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Religious Constraints on Prescribing Medication

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Religious Constraints on Prescribing Medication ANALYSIS ■ 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 world religions, including Islam, Judaism and Hinduism, 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. Religion 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 Muslims 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 belief implications for Hindu only voluntary one, so not everyone sufficiently to make it permissible for patients, as well as for some vegans and answered. Christians formed the largest observant Muslims to receive medicines vegetarians. Many Hindus 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. Sikhism 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 Christianity 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 thyro toxicosis 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 Buddhism 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 China or Vietnam, 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; 48 ❚ Prescriber December 2016 prescriber.co.uk Religion and prescribing l ANALYSIS ■ 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
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