Safe medicines management during Ramadan

Respectful, culturally safe conversations can prevent self-adjusted dosing while supporting informed patient choice.

Each year during Ramadan, Muslims fast from dawn to sunset, abstaining from food and drink during daylight hours, with this year’s fast taking place from 18 February to 20 March.

For many patients, this practice coincides with the management of acute or chronic diseases, creating medicines-related challenges.

At Emerton Amcal Pharmacy in Western Sydney – an area with a large Muslim community – pharmacist Zara Gul sees these challenges firsthand. 

Before turning to dose timing or formulation adjustments, Ms Gul emphasises a key message that pharmacists should reinforce.

Health comes first

For patients managing chronic conditions, fasting is not mandatory if it compromises their health. 

‘If you’re on things like insulin and you need to be eating, you’re not obliged to fast,’ Ms Gul said. ‘Or if you’re on medications that you need to take at certain times – for example, epileptic medication or Parkinson’s-related medications, you’re exempt from fasting.’

People who are pregnant, unwell, sick or elderly are also exempt. ‘You’re not any less of a good Muslim by not being able to fast because of your health.’

However, Ms Gul advised that some patients, particularly older people, may feel compelled to continue fasting.

‘Sometimes the older generation will try to push themselves, and think, “I can miss my dose and take it later,” and then they fall ill,’ she said. ‘So we have to remind them that their health comes first.’

Timing is everything

For those who are medically fit to fast, timing medicine doses becomes the primary challenge. During Ramadan, meals are limited to early morning (suhoor) and evening (iftar) – which makes midday dosing difficult.

In some cases, simple adjustments can maintain therapeutic coverage during the non-fasting window.

‘If patients are taking medicines such as antibiotics three times a day, they can take one while they’re having their morning meal, one when they break their fast and one before they go to bed,’ Ms Gul said.

Approaching chronic disease management

Managing conditions such as diabetes during Ramadan can prove to be a challenge, with patients using insulin or certain oral agents potentially at risk of hypoglycaemia if fasting without modification.

For patients who are highly motivated to fast, collaborating with prescribers can  allow for regimen simplification.

‘For example, if someone wants to go on a longer-acting insulin and they’re only taking it at night, that could be an option,’ Ms Gul said.

‘You’re not any less of a good Muslim by not being able to fast because of your health.’

zara gul 

But caution is essential.

‘You also don’t want to confuse the patient by changing things unnecessarily. If they switch insulin just for Ramadan and then go back afterwards, that can cause problems. And doctors might not want to change someone’s medicine if they’re already stable.’

But sometimes this may prompt a positive long-term change.

‘Perhaps the patient doesn’t actually need to take a medicine three times per day, and they can switch to using it once daily long-term.’

Self-adjusted dosing

It’s common for patients to independently alter or omit doses during Ramadan, Ms Gul said.

‘People will definitely try. They might skip doses, or they’ll say, “My doctor told me to take it at lunch, but I’m fasting, so I’m not taking it”,’ she said.

‘So if you know someone is observing Ramadan, you could ask, ‘How are you going to manage your medication? Are you finding it easy to manage it with the times?” That can open the door for them to have a chat.’

Often, patients raise the issue directly when collecting prescriptions.

‘When we’re handing medication out and we’re talking to the patient about it, they’ll often tell us they’re fasting and ask how to manage it,’ Ms Gul said. 

‘That’s a great opportunity for us to look at options – for example, if they’re taking Trajenta at lunchtime, you might be able to move it to the morning when they’re eating their early meal.’

Starting the conversation

While many patients initiate these conversations, others are not always so forthcoming. So, broaching the topic of Ramadan requires cultural sensitivity, acknowledging that not all Muslim patients fast.

‘It’s hard to identify who’s observing Ramadan and who’s not, so it’s good to ask – not just not assume,’ Ms Gul said. ‘Someone might not be fasting because they’re unwell, and you don’t want to make them feel worse by assuming they are.’ 

Rather than directly referencing fasting, she recommends broader open-ended questions.

‘An easy thing to ask would be “How is your Ramadan going?” Ms Gul said. 

This allows patients to disclose relevant information at their own pace.

‘They might say, “I’m not able to fast this month because of my health,” or “I am fasting and I’m finding it difficult to manage my medicine”. Or they might say everything is going well.’

Knowing what invalidates a fast

Understanding dosage forms is another practical consideration, with some patients worrying that using medicines during daylight hours may invalidate their fast.

As a general rule, oral medicines and substances entering through open cavities invalidate fasting.

‘So you can’t use anything oral, or anything inside your nose or ear,’ Ms Gul said.

However pharmacists can reassure patients about non-oral options. ‘Using a topical cream or an eye drop is absolutely fine,’ she said.

For more information on providing care to culturally and linguistically diverse communities, watch the PSA webinar ‘Interpreter services – what every pharmacist & GP should know’.