Pharmacology Update 

Effects of Religious and Personal Beliefs on Medication Regimen Design

Tara M. Hoesli; Kelly M. Smith, PharmD, BCPS, FASHP, FCCP

Several religions, including Hinduism, Judaism, and Islam, prohibit the consumption of swine and bovine products. More than 1000 medications contain inactive ingredients derived from these sources.

Poverty, distance, and language are the primary reasons patients fail to seek medical attention. However, there is another difficult barrier many patients face: More than 1000 medications contain inactive ingredients derived from pork or beef, the consumption of which is prohibited by several religions.1

Dire Consequences

The religion of Jehovah’s Witnesses is most commonly associated with its effect on medical care and its beliefs against the use of blood products. In 1 case, a young woman had an internal hemorrhage after a cesarean section of twins. As she was taken to the operating room, she gave consent for all diagnostic and therapeutic procedures necessary, except the administration of blood due to her religious beliefs. After stopping the bleed, physicians explained the severity of the situation if she did not receive a blood transfusion. The patient and family were asked repeatedly if she had changed her mind about receiving blood products. They were unwavering in their beliefs, and the patient subsequently died.2 While this is an extreme example, it illustrates the impact that patient beliefs may have on the outcome of care provided.

Religious and Personal Beliefs

Several world religions prohibit their followers from consuming certain foods, ranging from those not prepared in a specific manner to those derived from certain animals. Table 1 contains the primary food restrictions of several major religions. While Judaism opposes the ownership or consumption of pork, a related religious tenet is that a patient’s life is more sacred. Religious scholars debate whether this means porcine products are suitable once all other products have been used to obey the divine commandment of life preservation. Islam also prohibits the consumption of pork products, yet also upholds the sanctity of humans. Followers of Hinduism believe cows to be sacred but are allowed to use products produced from a living cow. The slaughtering of a cow is prohibited, and the use of bovine material in oral medication is considered offensive.3

Table 1: Prohibited Food Consumption According to Religious Beliefs and Personal Preferences

While not necessarily driven by religious beliefs, many individuals choose to practice a vegetarian lifestyle, which encompasses a variety of dietary restrictions. Vegans, considered the strictest vegetarians, do not eat any animal products, nor do they use products like leather or wool. Lacto vegetarians consume dairy products but not meat, eggs, fish, or fowl. However, ovo vegetarians consume eggs but not meat, fish, fowl, or dairy products. Lacto-ovo vegetarians consume eggs and dairy products, but no meat, fish, or fowl. The choice of a vegetarian lifestyle may not extend beyond dietary patterns; therefore, the assumption that a professed vegetarian is opposed to the consumption of oral medications that contain animal sources is often incorrect.4

Medication Implications

Many medications contain at least 1 inactive ingredient, the consumption of which may be prohibited by certain religions or personal beliefs. Gelatin, a common inactive ingredient in capsule shells, is made from the bone, skin, and connective tissue of animals, primarily pigs and cattle, but also poultry and fish.5,6 Stearic acid, made from the fat of cows and pigs (ie, tallow), is often seen in its salt form in medications.6 For example, magnesium stearate has binding and lubricating properties that help lubricate and aid in the ejection of tablets from the tablet press, the machine used during product manufacturing. Table 2 demonstrates how these ingredients impact the most commonly used medications in orthopedics.

Table 2: Common Orthopedic Drugs and Their Contents

Prescribing Considerations

When designing a treatment regimen, health care providers may only take into consideration a patient’s allergies, medical history, and other medications. However, the patient’s culture and religious or personal beliefs must be considered and the corresponding information actively solicited before designing a medication regimen. One study found that “63% of the total patient sample surveyed thought that physicians should inform them when prescribing drugs with ingredients that might be forbidden by patients’ religious beliefs.”1 By taking into consideration patient preference, there may be an increase in patient trust in the provider and in the likelihood of adherence to the medication.

Different Dosage Forms

Drug manufacturers can assist prescribers by providing a list of their products containing animal-derived ingredients. However, since inactive ingredients in medications vary, the generic form of a listed brand-name drug may not contain prohibited ingredients.

Since many capsules are made from gelatin, other dosage forms should be sought if possible. Many drugs are formulated not only as capsules, but also as tablets and solutions. Etodolac capsules contain gelatin while the tablet form does not. Fosamax tablets contain magnesium stearate while the oral solution does not. Coumadin injection could be used in place of the magnesium stearate-containing tablets. Also, some capsules can be opened and sprinkled on top of food, which bypasses the gelatin shell.

Customized Formulations

Compounding pharmacies formulate medications specifically for each individual patient they serve. They compound medications from pure powders without the use of lactose and dye for patients who are lactose intolerant or have dye allergies. Many active ingredients are available as pure powder, which can be compounded to exclude the inactive ingredient stearic acid. Pfizer makes capsule shells from a plant source that would be suitable for vegetarians and those with religious beliefs that forbid them to ingest animal-derived products. Jewish and Islamic patients are also permitted to consume these capsules since they are kosher and halal certified.8 Using pure chemicals, compounding pharmacies could create gelatin-free capsules for patients who wish to take medications in that form.

Manufacturer Response

Stearic acid and its salts (ie, magnesium stearate) are predominantly made from the fat of cows; however, there are also plant sources that many manufacturers use due to increases in bovine disease (eg, bovine spongiform encephalopathy).9 The source of magnesium stearate should therefore be verified with each manufacturer before switching to an alternative product.

Alternative Products

If a product is not available in a different dosage form, another product may need to be considered. For example, Prevacid and Prilosec contain possible offending substances in all of their available dosage forms, while Protonix delayed-release oral suspension is free of prohibited ingredients. Therefore, patients who have an ethical conflict with Prevacid or Prilosec could consider Protonix suspension as a treatment option. A summary of alternative products is listed in Table 2.

When all alternatives have been exhausted, Jewish, Muslim, and Hindu religious leaders suggest that an animal-derived medication is then acceptable because it is the only way to maintain life.3

Conclusion

The most important thing to consider when developing a medication regimen is the individual patient being treated. Each patient has a different view on how he or she wants to be treated, including the use of certain inactive ingredients in medications. However, most patients are unaware of these ingredients being in their medications. The clinician should be proactive and not leave it to the patient to broach the subject.1 Since patients have the right to make informed decisions about their medical treatment, it is important that health care providers involve the patient when making treatment decisions.

The Bottom Line
  • Hinduism, Judaism, and Islam restrict followers from consuming certain animal-derived products.
  • Most patients are unaware that medications often contain animal-derived ingredients.
  • Each individual’s view on religion and medication use should be taken into consideration.
  • Individual manufacturers should be consulted on the source of their ingredients.

References

  1. Sattar SP, Ahmed MS, Madison J, et al. Patient and physician attitudes to using medications with religiously forbidden ingredients [published online ahead of print October 12, 2004]. Ann Pharmacother. 2004; 38(11):1830-1835.
  2. Stotland NL. When religion collides with medicine. Am J Psychiatry. 1999; 156(2):304-307.
  3. Easterbrook C, Maddern G. Porcine and bovine surgical products: Jewish, Muslim and Hindu perspectives. Arch Surg. 2008; 143(4):366-370.
  4. The Vegetarian Resource Group. Most frequently asked questions. The Vegetarian Resource Group Web site. http://www.vrg.org/nutshell/faq.htm. Accessed October 18, 2010.
  5. Marques MRC, Cole E, Kruep D, et al. Liquid-filled gelatin capsules. Pharmacopeial Forum. 2009; 35(4):1029-1041.
  6. How we make gelatin. Gelatin Manufacturers Institute of America Web site. http://www.gelatin-gmia.com/html/rawmaterials.html. Accessed October 18, 2010.
  7. US Food and Drug Administration. Drugs@FDA. US Department of Health and Human Services Web site. http://www.accessdata.fda.gov/scripts/cder/drugsatfda/. Accessed November 2, 2010.
  8. Pfizer. How we do business. Annual Review 2009. Pfizer Web site. http://www.pfizer.com/investors/financial_reports/annual_reports/2009/iob-dobusiness.jsp. Accessed October 17, 2010.
  9. Hamad ML, Gupta A, Shah RB, Lyon RC, Sayeed VA, Khan MA. Functionality of magnesium stearate derived from bovine and vegetable sources: dry granulated tablets. J Pharm Sci. 2008; 97(12):5328-5340.

Authors

Ms Hoesli is a PharmD candidate and Dr Smith is from the Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky.

Ms Hoesli and Dr Smith have no relevant financial relationships to disclose.

The authors thank Scott Mudd and Allison Powell for their contributions and encouragement.

Correspondence should be addressed to: Kelly M. Smith, PharmD, BCPS, FASHP, FCCP, University of Kentucky College of Pharmacy, 789 S Limestone, Lexington, KY 40535-0596 (ksmit1@uky.edu).

doi: 10.3928/01477447-20110228-17

10.3928/01477447-20110228-17

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