What Patients On a Vegan Diet Need to Know About Medications

Veganism extends beyond food choices. An individual with a vegan diet may abstain from consuming animal by-products (eggs, milk, etc.) or even products manufactured with animals or animal by-products. For example, beer and wine may be clarified with isinglass (actually fish bladder gelatin). Carrageenan, made from red algae, is one alternative for gelatin used in vegan beverages. Lactose, lanolin (sheep wool wax), and beeswax are other common animal by-products in pharmaceuticals. Animal by-products are ubiquitous, although meat and other flesh are less commonly used.

Kosher and halal diet adherents share concerns with those on vegan diets. Vegan options are a solution when only non-conforming or uncertain products are available. For example, pig hoof is the usual gelatin source, the lac bug secretes shellac, and the cochineal scale insect produces carmine dye. Non-kosher creatures produce these products.

The FDA has a search engine to identify products containing a certain excipient, such as gelatin. Capsule shells are often composed of gelatin, but 115 different dosage forms (including dental pastes, syrups, and wafers) also contain gelatin.¹ Consult package inserts to identify inactive ingredients of interest. For example, 1 brand's levomilnacipran capsules’ package insert mentions shellac under “What are the ingredients in FETZIMA?”²

Fungal glucosamine is a vegan, and kosher alternative to shellfish chitin. Isinglass can be non-kosher if produced from sturgeon (its traditional source), but other fishes are available. Omega-3 fish oil may run afoul of kashrut/halal law depending on its source. Porcine-derived pharmaceuticals, such as desiccated thyroid, heparin, pancreatic enzymes, and non-human insulins, are strictly non-kosher/halal. Yet there is no single authority identifying kosher and halal goods, therefore there is some disagreement about whether dietary laws apply to these medications at all.

Porcine and bovine insulins are available outside the United States and patients may import them for personal use, if necessary. Porcine insulin has been unavailable in the United States since 2006 and the last bovine insulin producer discontinued its product in 1998. Bovine insulin may convey the infectious prions that cause bovine spongiform encephalopathy ('mad cow disease').³ The nervous tissues are the most likely to transmit BSE prions but any tissue, including the pancreas, may carry prions. Porcine and bovine insulins imported from the UK are available in Canada. However beef insulin importation to the US is complicated by its strict availability via a special access program (similar to “right-to-try” or compassionate use).⁴

Recombinant technology allows bacteria to produce the same insulin protein produced in the human pancreas. This avoids the need for human cadaver harvesting; both scant supply and strong taboo would limit human-derived insulin. Commercially available human insulin is both kosher and vegan.

Recombinant technology allows for vegan influenza vaccines, as well. The MMR, rabies, yellow fever, and most influenza vaccines are egg-based. The recombinant influenza vaccine is more expensive, and less widely available than egg-based vaccines and many providers are unaware of or unfamiliar with it. The recombinant influenza vaccine is cultured in a cell line derived from the fall armyworm (a type of moth native to eastern North America).⁵ Scientists have cultured this cellular isolate for (cell) generations, and no insects are harmed during vaccine production. Religious patients concerned by the vaccine’s insect origin may consult their faith experts for clarification. Patients with ovolactovegetarian diets, and egg-allergic patients may also prefer the recombinant vaccine, for ethical and health reasons.

The ovolactovegetarian diet is less constrained than veganism, and includes eggs, milk, and sometimes honey. These products’ producers can harvest them without harming the animal source. The humane collection of lanolin and wool fibers for non-food uses does not harm sheep either. Some ointments use organic, 'natural' lanolin, rather than mineral-based petroleum to assuage consumer concerns. Supplement manufacturers use lanolin to synthesize vitamin D as well.

A multitude of other animal-derived products may also concern patients with vegan, and vegetarian diets. Premarin is collected from pregnant mare urine (a product the horse would produce regardless) without harming the horse. Antivenom producers 'milk' the venom from its source, inject it into another animal (often a horse), then collect the serum antibodies to the venom. The antivenom manufacturer carefully selects the dose to avoid harming the animal in many, if not most, cases. Heme iron supplements have superior absorption compared to plant sources but are collected from blood. This blood may be a waste product at slaughterhouses without any additional animal slaughter or non-lethal harvesting. In addition, blood banks humanely collect whole blood, platelets, fresh frozen plasma, and clotting factors with minimal discomfort.

Encouraging patients to discuss their medication-related dietary concerns provides a greater personal sense of agency or control over their care. Whether a patient has ethical or religious convictions, a pharmacist is able to screen their medications and suggest alternative manufacturers or therapies. A pharmacist may also compound a product, as limited by patent law, or refer to another pharmacist who is able if necessary.

References

• Inactive Ingredient Search for Approved Drug Products. US Food and Drug Administration. https://www.accessdata.fda.gov/scripts/cder/iig/index.Cfm?event=BasicSearch.page. Updated April 6, 2018. Accessed April 10, 2018.
• Fetzima [package insert]. St. Louis, MO: Forest Pharmaceuticals Inc; 2014.
• Questions and Answers on Importing Beef or Pork Insulin for Personal Use. U.S. Food and Drug Administration Web site. https://www.fda.gov/Drugs/ResourcesForYou/ Consumers/QuestionsAnswers/ucm173909.htm. Published July 6, 2005. Updated October 28, 2015. Accessed April 7, 2018.
• Frequently Asked Questions: Animal-Sourced Insulin. Government of Canada Web site. https://www.canada.ca/en/health-canada/services/drugs-health-products/biologics-radiopharmaceuticals-genetic-therapies/activities/fact-sheets/questions-answers-animal-sourced-insulin.html. Updated October 10, 2015. Accessed April 7, 2018.
• Flublok [package insert]. Meriden, CT: Protein Sciences Corporation; 2017.