Pharmacists Can Support, Help Patients Manage Medication During Ramadan

Rania El-Desoky, PharmD, BCPS, a lecturer at the University of Western Australia, Perth, Australia, speaks with Pharmacy Times at the APhA 2023 Annual Meeting & Exposition to discuss the cultural, social, emotional, and physical impact of fasting during Ramadan on the pharmacists and patients who celebrate. She provides holistic advice for patients who have particular medication needs, and how a healthcare support system can help to promote an enriching experience.

PT Staff: What is the cultural significance of fasting during Ramadan?

Rania El-Desoky, PharmD, BCPS: So Ramadan is actually one of the 5 pillars of Islam. And so these are the core beliefs and foundations of Islam, and that Muslims follow. And so again, Ramadan being a core pillar, it's one of those practices, that's almost, it is mandatory for most people unless there is an exemption, of course, like a health condition. [There are] other exemptions as well. But it is a month in which you know, people feel like it's a communal event, they come together, they fast together, everybody's fasting, we break our fast as a family. And so it's really a both like a spiritual and an emotional celebration throughout the month of Ramadan. And so, for most people, they tend to want to fast—and a lot of times, even though we give our medical recommendations, patients may still choose to fast. And I think it's important for us as pharmacists to recognize that, that, you know, we may give a recommendation, but the patient chooses to go a different route. And so we have to make sure we support our patients and really educate them about the risks, but also support them if they you know, if they choose that that's the route they want to go. But yes.

PT Staff: What happens to a body during a period of fast?

Rania El-Desoky, PharmD, BCPS: Yes, that's a great question. So, again, from dawn until sunset, there is no fluid intake, and that does include water and no food intake. And so the body typically will go through a large change, especially because this is done over 30 days. And so overall, it's kind of like intermittent fasting with the exception of no fluid intake. So naturally, the body we call it flipping the metabolic switch. So it goes from using glucose as the main source of energy to using and mobilizing fat as the main source of energy. And so it kicks your body into ketosis. So, you can kind of think of, you know, you have an increase in ketone production, we also know it does have some benefits on the brain. For relatively again, this is relatively healthy patients, there is a increase in brain derived neurotrophic factor. And that's really just a substance that helps with rejuvenating stem cells, brain stem cells, and really increasing memory and cognition. And it does also help increase insulin sensitivity as well as decreased inflammation throughout the body. So, there are some beneficial effects that typically again, that's for a relatively healthy patient. Now, for our patients who have more advanced disease or chronic conditions, there's a risk versus benefit there. And very common one, especially for patients with diabetes, if their conditions not well controlled, that increasing ketone production can result in diabetic ketoacidosis. So, it's an acute complication of diabetes, or hyperosmolar hyperglycemic state (HHS). Yeah.

PT Staff: What is the social/emotional effect of fasting for patients and pharmacists who celebrate?

So that's a great last question. I think from a social perspective, again, that communal feel, feeling like part of the community; not only do we fast together and break our fast together, but usually there are prayers done after fasting, they're called Tarawih. So that's when most of the community will either gather at a mosque and pray, or they may do it at home— whatever the preference is. And so it's a full day event. And you know, at times, we stay up later to perform those different additional prayers, [and] it's a time where we go through spiritual reflection and rejuvenation because the focus here is really being able to have that self-control; and, a lot of times, it's a sense of accomplishment [that] I was able to abstain from food and drink, something that's very essential to us every day [and] for this amount of period of time. And so that tells me that I can really like I have the willpower to do a lot of other things. And in addition to that, it's also a feeling of feeling grateful that there are people every day that starve and so understanding that we have all these bounties and really you should be grateful and giving to those in need. So, it kind of provides that type of social aspect.

Now, the second part was the emotional. I think from an emotional aspect, again, it's more of that spiritual self-reflection and really dedicating that time to focusing on reconnecting with their religion and really reflecting on how to be a better person overall.

PT Staff: Does it impact medication adherence by those who fast?

Rania El-Desoky, PharmD, BCPS: It definitely can be, especially if patients- if their schedule for their medication conflicts with their fasting schedule it can impact their medication adherence. But I do think that's where pharmacists come in, is that if we're able to provide these alternative medication schedules to help align best with their fasting schedules, patients will feel empowered and feel confident that they can manage both their medications and their chronic disease states as well as their want to fast. So I think it's really important for us as pharmacists to give them that additional information and really come up with a very— I would say very concise— [and] also a clear plan as to when to take their medications.

PT Staff: Are there feelings of guilt when patients or pharmacists may need additional management for diseases during a Ramadan fast?

Rania El-Desoky, PharmD, BCPS: Yes, that's a great question. So a lot of times, you know, from a religious perspective, if you need to invalidate the fast and it is the guidance of a health care provider, or if you're not feeling well, then please do so. That is the recommendation, your health comes first. And a lot of times there are again specific exemptions; I'll share a few.

Children who are under the age of puberty are exempt from fasting; pregnant or breastfeeding people are exempt from fasting; the elderly, who can't tolerate fasting, are exempt from fasting; if you have an acute condition; if you're sick and you know that fasting will probably aggravate that acute or chronic condition, then you can break your fast.

So again, this is from a religious perspective, it is permissible to break that fast and actually encouraged because we don't want it to have a detrimental effect on our patient from both a medical or religious perspective. And a lot of times, if it's something that's, you know, 1 time, like today [if] I'm just not feeling well and I need to break my fast, we can actually make up the days later even though it's not in Ramadan. And so there's that option where you have a whole year to make it up, from Ramadan to Ramadan. And so that's 1 thing that we can kind of let our patients know about. And just remind them, you know, that that's an option, and it's okay. In addition to that, I think it's important to let them know when to break the fast, especially for patients with diabetes, like if blood glucose levels, if they're less than 70 or over 300, that would warrant breaking your fast.

In addition, if you have any symptoms of hypoglycemia, feeling dizzy, you know, dehydrated, that kind of thing, you will want to break your fast or hyperglycemia the same thing. So just giving them those tools and reminding them that it's okay. For patients who even can't make up those days—let's say, you know, our elderly patients who really can't tolerate fasting at any time of the year— they're able to financially; they usually give about $10 a day to feed someone poor or in need to make up for that. And so that's if they're able to and if they can't pay for that, then that's fine. And that's again, something that's religiously agreed upon. And like every year, it changes a little bit. It's about $10 or so.

We always say that Islam as a religion of ease and not hardship. And so even for travelers, you can break your fast so you can imagine like you go into a different state or hopping on a flight and there's a difference in time zones, and you may not be in your usual home and things like that you can break your fast. So, you know, just taking a step back and knowing that it's okay, it's really okay.

PT Staff: How can pharmacists support one another, and patients, during Ramadan?

Rania El-Desoky, PharmD, BCPS: I think it's really important for us to collaborate and communicate together. So share best practices; share the education, the knowledge, that we each gather from our different patient experiences with one another and that will help us really take care of our patients both safely and effectively and to the best of our abilities. On top of that is like continuing to constantly educate ourselves and really ask our patients about the different social and cultural factors that may impact their health beliefs and behaviors. Because if we don't ask a lot of times our patients will voluntarily let us know that you know, they will have a change in their diet for example, or in the way that they observe specific practices and so asking, I think, is a big part of that.

And in addition to that, I would say the ability to make those medication changes, even providing the support for them to have support groups for a couple patients who are fasting during Ramadan, [where] they can share their experiences with one another and talk about the hardships that sometimes come with it, and just being there to really answer your questions. I think that gives us that autonomy, and the patient's autonomy, to come and feel comfortable expressing some of the things that they're experiencing, whether positive or negative, during Ramadan and feel comfortable sharing, you know, their experiences and we adjust our recommendations appropriately.