Medical dilemmas during fasting

1. Medical dilemmas during fasting Dr Zeshan Ali & Dr Azhar Din July 2013 Ramadan 1434 AH 1

2. Important • Consult your own GP for medical issues • With regards to islamic aspects please consult a scholar if there is any doubt • Differences of opinion within Fiqh and scholars exist and we respect these. • Allah SWT knows best so forgive us for any mistakes we make - Ameen

3. Fasting - the basics • Anything that intentionally enters through the mouth into the intestine invalidates the fast. • Anything that is intentionally swallowed will invalidate the fast. • Tasting does not invalidate the fast. • Smoking/sexual intercourse invalidates the fast. • Monthly periods or post-natal period invalidates the fast.

4. Anything that is injected and is a source of nutrition which enters into the bloodstream invalidates the fast. • If a large amount of blood is lost during fasting ie. transfusion/cupping/a major accident this invalidates the fast • Intentionally bleeding/vomiting/excreting seminal/vaginal fluid during fasting invalidates the fast

5. Taking tablets • This invalidates the fast

6. Injections • Injections comparable to food/drink invalidate the fast. • Pain relieving medications do not invalidate the fast

7. Eye drops/ointments • Difference of opinion - majority say it is ok as its not swallowed. However some say it does as it can go down throat and thereby invalidate the fast.

8. Ear drops • Difference of opinion - majority say it is ok as its not swallowed. However some say it does as it can go down throat and thereby invalidate the fast.

9. Nasal sprays/drops • This invalidates the fast as this goes down throat.

10. Oral inhalers • Difference of opinion - Majority say invalidates the fast as part of the inhaled medication enters the gullet. Some say it is ok as long as you do not swallow it and you need it. • Therefore avoid this if possible due to difference of opinion. However if your condition will become worse avoiding it then take it.

11. Sublingual/buccal • Sublingual - these are medications which you place under the tongue e.g. GTN spray. • Buccal - these are medications which you place between the inside of your cheek and the teeth. • Are OK as these are not swallowed and are not nutritious.

12. Skin patches • Difference of opinion - some say it is ok as its not swallowed it and it is not nutritious. Others say it invalidates the fast especially nicotine as it goes against the spirit of the fast. • Therefore avoid this if possible due to difference of opinion.

13. Skin creams/ointments • Plus other topical medications are OK as these are not swallowed, not nutritious and not absorbed into the blood.

14. Toothpaste • This is OK as long as you don’t swallow it. If it happens without intention you do not have to repeat the fast. • Use a small amount of it if scared of swallowing it

15. Blood test • Small amounts of blood extracted for blood tests by way of needles and syringes does not invalidate the fast

16. Breastfeeding • Exempted and then compensate later/fidyah

17. Pregnant women • Exempted and then compensate later/fidyah

18. Bleeding returns whilst fasting • If post-natal bleeding disappears within 40 d and fasts some days and then bleeding returns during those 40 d then those fasts are OK

19. Going to the Dentist • To clean your teeth/remove your tooth/have an anaesthetic injection does not constitute anything nutritional and will NOT invalidate your fast as long as you do not swallow any of contents. • Once a tooth is removed very little blood flows which does NOT invalidate your fast

20. Case histories • Epilepsy • Glaucoma • Rheumatoid Arthritis • Psychosis • Diabetes

21. Epilepsy • Patient admitted to hospital for having seizure whilst driving. • Normally takes anti-epileptic medication phenytoin 100mg 3x daily • However during Ramadan he did not take his am and pm doses for fear of breaking the fast which lead to his seizure • Solution - Phenytoin has long ½ life so he could have easily taken 300mg daily instead which should have been advised before Ramadan

22. Glaucoma • A lady suffering from glaucoma prescribed eye drops to be used 4x daily at regular intervals • During Ramadan she wished to fast and only used eye drops at night. As a result her glaucoma deteriorated and she lost her vision • Solution - she could have continued using the drops 4x daily as eye drops do not invalidate the fast according to majority of scholars so she suffered unnecessarily.

23. Rheumatoid arthritis • A gentleman with well controlled RA on oral medication wanted to discuss alternative options of tx for Ramadan • The GP prescribed rectal suppositories but the patient thought inserting medication rectally was “not right” and hence did not take it during Ramadan so his condition worsened. • Solution - GP should have given an oral medication which is more long acting. He could have taken it once daily with his largest meal. There is a strong stigma of taking medication rectally in some Muslims

24. Psychosis • A lady suffering with severe depression and other psychiatric problems insisted on fasting despite the fact she was medically exempt. Her family advised her not to fast. • Solution - She does not have to fast as she is exempt due to her psychiatric illness. It should be clearly explained to her that there is a very real possibility of her mental state deteriorating if she does not take medication. According to Islam she would be harming herself which is wrong.

25. Diabetes • Groups at high risk which are exempt from fasting (Fiqh ruling): • Type 1 Diabetes Mellitus • Diabetics with severe complications • Insulin dependent Diabetes Mellitus • Diabetics on sulphonylureas (e.g. gliclazide) • Diabetics living alone • Old age/ill

26. People with diet-controlled diabetes can fast if they choose to. • Major meal is at sehri and space meals equally over non-fasting period. • Medication controlled – Dose varies according to type of medication (see table)

27. Regimen according to Professor Rayaz Malik

28. Insulin dependent diabetics • Avoid fasting if prone to DKA or wide swings in sugar levels. • If injection patients still want to fast generally take 1/3 of usual morning dose at sehri and 1/3 of the normal evening dose at iftar. • There are various types of insulin so please discuss with your GP.

29. Diabetics must stop fasting if... • Low blood sugar levels less than 3.5 mmol/L • Blood sugar levels less than 3.9 mmol/L in the first few hours after the start of the fast, especially on insulin or sulphonylureas (e.g. gliclazide) • Blood sugar levels exceeds 16 mmol/L

30. Symptoms low sugar levels

31. References • The Noble Quran-Darussalam • The Meaning of Holy Quran-Abdullah Yusuf Ali • Guidelines on Fatawa related to Sickness and Medical practice-Ibn Tamiyyah et al. Invitation to Islam • Fasting in Ramadan-Sheikh Abdul Kareem Awad, ISOC Liverpool University and Liverpool JMU • Ramadan Health and Spirituality Guide, Communities in Action, DOH, www.communitiesinaction.org • Caring for Muslim Patients, A Sheikh and AR Gatrad, Foreword by Sir Alexander Macara, Radcliffe • International Islamic Fiqh Academy. Decree 183(19/9) on “Diabetes and Ramadan” Beshyah SA (2009) Ibn o sina Journal of Medicine and Biomedical Sciences 1: 58–60

32. Please verify all that is being said with your GP and islamic scholar

33. Any questions?