Introduction

Fasting is common and widely practiced by the Eastern and Western cultures. Some of the reasons for fasting include religious, health and purification. There are various methods of fasting includes refraining from eating and drinking for a few hours or months. There are also restricting the intake of certain foods, to complement fasting according to their religious beliefs.

For Muslims, fast means abstaining from eating any foods, drinking and from doing anything, which could invalidate the fast, starting from dawn fajr (before sunrise,) until dusk (maghrib) which is approximately 14 hours a day.

The necessary nutrients needed by our body during fasting remain the same and need to be fulfilled. The thing that sets it apart is the food intake time. Fasting can discipline someone to eat food at a certain time and for a certain quantity only. It is recommended to take a complete and balanced diet during iftar (breaking of the fast meal) and sahur (predawn meal) to keep a person healthy and active.

Obligation of Fasting

Fasting is obligatory upon every Muslims at the age of puberty. However, from a medical point of view and religion in particular, the sick person is required to leave it, if is not capable of fasting. They should not fast and try to make up for it in qada. If they still want to fast, close monitoring is required. If harmful, they are obliged to break the fast.

For chronic patients and pregnant women, should consult their doctor or pharmacist first if they want to fast. Generally, they are fasting well, provided they comply with the dosing schedule, controlling diet and follow the doctor’s advice.

Use of Medicines and Medical Procedure during Fasting

To resolve concerns among patients, the following is important information for them to understand regarding things that invalidate the fast.

When fasting, we are refrain from putting anything into body cavities such as mouth, nose, ears, anus and vagina into a certain limit. However, there are some actions that are permissible to do while fasting, which will not invalidate the fast.

1. Matters relating to the medical treatment are NOT invalidate the fast:
   1. Use eye drops, ear drops and ear cleaning (provided no limit to the eardrum).
   2. Sublingual tablet (beneath the tongue) provided placed beneath the tongue and not swallowed.
   3. Perform dental procedures; fillings, extractions, cleaning teeth or brushing provided the individual who fasted did not swallow any substance during the treatment procedure.
   4. All types of injections either through layers of skin, muscles, joints or blood vessels.
   5. Donation, blood transfusion or blood sampling for laboratory tests.
   6. Applying cream or ointment, bandages and plaster to the skin surface.
   7. Inserting a catheter through blood vessels for inspection purposes, such as angiogram procedure to examine the heart.
   8. Laparoscopy, i.e. internal examination using a tool inserted through the abdominal wall to check the interior part of the body.
   9. Mouthwash gargle (almost to the throat) and therapeutic medicine spray to the mouth provided nothing is swallowed.
   10. Undergoing a biopsy.
   11. Use the nasal spray without inhaled.
   12. Half or local anaesthesia.
   13. Use of haemorrhoids medicine by re-entering the piles into place without involving the deep area.

   Note: Reference from Jabatan Kemajuan Islam Malaysia, Panduan Berpuasa bagi Pesakit. 2013

2. Matters relating to the medical treatment are INVALIDATE the fast:
   1. Taking oral medicines such as tablet or syrup.
   2. Use inhalers for the treatment of asthma or chronic lung disease.
   3. Entering any small tube (pessary) or medicine into the vagina including douching and internal inspection procedures.
   4. Introduction of any catheter tube, screening tools in the urinary tract
      (urethroscope) in men or women, barium or cleaning of the bladder
   5. Use enemas, suppositories tubes, protoscope or finger inserted into the anus or rectum for examination.
   6. Use intestine binoculars (endoscope) or stomach binoculars
      (gastroscope) for the examination of digestive system.
   7. Full anaesthesia, which involves the use of gas.

   Note: Reference from Jabatan Kemajuan Islam Malaysia, Panduan Berpuasa bagi Pesakit. 2013

How to take your medicines during fasting

For those who are sick, fasting is not an obstacle to continue with the treatment. Adjustments can then be made to medications regimens to allow fasting. Patients must be sensitive to their health status and get ready to break their fast if needed. This is important to prevent any unwanted adverse effects. Consult your doctor and pharmacist before making modifications of dose and time to taking medicines.

Some patients change their dosing regimen during fasting without consulting doctor or pharmacist. Worse yet, some of them did not want to take medicine during fasting.

Condition of patients who stopped taking their medicines while fasting is very worrying, especially with chronic diseases such as hypertension, diabetes and asthma. This can lead to complications of the patient’s disease.

General guide regarding adjustment of medications regimens during fasting

Diabetes patient who are on insulin, the dose and time for injections can be adjusted according to the doctor’s instructions base on sugar level in the blood. Discuss with doctor about medicines and dosage of insulin for the month of Ramadan because it can prevent blood sugar levels from getting too low (hypoglycaemia) or too high (hyperglycaemia). Patients who are determined to fast should undergo a pre-Ramadan medical assessment and receive Ramadan-focused education program with the Medical Officer, Dietitian, Pharmacist and Diabetes Nurse to achieve a safer fasting experience.

HYPOglycaemia (low blood sugar levels in the blood)

1. Drowsiness / Too weak
2. Extremely hungry
3. Shivering / Trembling
4. Cold sweats
5. Confused / Emotional instability / Anxiety
6. Dizziness / Easy blackouts

HYPERglycaemia (high sugar levels in the blood)

1. Very thirsty
2. Frequent urination
3. So tired

Break your fast as soon as you experiencing symptoms of hypoglycaemia, hyperglycaemia or dehydration as it can be harmful. Please consult your doctor if symptoms do not disappear or conditions worsening.

Several tips for patient

1. Having sahur (pre-dawn meal) and delaying it until just before fajr (dawn) time. Eating well, because if you eat too early or too little can lead to hypoglycaemia.
2. Break the fast on time with 1-2 dates.
3. Encouraged to take the main course after maghrib prayer. Avoid eating too much while breaking fast.
4. Eat foods with less sugar, fat and salt.
5. Take your medicines or insulin regimes according to the doctor’s instruction.
6. Recognize the signs of hyperglycaemia, hypoglycaemia and dehydration (lack of body fluids).
7. Break the fast as soon as if there are signs that can be harmful.
8. A patient’s decision to fast should be made after careful discussion with their doctor. Supervision, education, personal care, nutrition and medications modifications can help patients control the disease in the month of Ramadan. If the guidelines and conditions can be complied with, fasting can be done safely and it does not become a big obstacle for the patient to fast.

This information as a general guide only. There may be differences of opinion in matters related to medicines and matter that invalidate the fast or not invalidate the fast. Differences may be due to the method of determining the legal analogy and different sectarian or opinions. Accordingly, the information provided is based on the legal opinion of the Shafie sect and guide the patient to fast for JAKIM 2013.

References

1. Bahagian Perkhidmatan Farmasi, Kementerian Kesihatan Malaysia (2015). [Slide] Puasa dan Ubat.
2. Jabatan Kemajuan Islam Malaysia, Panduan Berpuasa bagi Pesakit. Cetakan kedua. 2013.
3. Know Your Medicine. Puasa & Ubat [Pamphlet]. Retrieved from: http://knowyourmedicine.gov.my/node/302.
4. Know Your Medicine. Ubat-ubatan dan Bulan Ramadhan. Retrieved from: http://knowyourmedicine.gov.my/node/873.
5. Mina F. (1998). Medical implications of controlled fasting. Journal Of The Royal Society Of Medicine 1998;91:260-263.
6. NHS Choices. Ramadan health FAQs Retrieved from: http://www.nhs.uk/Livewell/Healthyramadan/Pages/faqs.aspx
7. Pharmacy Unit, Hospital Bahagia Ulu Kinta. Pharmacy Bulletin, vol. 2, 2014.
8. Rohanah Pagi (2010). “Bolehkah Pesakit Diabetis Berpuasa di bulan Ramadan??,” Association of Diabetes Educators of Singapore. July-September, 2010.
9. Website: Article from Assoc Prof Dr Nor Azmi Kamaruddin, Malaysia, for Novo Nordisk Pharma (M) Sdn Berhad “Pengurusan Diabetes Ketika Berpuasa,” pp. 1–2.