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Religious constraints on prescribing medication

JOY OGDEN

It is important for SPL prescribers to take any religious dietary restrictions into consideration when prescribing in order to optimise treatment. This article summarises the main dietary restrictions of the largest religious groups in the UK and the problems that may be encountered with medication ingredients.

here is an ever-growing diversity of Treligious beliefs in UK society that prescribers need to take into account during their interactions with patients. Several , including , and , prohibit their followers from consuming certain foods and drinks, for instance alcohol, pork and/or beef products, or those not pre- pared in specified ways. Vegans and and interpreted differently by individuals, vegetarians, not necessarily for religious so some practices may be acceptable to reasons, also restrict their consumption some patients and others may not. An of animal-derived products. Very many open dialogue between a healthcare pro- medications contain at least one active fessional and a patient is necessary, so or inactive ingredient derived from prohib- proper consideration can be given to the ited sources.1 Most patients and many patient’s religious beliefs before prescrib- physicians are unaware that these ingre- ing drugs or treatment. Healthcare pro- dients might be in their medicine and pre- fessionals, including pharmacists, need scribers need to understand the issues to be able to define and explain medical and be sensitive to patients’ views necessity and to explore the existence before prescribing medication or treat- of suitable alternatives to haram or non- ment. is an important question, kosher medications, feeds and nutri- not always recognised in this context, but tional supplements.” how do you raise it? The RPS further advises: “It’s good Sid Dajani, Royal Pharmaceutical for prescribers and pharmacists to be Society (RPS) English Pharmacy Board aware of patients who fast, as it may well member and an independent community be possible to make modifications to a pharmacist, says: “Religions are followed patient’s medicine regimen. If not, and if prescriber.co.uk Prescriber December 2016 ❚ 47 ■ ANALYSIS l Religion and prescribing

by fasting the patient puts their health at misbehaviour and has a negative impact uals. They do not usually eat eggs, but risk, then healthcare professionals need on health, therefore it is classed as cakes or biscuits containing eggs are to clearly communicate the risks and haram and prohibited. Something consid- often considered acceptable. All other advise the patient to seek the advice of ered halal can become haram in prepa- meat and fish is restricted or avoided. the local scholars and imams.” ration, for instance by using alcohol in The cow is sacred, therefore beef cannot the process. Pork and its by-products are be eaten, but cows’ produce is pure and How many people in the UK haram for observant but accord- desirable. There are numerous fasting have religious affiliations? ing to a letter by the WHO on the findings days. The use of bovine-based drugs or In the 2011 UK Census,2 the question of Islamic legal scholars,3 transformation cartilage transplants derived from cattle, asking for religious affiliation was the of pork products into gelatin alters them would have implications for Hindu only voluntary one, so not everyone sufficiently to make it permissible for patients, as well as for some vegans and answered. formed the largest observant Muslims to receive medicines vegetarians. Many will maintain a religious group in England and Wales, containing pork gelatin, although others vegetarian diet during Diwali and Navratri, with 33.2 million people (59 per cent of do not agree. even though they might eat some meat at the population). Muslims were the sec- Animals not slaughtered in a speci- other times. ond largest group, with 2.7 million peo- fied way or that are unhealthy, diseased or ple (5 per cent of the population). Other a possible cause of death are all haram. major religious groups included Jewish, Foods containing animal fats or emulsifi- Some Sikhs are vegetarians, and may Sikh, Buddhist and Hindu, while a quarter ers from animal derivatives, blood or its avoid all meat, fish and eggs. Others of the population, 14.1 million (25 per by-products are haram. The acceptance might eat meat but not that slaughtered cent) reported that they had no religion of shellfish varies by community. Muslims according to the guidelines of other reli- and a small number had other religious sometimes use the term ‘mushbooh’ gions (halal or kosher), and some do not affiliations. These figures are subject to when it is unclear whether substances eat beef or pork. Observant Sikhs will not significant regional differences. are halal or haram. Practising Muslims consume alcohol. fast from food and drink from dawn to What are the main dietary sunset during the month of Ramadan, the Which medications and restrictions of these religions? ninth month of the Islamic lunar calendar. ingredients are generally in question? Christians have few restrictions on Judaism Pharmaceutical drugs come from a vari- their diet, and none are compulsory. Judaism has a complex set of dietary laws ety of sources, including plants, minerals The historical recommendation to avoid (kashrut) that determine what food and and animals. Micro-organisms are also meat on Fridays is now largely ignored drink are permitted. Those that can be the source of some drugs, for example by Protestants although devout Roman eaten are ‘kosher’ and divided into three certain antibiotics, although most are Catholics may restrict their consump- categories: meat, dairy and pareve (permit- now manufactured in laboratories. tion. Practising Roman Catholics are ted foods that are neither meat nor dairy). Certain pharmacologically active con- also more likely to observe fasting on Meat and dairy products must not be eaten stituents of plants are also used in medi- holy days and specified periods of the together; pareve products can be eaten cal treatment, such as digitalis extracted church year, such as Lent. Seventh-day with either meat or dairy. Shellfish and from foxglove. Minerals have been used Adventists are encouraged to eat a vege- pork are strictly forbidden by Jewish dietary to treat various afflictions for centuries, tarian diet and have prohibitions on pork, laws. Observant Jews will only consume such as iodine for thyro­toxicosis and gold alcohol, coffee and tea. kosher meat, ie from ruminant animals with for arthritis. split hooves (eg beef, lamb, mutton and Drugs that include animal ingredients goat) or poultry (chicken, duck, turkey and can be roughly divided into those with Buddhists have no set dietary laws and goose) that has been slaughtered accord- animal-derived active constituents and there is a great diversity. Many Buddhists ing to kashrut law to be passed as kosher. those containing more or less inert, inac- refrain from meat and encourage a vege- Foods not complying with these specifica- tive animal-derived excipients that are tarian diet, with moderation in all foods, tions are non-kosher. included to produce an effective vehicle and some are vegan. Other Buddhists, Prescribers need to consider and for a drug. often from or , will not eat alert their patients about medications Many pharmaceutical products have ‘pungent spices’ eg onion, garlic or leek. that might contain wheat starch during constituents that would have implica- the festival of Passover, when wheat, bar- tions for Jewish, Muslim, Hindu and Sikh Islam ley, rye, oats and spelt are not permitted. patients. Those with active ingredients In Islam, under sharia law, all food and directly derived from animals include: drink is permitted, ie ‘halal’, unless Hinduism heparin, an injectable anticoagulant, explicitly prohibited, in which case it is Many Hindus practise vegetarianism, but that is commonly extracted from por- ‘haram’. Alcohol can lead to addiction, dietary practices vary between individ- cine intestinal mucosa or bovine lung;

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conjugated oestrogens, used in some – although still available on prescription – calcium tablets, from animal bones; glu- HRT preparations, derived from preg- has largely been replaced by human insu- cosamine, from shrimp, lobster and crab nant mares’ urine; and insulin (bovine or lin or insulin analogues. Supplements shells; chondroitin from shark, bovine or porcine) extracted from the pancreas of with active ingredients that could be porcine cartilage; and heme iron supple- cows or pigs. These days, animal insulin derived from animal products include: ments, from animal blood.

Advanced Product listed SPC section Relevant information search term (limited to SPC)

Porcine Creon (pancreatin) 5.1 Pharmacodynamic properties Contains porcine pancreatin formulated as enteric-coated (acid-resistant) mini-microspheres within gelatin capsules

Curosurf (poractant alfa) 2. Qualitative and quantitative A natural surfactant, prepared from porcine lungs composition

Defitelio (defibrotide) 2. Qualitative and quantitative Produced from porcine intestinal mucosa composition

Fluenz Tetra nasal spray 6.1 List of excipients Contains porcine (Type A) gelatin (influenza vaccine)

Fragmin (daltaparin sodium) 5.1 Pharmacodynamic properties Produced from porcine-derived heparin sodium

Hypurin Porcine (insulin) 2. Qualitative and quantitative Porcine-derived insulin composition

Nutrizym 22 5.1 Pharmacodynamic properties Enzymes (lipases, proteases and amylases) Pancrease HL derived from porcine pancreas Pancrex (pancreatin)

Bovine Hypurin Bovine (insulin) 2. Qualitative and quantitative Bovine-derived insulin. composition

InductOs (dibotermin alfa) 6.1 List of excipients Contains bovine (Type 1) collagen

NovoSeven (eptacog alfa) 4.4 Special warnings and May contain trace amounts of mouse IgG, bovine precautions for use IgG and other residual culture proteins (hamster and bovine serum proteins)

Ethanol/alcohol Daktarin oral gel 2. Qualitative and quantitative Alcohol 7.59mg/g (miconazole) composition

Diazepam 5mg/ml solution 2. Qualitative and quantitative Ethanol 96% 100mg/ml for injection composition

Amitriptyline hydrochloride 2. Qualitative and quantitative Approximately 10.5mg ethanol per 5ml 25mg/5ml and 50mg/5ml composition oral solution

Co-trimoxazole for infusion 2. Qualitative and quantitative 13.2 % vol ethanol (alcohol) per 5ml 16mg/80mg per ml composition 6.1 List of excipients

Priadel liquid (lithium citrate) 2. Qualitative and quantitative 211mg ethanol 96% per 5ml composition 6.1 List of excipients

Table 1. Examples of searches within summaries of product characteristics (SPCs) held on the electronic Medicines Compendium (eMC; www.medicines. org.uk) to identify possible haram constituents of UK licensed medications6 prescriber.co.uk Prescriber December 2016 ❚ 49 ■ ANALYSIS l Religion and prescribing

Pharmaceutical companies are calcium and magnesium stearate and searched to identify possible haram becoming more aware of the need to mono- and diglycerides.5 The term constituents of UK licensed medica- cater for patients with particular dietary ‘tayyib’ is sometimes used to refer to tions – should be consulted with caution restrictions, so their major drugs with pharmaceutical products that are of because the details of any haram active active ingredients derived from animals good quality and produced by standard- ingredient or excipient needs a proper may well have synthetic alternatives, ised processes under sharia law.6 understanding of haram and of how to manufactured in the laboratory. search within the SPC for relevant infor- Medicines with largely inactive excip- Kosher or non-kosher mation (see Table 1). ients that may cause problems include In Judaism, porcine-derived and other A spokesperson for NICE says it has those containing ethanol (used as a sol- non-kosher products are allowed in not issued any specific guidance around vent), gelatin (common in capsule shells) non-oral medications used to treat an religious dietary requirements for the or stearic acid (often made from bovine illness, even if it is not a life-threaten- drugs it has examined, but stresses NICE fat and may be included in a salt form ing condition.3 However, some orthodox has not assessed all prescription drugs. in medicines; for instance, magnesium Jews might not agree with this and might However, for each piece of guidance or stearate is used as a lubricant during refuse treatment. drug appraisal NICE undertakes, it also tablet manufacture). Lactose, which is milk-derived, should carries out an equality impact assess- not be taken at the same time as medica- ment to determine whether there are Halal or haram tions containing meat-derived products. any issues it should take into account. For a medicine to be passed as halal, Products derived from shellfish or non- The spokesperson noted two references its ingredients and production methods scaly fish are not permitted. Hence, glu- to religious dietary requirements in the must be rigorously checked to ensure cosamine and chondroitin are generally NICE guidance on Food Allergy in Under they comply with sharia law. Gelatin considered non-kosher. However, some 19s: Assessment and Diagnosis,7 and ref- used to encapsulate medications is authorities may regard the considerable erences to religious beliefs in guidance often sourced from bovine or porcine processing of the shells and cartilage on fertility8 and blood transfusion.9 (and occasionally fish) skin, bones and and their nonchewable pill form to render The Royal Pharmaceutical Society’s connective tissue. If derived from pigs, them inedible nonfoods, and therefore practice support team say they do not it can be a problem for some Muslims, not required to be kosher for those in have any specific guidance for prescrib- although the issue is contentious. A need of treatment. ers on the need to ask a patient about paper issued by Sussex Partnership religious affiliations or attitudes to med- NHS Foundation Trust to clarify the sit- Who supplies halal medicines in ications with forbidden ingredients. They uation included a guidance statement the UK? add: “However, we follow the guidance by the Islamic Organization for Medical Halal medicines are available and used from the Specialist Pharmacy Service Sciences in Kuwait in 1995,4 which in some over-the-counter (OTC) remedies when we need to advise pharmacists on concluded that istihalah (the process but the production of solely halal pharma- an individual basis.” of change of a substance into one with ceuticals is currently limited to manufac- Patients and prescribers who are in different characteristics) can convert turers in countries that are predominantly doubt about treatment are advised to an impure substance into a pure sub- Muslim. The Halal Food Authority (HFA) is consult a religious leader. For Muslims stance, and thus the transformation of a halal certification company in the UK this would be an Islamic scholar, such bones, skin and tendons of impure ani- that includes some OTC medicines in its as a recognised local imam, or they can mals into the form of gelatin is sufficient lists of products. Some Muslims, how- contact the Muslim Council of Britain to render it permissible for consump- ever, might not consider the certification (MCB) for specific queries.10 A point of tion. However, there is much disagree- processes acceptable to their own inter- contact for Jewish patients and health ment on this issue. pretation of their beliefs. professionals would be their local rabbi. On the other hand, substances con- sidered halal can be rendered haram, Where do you find information How can prescribers help? if the preparation process is not cor- about specific medicines? Many drugs come in different forms (eg rect. Medicinal products containing Prescribers and patients should con- tablets or solution, as well as capsules), alcohol are not permissible although tact the manufacturers of pharma- so a different formulation with permissa- some religious leaders consider that ceutical products to ascertain their ble ingredients could be considered. Some if the alcohol is used for the purpose constituents and the process of prepa- manufacturers make capsule shells from a of dissolving or preservation only, it ration to determine if they are suitable plant source, allowing Muslim and Jewish can be deemed halal. Pharmaceutical for a halal diet, for example. The UK patients to consume them, as they are ingredients that might be considered Medicines Information (UKMi) advice kosher and halal certified. There are also mushbooh by some Islamic scholars sheet on medicines suitable for a halal plant sources for stearic acid and its salts, include butyl and cetyl alcohol, glyc- diet6 says that the Summaries of Product therefore the source of magnesium stea- erine, glycerol monostearate, lactose, Characteristics (SPCs) – which can be rate needs to be verified with the manu-

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facturer before deciding on an alternative access to information to allow patients to muslimconsumergroup.com/halal-har- source. If the chosen treatment is not avail- make an informed decision.” am-mushbooh_ingredients.html?panna=2 able in a different formulation, there might In the UK’s multicultural society, it 6. Specialist Pharmacy Service. UKMi. What be a similar treatment from the same is vital for prescribers and patients to factors to consider when advising on med- drug class that is free of nonpermitted engage in an open dialogue and to take icines suitable for a Halal diet? February 2016. https://www.sps.nhs.uk/articles/ substances. If all alternatives have been religious dietary restrictions into consid- how-can-i-find-out-if-medicines-may-be-con- explored without success, patients might eration when prescribing in order to opti- sidered-okoshero-or-ohalalo/ wish to consult their religious leader for mise treatment. 7. NICE. Food allergy in under 19s: assess- advice. Jewish, Muslim and Hindu religious ment and diagnosis. CG116. February 2011. leaders will interpret their scriptures in the References nice.org.uk/guidance/cg116. www.nice.org. case of a patient that has a life-threatening 1. Sattar SP, et al. Patient and physician atti- uk/guidance/cg116 illness, to determine whether there can be tudes to using medications with religiously 8. NICE. Fertility problems: assessment an exemption for a medication that is nor- forbidden ingredients. Ann Pharmacother and treatment. 1.9.1 Intrauterine insem- mally classified as nonpermitted. However, 2004;38(11):1830–5. ination. CG156. August 2016. Do not some patients might have their own inter- 2. Office for National Statistics. Full Story: do recommendation. https://www. What does the Census tell us about religion nice.org.uk/guidance/cg156/chap- pretations of their . in 2011? 16 May 2013. http://www.ons. ter/Recommendations#intrauterine- Muniba Naeem, a locum pharmacist in gov.uk/ons/rel/census/2011-census/ insemination south London, endorses RPS board mem- detailed-characteristics-for-local-authori- 9. NICE. Blood transfusion. NG24. November ber Sid Dajani’s recommendations and ties-in-england-and-wales/rpt---religion.html 2015. Do not do recommendation. https:// adds: “It is of great importance to make 3. Institute for Vaccine Safety. WHO letter www.nice.org.uk/donotdo/do-not-of people feel involved in decisions regarding reports on Islamic legal scholars’ verdict on opoietin-to-reduce-the-need-for-blood- their healthcare. As a practising Muslim, I the medicinal use of gelatin derived from pork transfusion-in-patients-having-surgery-un- believe that for the purpose of improving products. 2014. http://www.vaccinesafety. less-the-patient-has-anaemia-and-meets-the- health, it is acceptable to take medication edu/Porcine-vaccineapproval.htm criteria-for-blood-transfusion-but-declines-it- containing gelatin. However, in day-to-day 4. Sussex Partnership NHS Foundation Trust. because-of-religious-beliefs-or-other-rea- sons-or-the-appropriate-bl practice, I come across people of the Can Muslims use medicines containing ani- mal products? June 2011. http://www. 10. Muslim Council of Britain. Tel: 0845 2626 same religious background with opposing sussexpartnership.nhs.uk/sites/default/ 786 or www.mcb.org.uk views, resulting in poor compliance with files/documents/animal_products_in_medi- their medicines. As pharmacists, we are cines_-_guidance_for_muslims_-_jun_15.pdf Declaration of interests in a good position to cater to their needs 5. Muslim Consumer group. Your source None to declare. where possible to improve adherence. for Halal foods information. Halal-haram- We have the necessary knowledge and mushbooh ingredients. http://www. Joy Ogden is a freelance journalist

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