For patients on long-term medication, religious fasting is one of the most predictable and one of the most under-addressed risks in primary care. The community pharmacist is often the most accessible adviser, and a five-minute counselling conversation in the days before a fast can prevent hypoglycaemia, dehydration, missed doses and the breakthrough symptoms that follow.
This guide covers the principles community pharmacy teams in the UK can apply during Ramadan, Yom Kippur and other observances, drawing on guidance from the Diabetes UK / South Asian Health Foundation Ramadan position statement, the BNF and the NHS England guidance for pharmacy professionals supporting fasting patients.
What religious fasting looks like
The two fasts most relevant to UK pharmacy practice are Ramadan and Yom Kippur, although Lent, Bahá'í, Hindu and Jain fasts also touch the dispensing process for individual patients.
| Fast | Duration | Typical UK timing | Pattern |
|---|---|---|---|
| Ramadan | 29–30 days | Annual lunar month | Dawn-to-sunset, daily, no oral intake |
| Yom Kippur | ~25 hours | September/October | Sunset to nightfall the next day, no food or fluids |
| Eastern Orthodox Lent | 40 days | Spring | Often dietary restriction rather than full fast |
Most religious authorities exempt the seriously unwell, pregnant and breastfeeding women, children and travellers. The decision to fast is the patient's; the pharmacy's role is to make whichever decision is taken as safe as possible.
What breaks a fast
The Islamic theological consensus, summarised by the British Islamic Medical Association, is that medicines reaching the stomach via swallowing break the fast. By that test, oral tablets, capsules, syrups and lozenges are usually considered fast-breaking. The picture is more nuanced for the following routes, where many scholars accept use during fasting:
- Inhalers — generally considered not to break the fast
- Eye drops and ear drops — most opinions accept use
- Topical creams, ointments and transdermal patches — accepted
- Subcutaneous, intramuscular and intravenous injections — accepted by most authorities
- Suppositories and pessaries — varied opinion; many accept
Patients should be encouraged to discuss specific products with their imam where doubt exists. Pharmacy teams should describe the route of administration and the safety implications without offering a religious ruling.
Diabetes — the highest-stakes consultation
The 2021 Diabetes UK / SAHF Ramadan position statement classifies patients as low, moderate, high or very high risk for fasting. The very-high-risk category — type 1 diabetes, history of severe hypoglycaemia in the past three months, eGFR < 30, pregnancy, hyperosmolar state in the past three months — is generally advised against fasting.
For lower-risk patients who do fast, the table below summarises typical dose-timing changes:
| Medication | Pre-fast adjustment | Counselling point |
|---|---|---|
| Metformin once daily | No change | Take with iftar (breaking of fast) |
| Metformin twice daily | Two-thirds at iftar, one-third at suhur (pre-dawn) | — |
| Metformin three times daily | Switch schedule: full evening dose at iftar, lunchtime dose moved to suhur | — |
| Sulfonylureas (gliclazide, glimepiride) | Often dose-reduced at suhur, full at iftar | Hypoglycaemia risk; recheck glucose if symptomatic |
| SGLT-2 inhibitors | Generally continued | Dehydration risk — emphasise rehydration at iftar |
| GLP-1 agonists | Continued | Lower hypo risk |
| Basal insulin | 15–30% reduction often advised by clinician | Patient should consult diabetes team before Ramadan |
| Mixed insulin | Reverse the dose split | Clinician-led adjustment |
Pre-Ramadan structured education programmes are associated with lower rates of severe hypoglycaemia and should be discussed with the patient's GP or diabetes nurse two to three months before the fast.
Other long-term medicines
Antihypertensives. Once-daily formulations are usually taken at iftar. Diuretics are sometimes paused for the fasting period to reduce dehydration risk; this is a prescriber decision.
Antiepileptics. Twice-daily regimens may be acceptable as iftar/suhur dosing, but modified-release formulations should not be split or crushed. A pre-Ramadan medication review is advisable.
Inhaled corticosteroids and bronchodilators. Continued throughout the fast, generally considered not fast-breaking.
Oral contraceptives. Combined and progesterone-only pills must be taken on schedule. Patients should plan dosing within the eating window — for combined pills the established missed-pill rules apply.
HRT. Usually continued; oral preparations taken at suhur or iftar.
Anticoagulants. Warfarin INR can drift with dietary changes (Ramadan tends to lower vegetable intake and shorten meal frequency). Consider an INR check during the fast. DOACs are generally well tolerated as once- or twice-daily within the eating window.
Bisphosphonates. The empty-stomach 30-minute restriction is most easily met at suhur with a full glass of plain water before any food.
Yom Kippur
A 25-hour fast generally permits scheduling once-daily medicines outside the fast. Time-critical medicines — insulin, anticonvulsants, immunosuppressants, transplant medication — should not be omitted, and most rabbinical authorities explicitly permit medical exemptions.
A practical pre-fast checklist
The most useful intervention pharmacy teams can offer is a structured ten-minute review in the two weeks before the fast:
- List every regular medicine, dose and timing
- Identify those that need a clinician decision (insulin, diuretics, sulfonylureas, modified-release preparations)
- Discuss what counts as fast-breaking for each route
- Plan a written dose schedule for fast and non-fast days
- Provide a hypoglycaemia plan for patients with diabetes
- Confirm the patient knows when to break the fast (chest pain, severe hypo, symptoms of dehydration, fever requiring antibiotics)
PharmSee's salary data shows that clinical pharmacist roles in primary care now make up a meaningful share of the NHS pharmacy workforce; PCN pharmacists are well placed to lead these pre-Ramadan reviews, although community pharmacy is often the patient's first stop. The PharmSee pharmacy directory helps patients identify community pharmacies in their area for medicines reviews.
Sources
- Diabetes UK / South Asian Health Foundation, Ramadan and Diabetes — Position Statement
- British Islamic Medical Association — Ramadan Compendium
- BNF — Drug administration and timing in fasting patients
- NHS England — Pharmacy professional support for patients fasting in Ramadan