Keywords

Cultural; Diet; Excipient; Medication; Prescribing; Religious; Values; Vegan; Vegetarian

Description

Doctors, nurses, pharmacists and other prescribers are duty bound to respect the values, preferences and beliefs of patients they prescribe for [1,3]. Just as religious, cultural and philosophical dietary preferences are respected in the provision of hospital food, patients have a right to know if their medication contains substances that might be prohibited [4,5]. reports on some of the issues prescribers face in meeting these requirements as many medications use alcohol or animal products in their manufacturing processes that might be contentious for many patients. This commentary summarises the findings of her study and makes recommendations for further research.

Taylor 2020 undertook a search of the product characteristics of 18 commonly used medications used for symptom management in palliative care, including analgesics, anti-emetics, laxatives, anti-psychotics and steroids. While animal products and alcohol were included in the list of excipients, it was unclear whether these substances were used in the manufacturing processes. Taylor therefore contacted 39 pharmaceutical companies that produced these medications to enquire about the processes involved. Although some companies responded very quickly, others were unable to provide the information sought after 21 days. Although some pharmaceutical companies source halal gelatine [6] .none of the companies contacted could confirm that this was used in their UK products and some were unable to specify the species from which the gelatine originated. This has implications for patients who want to avoid porcine or bovine products [7]. Animal rennet was often used in the extraction of lactose. While many companies confirmed rennet’s bovine origin, others were unable to specify the animal source and most could not confirm whether they had been slaughtered in accordance with any religious tradition Halal or Kosher. Stearates improve the solubility of medicines and have historically been derived from cow, pig or sheep fat [8]. Taylor 2010 found that most companies reported using stearates from vegetable or mineral sources, though this could not be guaranteed as manufacturing processes change. It is evident from Taylor’s study that the summary of product characteristics cannot be relied upon to provide sufficient information to meet the requirements of patients with religious or philosophical dietary preferences that prohibit the ingestion of animal products. Her article highlights individual variation in the views of patients as well as religious scholars in how they interpret religious and philosophical rules. Prescribers and pharmacists are called upon to establish patients’ wishes and preferences that could affect their choices around medication [9]. This requires consideration of medication excipients, the production processes involved, and any preferences regarding fasting. If acceptable alternative formulations or products are available, there may be cost implications [5]. Taylor 2020 further highlighted the wide variety of religions that promote fasting and its implications. During the month of Ramadan, for example, when Muslims abstain from food, drink and oral medication between dawn and sunset, they have reported arbitrarily modifying the times, frequency and interval between medication doses, sometimes taking all their daily medication at once [10].

Research Considerations

This is a significantly under-researched area of clinical practice. There is concern among some doctors that adherence could be compromised if patients are informed of medication excipients [11]. In the only study of patients, 88% of the 200 respondents with vegetarian dietary restrictions expressed a preference for medication that did not contain animal products, yet had unknowingly consumed them in the medication they had been prescribed [12]. Half said they would take medication containing animal products if there was no other alternative yet only 20% of those who preferred vegetarian medicines had asked their doctor or pharmacist about the ingredients. The reason for this lack of enquiry is unclear.

Further Research is needed to Establish

• The extent of patients’ concerns about animal products and alcohol - as medication excipients and in manufacturing processes;

• The knowledge and views of prescribers on culturally sensitive prescribing, and the communication process for effectively negotiating concordant prescribing;

• The experiences of hospital and community pharmacists in discussing these issues with patients;

• How to establish clarity from manufacturers about manufacturing processes that is timely and accurate;

• The views of religious leaders on the acceptability of medication (including excipients and production processes);

• The factors influencing whether patients discuss such concerns with health care professionals, whether they would be prepared to pay for alternative medication if it is more costly, and the impact on concordance if alternative medication is not available;

• Effective strategies for establishing patients’ wishes and negotiating medication management during periods of fasting.

Conclusion

In order to meet the needs of patients with religious, cultural or philosophical reasons for avoiding certain substances in medication, the summary of product characteristics cannot be relied upon. In order to establish whether animal products and alcohol are involved in manufacturing processes, contacting pharmaceutical companies is the only reliable method, though this in itself is not without its problems as product sources and manufacturing processes change; it is currently not possible to provide a list of ‘acceptable’ medication. Further research in this area is much needed.

References

1. Good Medical Practice: General Medical Council, Manchester.
2. Nursing and Midwifery Council; The Code. London.
3. Royal Pharmaceutical Society of Great Britain A competency framework for all prescribers. In: A Compet Frame for all Prescri. 2016.
4. Mehta N (2007) People have a right to know if their medicines contain animal ingredients. Pharm J 279:98.
5. Taylor B (2020) Culturally sensitive prescribing of common symptom management drugs. BMJ Supportive & Palliative Care. BMJ
6. Strickland S (2014) Dietary restrictions: implications on medication choice. Br J Gen Pract64: e670â??e671.
7. Tatham K, Patel K (2014) Suitability of common drugs for patients who avoid animal products. BMJ348: g401.
8. Tatham K, Patel K (2014) Why canâ??t all drugs be vegetarian? BMJ348: 18-20.
9. Ogden J (2016) Religious constraints on prescribing medication. Prescriber 47-51.
10. Aadil N, Houti IE, Moussamih S (2004) Drug intake during Ramadan. BMJ 329: 778â??82.
11. Sattar SP, Ahmed MS, Madison J, Olsen DR, Bhatia SC, et al. (2004) Patient and physician attitudes to using medications with religiously forbidden ingredients. Ann Pharmacother38:1830-5.
12. Vissamsetti B, Payne M, Payne S (2012) Inadvertent prescription of gelatin-containing oral medication: Its acceptability to patients. Postgrad Med J 883:499-502.