Dispensing Medication for Muslims: A Guide for Pharmacists

Introduction

Many situations call for pharmacists to dispense medications with ingredients that are unlawful (haram) in Islam. Per their beliefs, Muslim patients often need to avoid haram medications unless a viable, Islamically permissible (halal) alternative is lacking and there is a genuine medical need for the medication. This can complicate the dispensing process as pharmacists strive to meet Muslim patients’ requests for halal medication while ensuring that their patients receive the necessary care. Despite Muslim patients’ need for halal medication, more than 80% of pharmacists were found to lack knowledge about where to look to find alternative medications that are halal.¹

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What can pharmacists do to ensure halal medication dispensing for Muslim patients? By understanding various haram medication ingredients and production methods as well as providing a multi-faceted approach to the safe modification of pharmacotherapy that caters to Islamic law and bioethics, pharmacists can provide the best possible care to this large patient population.

Potentially Haram Medication Ingredients and Production Methods

Generally, haram medication ingredients and production methods include those sourced from pigs, animal carrion, humans, and alcohol.² Due to differences in opinion among Islamic scholars regarding which specific ingredients are haram, it is important to inform Muslim patients about the ingredients in their medications and employ shared clinical decision-making to guide treatment decisions. Table 1 reviews potentially haram medication ingredients and production methods.

Table 1.^3-14 Potentially haram medication ingredients and production methods.

Orally disintegrating tablets (ODT); Chinese Hamster Ovary (CHO); Medical Research Council cell strain-5 (MRC-5)

The above examples are not intended to be comprehensive. It should be noted that these examples are problematic to Muslims only if there is no genuine medical need for the medication (such as when used for cosmetic purposes) or if there is a viable halal alternative.² What follows is a set of strategies for pharmacotherapy modification that aims to adequately scrutinize the presence or absence of such halal alternatives.

An Approach to Pharmacotherapy Modification

A stepwise approach to pharmacotherapy modification in the setting of haram medication components is described below. Figure 1 shows this 4-pronged approach to pharmacotherapy modification.

Figure 1. The 4-pronged approach to pharmacotherapy modification in the setting of haram medication components

Step 1: Change the Manufacturer

The first step to be considered for pharmacotherapy modification is changing the manufacturer. This includes conversions between brands and generics/biosimilars. This first-line step offers many advantages, including preserved dosage forms, methods of administration, and medication identities; prescriber authorization is generally not needed; and the information needed is easily accessible (e.g., drug inventory). Non-pharmacist providers, however, may need to consult pharmacy staff to determine the availability and insurance coverage of medications made by specific manufacturers.

For example, depending on the manufacturer, albuterol metered-dose inhalers may or may not contain alcohol. DailyMed can help assess manufacturer-specific package inserts so that pharmacists can substitute an alcohol-free alternative.¹⁵

Step 2: Change the Dosage Form

The second step to be considered is changing the dosage form. For example, gelatin-containing capsules can be substituted with tablets or liquid dosage forms. Advantages of this step include the preservation of the method of administration and medication identity as well as ease of access to information regarding available dosage forms. However, the disadvantages of this approach include potentially altered medication palatability and a general need for prior prescriber approval.

Step 3a: Change the Method of Administration

If manufacturer and dosage form changes are not feasible, a change in the method of drug administration can be considered. Advantages of this strategy include the preservation of medication identity and the general lack of need for prescriber approval. Disadvantages include a potential change in medication palatability, associated tediousness with administration, and the lack of ability to alter the method of administration for many medications.

One example is when a patient with amoxicillin capsules asks if the capsules can be opened. The pharmacist would need to make sure that the method of administration for the medication in question can indeed be altered, and according to American Academy of Pediatrics recommendations, amoxicillin capsules can be opened.¹⁶ The pharmacist can inform the patient that the capsules can be opened and mixed with a liquid or semisolid food, such as applesauce.

Step 3b: Change the Medication

A medication change may be considered if manufacturer and dosage form changes are not feasible. Note that this step may or may not be preferred over a change in method of administration, depending on the medical context. For example, a switch to a very similar medication in the same pharmacologic class may be preferred over introducing administration difficulties associated with an alteration of the method of administration.

Table 2 reviews the advantages and disadvantages of various interventions.

Table 2. Summary of advantages and disadvantages of various interventions to modify pharmacotherapy in the setting of haram medication components

Good Practices

Interprofessional collaboration between physicians and pharmacists is essential in this context. Physicians can scrutinize the need for an otherwise haram medication, and pharmacists are the most qualified to assess the presence of halal medication alternatives. For example, an Islamic ruling on heparin calls for health care practitioners to consult pharmacists before prescribing the medication.¹⁷

Importantly, a significant barrier to adequate interprofessional collaboration lies in the lack of provider status for pharmacists. Pharmacists frequently cannot bill for the clinical services they are trained to provide, such as consultations. Consequently, employers are not financially incentivized to staff or are incapable of staffing their pharmacies or other clinics with enough pharmacists to meet the standards for interprofessional collaboration needed to adequately scrutinize available alternatives to potentially haram medications.

One example is when a physician wants to escalate antilipemic therapy for a patient with very high-risk atherosclerotic cardiovascular disease on maximal statin therapy. National guidelines do not consider the immediate addition of a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor superior to the immediate addition of ezetimibe.¹⁸ However, pharmaceutical representatives have leeway to market PCSK9 inhibitors as the immediately next-line agents. Currently, approved PCSK9 inhibitors are derived from the Chinese Hamster Ovary cell line,^19,20 and opportunities to mitigate the inappropriate use of these agents in some patients are missed when pharmacists are not accessible as consultants to clarify the guidelines. This may lead to unneeded prescription of haram medication. Therefore, advocacy for global pharmacist provider status remains essential.

It is also good practice to consult or refer patients to dieticians or other nutritionists who may be able to optimize dietetic management. This may mitigate the need for pharmacotherapy later on.

Finally, if a patient is initiated on an otherwise haram medication, then patient monitoring and follow-up is essential to both scrutinize any continued need for the medication as well as to stay up to date on available alternatives. An otherwise haram medication that fulfills Islamic conditions for usage now may become haram in the future.

Conclusion

There are many ingredients and production methods associated with medications that are problematic from an Islamic standpoint. Changes in manufacturer, dosage form, method of administration, and medication are viable strategies to mitigate the use of potentially haram medications. Interprofessional collaboration and continued monitoring are good practices in this context.

References

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2. Farooki, A. Medication with unlawful ingredients. MuslimMed. November 23, 2016. Accessed May 25, 2024. https://muslimmed.org/2016/11/23/using-medication-with-unlawful-ingredients/

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17. Khan MA, Judge R. Islamic ruling on heparin. MuslimMed. March 17, 2022. Accessed May 24, 2024. https://muslimmed.org/2022/03/17/islamic-ruling-on-heparin/

18. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Circulation. 2019;139(25):e1082-e1143. doi:10.1016/j.jacc.2018.11.002

19. Praluent. Prescribing information. Regeneron Pharmaceuticals; 2021. Accessed May 24, 2024. https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/125559s029s030lbl.pdf

20. Repatha. Prescribing information. Amgen; 2021. Accessed May 24, 2024. https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/125522orig2s000lbl.pdf