1. FASTING,MEDICAL PROBLEMS,SHARIA GUIDANCE
DR BAKHT BILAND KHAN
ASSOCIATE PROF.OF MEDICINE
PESHAWAR MEDICAL COLLEGE

4. Importance of Fasting in Ramazan
يَا أَيُّهَا الَّذِينَ آمَنُواْ كُتِبَ عَلَيْكُمُ الصِّيَامُ كَمَا كُتِبَ عَلَى الَّذِينَ مِن قَبْلِكُمْ لَعَلَّكُمْ تَتَّقُونَAl-Baqara .
O YOU who have attained to faith! Fasting is ordained for you as it was ordained for those before you, so that you might remain conscious (of God){2:183}.

5. Importance of Fasting in Ramazan & dispensation thereof
أَيَّامًا مَّعْدُودَاتٍ فَمَن كَانَ مِنكُم مَّرِيضًا أَوْ عَلَى سَفَرٍ فَعِدَّةٌ مِّنْ أَيَّامٍ أُخَرَ وَعَلَى الَّذِينَ يُطِيقُونَهُ فِدْيَةٌ طَعَامُ مِسْكِينٍ فَمَن تَطَوَّعَ خَيْرًا فَهُوَ خَيْرٌ لَّهُ وَأَن تَصُومُواْ خَيْرٌ لَّكُمْ إِن كُنتُمْ تَعْلَمُونَ Al-Baqara - 2:184.
[fasting] during a certain number of days. But whoever of you is ill, or on a journey, [shall fast instead for the same] number of other days; and [in such cases] it is incumbent upon those who can afford it to make sacrifice by feeding a needy person.  And whoever does more good than he is bound to do  does good unto himself thereby; for to fast is to do good unto yourselves - if you but knew it.

6. When Fasting to be DISPENSED
شَهْرُ رَمَضَانَ الَّذِيَ أُنزِلَ فِيهِ الْقُرْآنُ هُدًى لِّلنَّاسِ وَبَيِّنَاتٍ مِّنَ الْهُدَى وَالْفُرْقَانِ فَمَن شَهِدَ مِنكُمُ الشَّهْرَ فَلْيَصُمْهُ وَمَن كَانَ مَرِيضًا أَوْ عَلَى سَفَرٍ فَعِدَّةٌ مِّنْ أَيَّامٍ أُخَرَ يُرِيدُ اللّهُ بِكُمُ الْيُسْرَ وَلاَ يُرِيدُ بِكُمُ الْعُسْرَ وَلِتُكْمِلُواْ الْعِدَّةَ وَلِتُكَبِّرُواْ اللّهَ عَلَى مَا هَدَاكُمْ وَلَعَلَّكُمْ تَشْكُرُونَ. Al-Baqara- 2:185 .

7. Translation of Verse 2; 185
It was the month of Ramadan in which the Qur'an was [first] bestowed from on high as a guidance unto man and a self-evident proof of that guidance, and as the standard by which to discern the true from the false. Hence, whoever of you lives to see this month shall fast throughout it; but he that is ill, or on a journey, [shall fast instead for the same] number of other days. ALLAH (swt) wills that you shall have ease, and does not will you to suffer hardship; but [He desires] that you complete the number [of days required], and that you extol ALLAH (SWT) for His having guided you aright, and that you render your thanks [unto Him]. - 2:185   

8. Importance of Fasting; Sayings of Holy Prophet (s. a.w.s)
۱۔عن ابی ھریرۃ قال قال رسول اللہ من صام رمضان ایمانا و احتسابا غفر لہ ما تقدم من ذ
ذ نبہ۔ بخاری شریف
Narrated abu huraira(r.A): the messenger of allah (saw) said:"... Whoever fasts during ramadan out of sincere faith and hoping to attain ALLAH's rewards, then all his past sins will be forgiven." (Imam bukhari).

9. Importance of Fasting; Sayings of Holy Prophet (s. a.w.s)
عن أبي هريرة رضي الله عنه أن رسول الله صلى الله عليه وسلم قال: (إذا جاء رمضان فُتّحت أبواب الجنة، وغُلّقت أبواب النار، وصُفّدت الشياطين) رواه مسلم
The Messenger of Allah (saw) said, "When the month of Ramadan starts, the gates of the heaven are opened and the gates of Hell are closed and the devils are chained." (Imam Bukhari) ...

10. Importance of Fasting; Sayings of Holy Prophet (s. a.w.s)
عن أبي هريرة رضي الله عنه أن رسول الله صلى الله عليه وسلم قال: (قال الله عزوجل: كل عمل بن آدم له إلا الصيام؛ فإنه لي وأنا أجزي به، رواه البخاري ومسلم
The prophet (pbuh)said ,Allah says that the son of Adam will get reward for his every action,but fast is for me and I will give directly or I will be the reward for it.

11. Importance of Fasting; Sayings of Holy Prophet (s. a.w.s)
عن عثمان بن عفان رضي الله عنه، قال: سمعت رسول الله صلى الله عليه وسلم يقول: (الصيام جُنّة من النار، كجنّة أحدكم من القتال) رواه ابن ماجه
"Fasting is a shield with which a servant protects himself from the Fire." [Imam Ahmad, Saheeh]
On the Day of Judgment, "Fasting will say: O My Lord I prevented him from food and desires so accept my intercession for him." [Imam Ahmad, Imam Haakim and Abu Nu'aim, Hasan

12. Importance of Fasting; Sayings of Holy Prophet (s. a.w.s)
Abdullah ibn `Amr reported that the Messenger of Allah (saw), said: "The fast and the Qur'an are two intercessors for the servant of Allah on the Day of Resurrection. The fast will say: 'O Lord, I prevented him from his food and desires during the day. Let me intercede for him.' The Qur'an will say: 'I prevented him from sleeping at night. Let me intercede for him.' And their intercession will be accepted." [Imam Ahmad]

13. The Penalty (moral) Whoever breaks fast intentionally (un-necessarily)
عن ابی ھریرۃ قال قال رسول اللہ من افطر یوما من رمضان من غیر رخصۃ و لا مرض لم یقض عنہ صوم الدھر کلہ وان صامہ ۔ رواہ احمد والترمذی،و ابو داود و ابن ٘ماجہ ، Hazrat abu huraira narrated that the one who broke his fast without any reason or any disease and then keep fast for the whole life will not be compensated والدارمی،والبخاری۔

14. THE BLESSED NIGHT IN RAMADHAN.
INTERCESSOR.RAMAZAN AND QURAN
BAB E RIYAN
SAHOOR AJAR

15. Problem ? A 28-year-old lady recently diagnosed as type 1 DM.
She has one child and she plains for pregnancy.
She is on Mixtard 70/ units morning and
14units evening.
She exercises regularly and is stick to her diet.
Physical examination is unremarkable.
Sugar profile 99, 112, 116 and 102 mg%.
U/Es, LFT, lipid profile, urine analysis are negative.
A. How you will counsel her regarding fast?

16. Problem ? A 40-year-old smoker with dyspepsia.
Upper GI endoscopy showed duodenal ulcer, 10 days before Ramadan.
What is your advice?
Fifty-seven (57) patients with acute duodenal ulcer. All received Lansoprazole 30 mg per day. Randomized to fasting or dispension. Endoscopy performed at end of Ramadan. Symptoms were not different. Healing rate: Fasting 90%, dispension 88.8%. Patients on Lansoprazole may fast with any risk.

17. Problem?
A young university student has a viral upper respiratory tract infection. His temperature is 102 0F, and his throat is severely congested.
Chest: clear.
What is your advice regardind fast?

18. Case History
A 48 years old patient Mr. NJK who is a known hypertensive is brought to the OPD of Mercy teaching hospital with severe upper abdomen pain for last 8 hours starting in the middle of the night. It did not relieve with antacids syrup.
He has been having recurrent abdominal pain for the past seven years that would generally improve with medications prescribed by his doctor.
Mr. NJK works as CEO of a business organization and sometimes has to work till late night. He is a chronic smoker and smokes 20 cigarettes a day.
On examination he is pale and sweaty with pulse is 126/mt and BP 95/70 mmHg. He is markedly tender in upper abdomen.
What is the most likely diagnosis and why?
What three immediate investigation would you do in order of priority?
What treatment would you prescribe?
What advise you will give for fasting.? ?

19. The Need To Know Basics of Sharia Rules about Fasting 0f Patients
100 % Muslim Patients.
Doctor’s duty to counsel / educate patients regarding different diseases/ conditions and their effects on the body in fasting.
Its clear that a doctor is not supposed to give “FATWA” but only basic guidance.
Serious lack of understanding this fact on our behalf as our medical curriculum has never been built on these grounds in our medical schools in our country.

20. Objectives At the end of this session the student;
Must have an awareness of the sanctity of Ramazan from Quran and Hadith.
Develop the concept of dealing with common- place problems faced by their patients during FASTING.
Are sensitized to seek and pursue the knowledge about the situations arising from time to time.
Give clear concept to PATIENT about ramzan farziat ,QAZA,FIDYA.
Where islam insist on fasting where to not fast.it is not on our well, like and unlike(specially in pathans).
Educate pt about FATWA,TAQWA,and rukhsat.
Normal physiological conditions where fasting can be postponded for later on as in pregnancy and lactation.
Know about common problem as blood transfusion,blood donation
Cigarette , naswar. miswak, cathetrisation, endoscopy, local drug application and fasting.

21. ANY PROBLEM??? QURA’ANIC SOLUTION
(Al-Anbiya - 21:7) فَاسْأَلُواْ أَهْلَ الذِّكْرِ إِن كُنتُمْ لاَ تَعْلَمُونَ
(An-Nahl) فَاسْأَلُواْ أَهْلَ الذِّكْرِ إِن كُنتُمْ لاَ تَعْلَمُونَ  (16:43)
True about every problem; ask from the relevent expert.
DOCTORS / ULEMA KIRAM
Not advisable to give an opinion untill you really know yourself up to a standard; the penalty would fall twofold over us in wrong advise.

22. The Basic Tenets of Dispensation of an “ACT” From Holy Qura’an
لاَ يُكَلِّفُ اللّهُ نَفْسًا إِلاَّ وُسْعَهَا   Al-Baqara - 2:286
Allah (swt) does not burden any human being with more than he is well able to bear:

23. The Basic Tenets of Dispensation From Holy Qura’an
فَاتَّقُوا اللَّهَ مَا اسْتَطَعْتُمْ وَاسْمَعُوا وَأَطِيعُوا وَأَنفِقُوا خَيْرًا لِّأَنفُسِكُمْ وَمَن يُوقَ شُحَّ نَفْسِهِ فَأُوْلَئِكَ هُمُ الْمُفْلِحُون At-Taghabun - 64:16
Remain, then, conscious of ALLAH (swt) as best you can, and listen [to Him], and pay heed. And spend in charity for the good of your own selves: for, such as from their own covetousness are saved – it is they, they that shall attain to a happy state! 

24. The STRENGTH/ WIIL POWER of a PERSON
بَلِ الْإِنسَانُ عَلَى نَفْسِهِ بَصِيرَةٌ  Al-Qiyamah - 75:14,15.
nay, but man shall against himself be an eye-witness.
وَلَوْ أَلْقَى مَعَاذِيرَهُ
even though he may veil himself in excuses. 

25. The Strength of Man is well judged by ALLAH(swt).
لِّلَّهِ ما فِي السَّمَاواتِ وَمَا فِي الأَرْضِ وَإِن تُبْدُواْ مَا فِي أَنفُسِكُمْ أَوْ تُخْفُوهُ يُحَاسِبْكُم بِهِ اللّهُ فَيَغْفِرُ لِمَن يَشَاء وَيُعَذِّبُ مَن يَشَاء وَاللّهُ عَلَى كُلِّ شَيْءٍ قَدِيرٌ  Al-Baqara - 2:284
Unto ALLA(SWT) belongs all that is in the heavens and all that is on earth. And whether you bring into the open what is in your minds or conceal it, ALLAH(swt) will call you to account for it; and then He will forgive whom He wills, and will chastise whom He wills: for ALLAH (swt) has the power to will anything. - 

26. Guiding Principles for Doctors to Advise patients about Fasting
It is a generalization in the verse مریضا فمن کان منکم
It is the duty of a Muslim doctor to advise whether to fast or otherwise to patients in Ramazan.
The nature of diseases & the possible effects of Fasting there upon are the decisive factors whether to keep/ not to keep fasting.
Pts with mild diseases with no unbearable discomfort should keep on fasting.
Any such a disease where there is a fear of loss of an organ or of its function due to fasting should abandon it.

27. Guiding Principles for Doctors to Advise patients about Fasting
The monetary compensation of not observing fasting (فدیہ)will be in chronic, progressive , irreversible situations.
In Temporary ailments this is to postpone the fasting till recovery and to compensate (قضا)with the equal number of days in some non- Ramazan period.
If already has given of the فدیہ even then to fast if patient recovers from some chronic condition.

28. Guiding Principles for Doctors to Advise patients about Fasting
Modifications of drug doses and intervals if possible.
Patients in convalescence may postpone fasting till reasonable recovery.
It is not morally acceptable for those who don’t keep fasting due to illness or travelling to eat & drink in front of others who observe fasting if possible;
so bring it to the notice of the patient as it is also a sin in its own.

29. Guiding Principles for Doctors to Advise patients about Fasting
Fast is not effected by blood donation and blood transfusion
Drugs applied to skin superficially.
Catheteriasation
Miswak
Fast is despensed by
Endoscopy
Cigarette, naswar.

30. Common situations which may arise during fasting
Parenteral route drug administration
Injections ; “TONICS”/ Medications.
Nasal, aural, ophthalmic use drugs.
Sub – lingual, Cutaneous drugs
Inhalers, nebulisations / spacers/ rota halers.
DRE/ PV examination
Pregnant / lactating mothers
Dentistry ; tooth extraction, filling, scaling.
Surgeries in fasting
Miscellaneous conditions
Some Common diseases and fasting
DRE. Digital Rectal Examination
PV. Per Vaginal

31. Injections and Fasting
As a ‘Principle’ anything which is introduced into the body through non- natural routes ( eg apart from mouth , rectum, vagina, ears) will not harm the fasting.
Injections for gaining “energy” or quench thirst or hunger not allowed-( is against the spirit of fasting).
Injections for pain , fever etc allowed.
The problem will demand the ‘Fatwa’ & ‘ Taqwa’ of the individual person.
Highly dependent upon the decision of the doctor how much it is needed to give an injection in a particular case to a fasting patient.

32. EYE & EAR
Ophthalmic preparations. Not harming fasting; as it is not a natural orifice in that sense
Nasolacrimal duct? Leakage to the nasopharynx and deep into the throat.
Aural preparations in case of intact tympanic membrane will not harm the fasting;
A perforation there in can take the drug into the middle ear and there from to throat via Eustachian canal , so probably it may harm the fasting

33. DENTESTRY Minor procedures are usually performed under LA.
Use of plenty of water for repeated cleansing and gargling; so more possibility of swallowing of water/ debris etc
To be on the safe side , best to perform such procedures like extraction, scalling, filling done after breakfast.

34. Sub- Lingual Drugs Used mostly as anti-anginal or as pain killers.
Some of the drug may be swallowed with saliva.
So may harm fasting, hence may not be allowed to use in fasting condition.
Alternatives are skin patches.

35. Use of Inhalers , Nebulizers
Used to administer drugs deep to the respiratory tract through breathing, to increase the therapeutic effects & minimize the systemic side effects.
The administered drug particles may certainly stick to the oropharynx and swallowed down to the stomach, damaging the fasting.
As a principle such like preparations should be avoided during fasting.
To address the above benefits, long acting preparations available which could be used in Sihri and after Iftari hours.
Asthma:
Ibn Othaymeen:
The spray used for asthma does not reach the stomach and there is no harm from using it during fasting. Now, we have long acting inhalers (e.g., Salmetrol which could be used after sunset and before dawn.

36. SURGERIES & FASTING
Elective surgery may be planned to be postponed off after the Ramazan. Its not advisable to go for such surgeries in Ramazan as other matters are being low profile during this month, or to have surgery in hot , lengthy days of summer Ramazan. Such practice needs to be discouraged.
Emergency surgery are allowed.
Minor procedures , done under local anaesthesia may be performed during fasting without any harm.
EYE SURGERY UNDER LOCAL ANAESTHESIA??

37. DRE, PV, Rectal Crème, suppository, enemas
If performed with dry finger would not harm fasting.
Re-insertion of the “used” finger??
If finger lubricated, will break the fast ,making compensatory fasting later on obligatory.
Introduction of any drug via PR/PV route bears the above principles.
Per urethra will not harm fasting.

38. Pregnancy & Breast feeding
A pregnant woman can avoid fasting in Ramazan if there is probability of harm to herself or to the foetus.
Similarly a lactating mother can postpone fasting.
Its obligatory to complete the count of fasting days in some other time of feasibility.
If it is deemed certain that a pregnant or lactating lady may endanger her or her child’s (born/ unborn) health by fasting in Ramazan, she should be advised strictly against fasting and to compensate in other times of year.

39. Some other procedures GI endoscopy (upper/ lower) breaks the fasting.
Blood transfusion will not break the fasting.
Blood donation/ phlebotomy does not harm fasting.
Cutaneous application of drug does not harm fasting.
Smoking , Snuff breaks fasting.
Miswak allowed… avoid chewing Miswak.
Tooth paste may be desist able. If swallowed would break fast.

40. Kidney Diseases
During Ramadan, fasting patients with significant renal failure need close monitoring to offer appropriate advice.

41. KIDNEY DISEASES
Nephrolithiasis, ureterolithiasis may cause much discomfort, especially when there is movement of the stone,
If it is aggravated by FASTING particularly of hot summer weather, it may be postponed.
Stone formation may be enhanced by precipitation of crystals due to dehydration in fasting of summer season , so FASTING may be postponed there of.
It may depend upon the individual situation and the personal experience of a particular patient.
Renal Function in Fasting
Urinary volume, osmolality, solute and electrolyte excretion remain normal
Slight increase in BUN (insignificant)
Increase in Uric acid (less in Ramadan fasting than in prolonged fasting)

42. KIDNEY DISEASES (Cont…)
Chronic Kidney Disease patients are advised not to observe fasting and advised to adopt the allowance فدیہ ۔
Similar in patients on haemodialysis.
Renal transplant?
Donor in acute stage??
Acute Renal Failure (AKI) patients may have a chance of recovery so such patients may be advised not to fast but later on observe the قضا.
Drugs used by renal transplant patient may be safely adjusted in Ramazan.

43. JAUNDICE, HEPATITIS(Acute/ Chronic)
Jaundice as such may not be a reason to postpone fasting as in Gilbert syndrome.
However the cause of jaundice may be considered as a basic for the taking decision about fasting.
Acute hepatitis of any sort may warrant postponement of fasting in first couple of weeks.
Patients of chronic hepatitis may observe fasting, similarly patients of compensated cirrhosis.
Decompensated cirrhotics may not be able to keep fasting and they may be advised about the “FIDYA”. Some patients if feel improvement they can have fast by mutual understanding of the doctor and patient.
Other Effects of Fasting
Slight rise in Bilirubin but no change in SGOT or SGPT
Fall in Gastric secretions
No change in Heart rate and BP
No change in Ca+ or Electrolytes
No change in Hb, blood counts or Fe store
Weight loss of Kg (obese lost more weight than non obese)
Decrease in appetite due to ketosis and increase in Beta-endorphins
Fewer suicide in Ramadan than in other months (reported in Jordan)
No change in outcome of pregnancy or in birth weight in those who fasted and those who did not (reported in Gambia)

44. Chronic Hepatitis C & B Treatment
Interferon in B & C
Ribavirin in C
Sofosbuvir in C
Nucleosides /Nucleotides in B

45. DIABETES MELLITUS
Type I may not be able to keep fast for ever, so better to go for the فدیہ.
Type II;
dose adjustment is required & it is usually sufficient to bridge over the fasting day;
Pt must be clearly educated about symptoms and signs of hypoglycemia and its immediate management.

46. Fasting for NIDDM Benefits of Fasting in Ramadan
A. Better control of Diabetes
B. Better control of Hypertension
C. Better control of Lipid
D lb weight loss
Thus Fasting is advised for stable NIDDM

47. Diseases of the Stomach
Ulcers get worse on empty stomach due to increased release and effect of acids on the ulcer, with a risk of bleeding and perforation.
The availability of more effective and long acting acid suppressants and ulcer healing drugs make it possible to keep fasting easily. Non responders or Zollinger Ellison syndrome pts may postpone fasting till recovery or go for FIDYA.
Non ulcer Dyspepsias usually get better in fasting.
Pts may be advised to avoid spicy and fatty meals in Sihri & Iftari.

48. Cardiac Patients
Angina Pectoris if possible to be controlled with BD medications , pt may be advised fasting۔
If needs to take drugs during day time pts should be advised to postpone fasting till they improve.
Pts of other chronic cardiac problems usually improve in due course of time with effective & appropriate treatment so they can postpone fasting to observe قضاlater.
Some pts with irreversible problems eg Cardiomyopathies may opt for Fidya.

49. Psychiatric Patients
Most of the disease like schizophrenia, depression, anxiety may be well controlled wit OD/ BD drugs , so most of these patients may be able to keep fasting once their acute stage is over.
Epilepsy may be controlled with appropriate adjustment of drugs.

50. Gynecological /obstetrical problems
وَيَسْأَلُونَكَ عَنِ الْمَحِيضِ قُلْ هُوَ أَذًى فَاعْتَزِلُواْ النِّسَاء فِي
(Al-Baqara - 2:222) الْمَحِيضِ وَلاَ تَقْرَبُوهُنَّ حَتَّىَ يَطْهُرْنَ 
Menstruation
Puerperium
so fasting is dispensed to women during mensturation and pueperium
but she will take the QAZA later on.

51. Blood Diseases
Anaemia
Sickle cell anemia
Polycythemias

52. Thyrotoxicosis

53. Thyrotoxicosis A hyperketabolic state.
Warning signs in a newly diagnosed or untreated thyrotoxic patient include the development of polydipsia, dehydration, diarrhea, and tachycardia, which would further worsen in the case of prolonged fasting.
These patients can skip fasting for few days till their symptoms improve.
They need to compensate for the missed days of Ramadan later.
Patients with mild to moderate symptoms of hyperthyroidism can fast safely.
Methimazole can easily be given in BD dosing, however propylthiouracil needing 4-6 hourly administration, requires swithing over.
Endocrine functions in Fasting
Fall in free T3 but rise in rT3
Slight fall in total T4 (due to fall in TBG) but normal freeT4 and TSH
TSH response to TRH unchanged
Serum Testosterone, LH, FSH may be normal or slightly low but GNRH response is normal
Plasma Prolactin and PTH are normal

54. Anti- Tuberculosis Drugs

55. Anti- Tuberculosis Drugs
As principle tuberculous patients are very ill, debilitated and demand high intake of calories; such pts may be advised to postpone fasting, however if pt is stable and tolerate fasting , may be advised to keep on
Important issue is taking the important component of the drug on empty stomach well before the next meal.
Needs re- scheduling of taking the drugs.
Will be better after the Taraweeh; most probably would fall after good 2 hours of Iftar.

56. Acute Febrile illness Generally, patients are dispensed from fasting.
THE ILLNESS IS INTENSE; that increases by fasting, or recovery is delayed.
Ahmad Bin Hanbal was asked, when is the patient dispensed from fasting. “If he could not” he answered.
They asked: fever, for example?.
He answered: “What disease is more severe than fever?”.

57. General advice for those who fast
Consult your (Muslim) doctor first
Practice fasting in Shaban first
With the approval of physician switch to either long acting or twice daily medication
Elderly patients on NSAID should have frequent monitoring of renal functions
Anticoagulant and Antiepileptic medications should be given at night .

58. Patients who should not fast
Diabetes Mellitus Type 1
Chronic Renal Failure including Renal Transplant and Nephrolithiasis
Severe cardiac and pulmonary conditions
G.I. Bleed and acute ulcers
Severe Epilepsy
Severe Migraine

59. سبحانک اللھم و بحمدک اشھد ان لا الہ الا انت نستغفرک و نتوب الیک
(ترمذی، ابو داؤد،ابن ماجہ و نسائی)

60. Reference