. Fasting is not only abstinence from food and drink; sexual activity, smoking and taking medicines (orally and injection) are also prohibited. These activities can continue at sunset each day until dawn of the next. It is obligatory for Muslims to fast in Ramadan unless they fall under the following exemptions:
- Elderly or frail patients
- Menstruating women
- Pregnant or breastfeeding women
- Those with learning difficulties or severe mental health problems
- Those with chronic conditions, where fasting would be detrimental to their health
Muslims that fall into the above categories may still feel obliged to fast. Therefore, as healthcare professionals, knowledge on the effects of fasting on a patients health is essential to advise patient’s appropriately regarding their decision to fast.
What effect does fasting have on the body?
During a fast, the body generates its own energy by utilising stored excess fats, carbohydrates and sugars. The body is in fasting state after eight hours passes without eating when the gut will have absorbed all the nutrients of the last meal. At this point, the insulin secretion is reduced and glycogenolysis (glycogen breakdown) and gluconeogenesis (glucose production) occurs. There is an increase in fatty acids and ketones, as well as a rise in glucagon.
Hypoglycaemia is common, reducing one’s ability to think clearly, and can cause irritability, forgetfulness and confusion. This can be more serious in patients that have mental health problems, leading to a worsening of their condition.
Does Ramadan have an effect on medical conditions?
Studies have shown that patients with stable conditions (cardiac disease, chronic kidney disease and respiratory disease) can fast with minimal effect to their health. However, this should be under their doctor’s guidance and on an individual basis, while considering the length of the fast.
Patients with diabetes, however, must be treated with caution. Excessive glycogenolysis, gluconeogenesis and ketogenesis can occur in patients with insulin deficiency while fasting; especially those with type 1 diabetes. This can result in hyperglycaemia and ketoacidosis. Therefore, it is recommended that type 1 diabetic patients – especially those that are poorly controlled (type 2 included) – do not fast.
If a patient on medication has decided to fast, certain changes can be made to their dosage schedule under prescriber supervision. Patients on once-daily medication taken at night are not likely to have any problems. Also, some medication can easily be switched from morning to evening. However, patients on twice a day or more dosage regimens may need adjustments. Modified release preparations may be an option during the month, although these can be more expensive.
It is important to counsel patients about medication that needs to be taken on an empty stomach, especially during the longer fasts, as these may then be taken on a ‘full stomach’ after the day’s fast ends. These medicines may be subject to reduced absorption and bioavailability.
Insulin dosages would need to be reviewed and changed according to the change in eating habits. It may be beneficial to use short-acting insulin instead of normal insulin, as this can cause fewer postprandial peaks and hypoglycemic attacks.
It is important to promote a healthy, balanced diet, including plenty of water, during Ramadan.
It is important to acknowledge the patient’s desire to fast alongside his/her physical health. In order to advise whether it is safe for a patient to fast, certain factors need to be taken into account: the length of the fast, patient’s age, their long-term conditions and any medicines taken.
Further advice about medication can be provided by your pharmacist.