Use of Orally Dissolving and Sublingual Medications While Fasting

Question: Do orally dissolving or sublingual medications like ondansetron and lorazepam break the fast? 

Answer:

Bismihi Ta’ala

Orally dissolving tablets (ODT) and sublingual (SL) routes allow for mucosal absorption of medications. This is particularly beneficial in patients with difficulty swallowing (dysphagia). It also bypasses gastric and enteral breakdown and liver first-pass metabolism. The medication must first be diluted into saliva before absorption into the mucosa. The patient must avoid eating, drinking, smoking, and possibly talking to keep the tablet in place to dissolve and give time to transfer from the saliva into the mucosa. This time is variable depending on drug and patient characteristics. 

In the case of ondansetron ODT and lorazepam SL, bioavailability is about 56% and 94% respectively indicating some portion of the drug remains in the saliva. This is likely the case even more so for the delivery (filling) agents. This is also reflected in the package insert administration instructions: 

  • Ondansetron ODT: “Immediately place the Zofran ODT tablet on top of the tongue where it will dissolve in seconds, then swallow with saliva.” 
  • Lorazepam SL: “The sublingual tablet, when placed under the tongue, will dissolve in approximately 20 seconds. The patients should not swallow for at least 2 minutes to allow sufficient time for absorption.” 

If the package insert is followed for Ondansetron ODT and the medication is swallowed, the fast is broken, and it will need to be repeated (qaā). If there was a medical necessity for taking it, there is no penalty (kaffārah). Otherwise, there is a penalty. 

If the package insert is followed for lorazepam SL, it presents us with two scenarios: 

  1. The drug is not necessary while fasting. Taking the medication is impermissible (makrūh taḥrīmī) because the chances of it entering the posterior pharynx is high and thus, unnecessarily risks one’s fast. If one were to take it, one would incur the sin. Additionally, if any portion of saliva or drug is swallowed unintentionally, the fast breaks, and it will need to be repeated (qaḍā’) without a penalty (kaffārah). If it is swallowed intentionally, then a penalty would also be due. 
     
  2. The drug is necessary. Taking the medication via the orally dissolving or sublingual route is permissible. The saliva should not be swallowed, and any traces of the drug should be washed out of the mouth. If any portion of saliva or drug is swallowed either intentionally or unintentionally, the fast breaks, and it will need to be repeated (qaḍā’) without a penalty (kaffārah).

And Allah knows best

Shaykh Mateen Khan, MD

Mufti Adil Farooki, MD

Dr Ramzan Judge, PharmD

Dr Samad Tirmizi, Pharm D

References

Sublingual route for systemic drug delivery, https://doi.org/10.22270/jddt.v8i6-s.2097 

Orally Disintegrating Tablets: A Review, https://doi.org/10.4314/tjpr.v8i2.44525 

Pharmacokinetic Comparison of Sublingual Lorazepam with Intravenous, Intramuscular, and Oral Lorazepam, https://doi.org/10.1002/jps.2600710227 

Efficacy of orally disintegrating ondansetron in preventing postoperative nausea and vomiting after laparoscopic cholecystectomy, https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2044.2008.05860.x 

حاشية الطحطاوي على مراقي الفلاح شرح نور الإيضاح، دار الكتب العلمية بيروت، 679 

قوله: “لما فيه من تعريض الصوم للفساد” لأن الجاذبة قوية فلا يؤمن أن تجذب منه شيئا إلى الباطن عناية 

الفتاوى الهندية، دار الفكر، 1:199 

وَكُرِهَ ذَوْقُ شَيْءٍ، وَمَضْغُهُ بِلَا عُذْرٍ كَذَا فِي الْكَنْزِ. وَمِنْ الْعُذْرِ فِي الْأَوَّلِ مَا لَوْ كَانَ زَوْجُ الْمَرْأَةِ وَسَيِّدُهَا سَيِّئَ الْخُلُقِ فَذَاقَتْ الْمَرَقَةَ، وَمِنْ الْعُذْرِ فِي الثَّانِي أَنْ لَا تَجِدَ مَنْ يَمْضُغُ الطَّعَامَ لِصَبِيِّهَا مِنْ حَائِضٍ أَوْ نُفَسَاءَ أَوْ غَيْرِهِمَا مِمَّنْ لَا يَصُومُ، وَلَمْ تَجِدْ طَبِيخًا، وَلَا لَبَنًا حَلِيبًا كَذَا فِي النَّهْرِ الْفَائِقِ وَذَكَرَ فِي التَّجْنِيسِ أَنَّ كَرَاهَةَ الذَّوْقِ فِي صَوْمِ الْفَرْضِ، وَأَمَّا التَّطَوُّعُ فَلَا بَأْسَ كَذَا فِي النِّهَايَةِ. وَيُكْرَهُ لِلصَّائِمِ أَنْ يَذُوقَ الْعَسَلَ أَوْ الدُّهْنَ لِيَعْرِفَ الْجَيِّدَ مِنْ الرَّدِيءِ عِنْدَ الشِّرَاءِ كَذَا فِي فَتَاوَى قَاضِي خَانْ. وَقِيلَ لَا بَأْسَ بِهِ إذَا لَمْ يَجِدْ بُدًّا مِنْ شِرَائِهِ أَوْ يَخَافُ الْغَبْنَ كَذَا فِي الزَّاهِدِيِّ. 

الفتاوى الهندية، دار الفكر، 1:202 

لَوْ أَكَلَ مُكْرَهًا أَوْ مُخْطِئًا عَلَيْهِ الْقَضَاءُ دُونَ الْكَفَّارَةِ كَذَا فِي فَتَاوَى قَاضِي خَانْ. الْمُخْطِئُ هُوَ الذَّاكِرُ لِلصَّوْمِ غَيْرُ الْقَاصِدِ لِلْفِطْرِ إذَا أَكَلَ أَوْ شَرِبَ هَكَذَا فِي النَّهْرِ الْفَائِقِ. وَالنَّاسِي عَكْسُهُ، هَكَذَا فِي النِّهَايَةِ وَالْبَحْرِ الرَّائِقِ. 

الهداية في شرح بداية المبتدي، دار احياء التراث العربي، 1: 122-123 

ولو أكل أو شرب ما يتغذى به أو ما يداوى به فعليه القضاء والكفارة 

ومن كان مريضا في رمضان فخاف إن صام ازداد مرضه أفطر وقضى 

Jadīd Fiqhī Masā’il, 1:128-129 

Kitāb al-Nawāzil, Muftiī Muḥammad Salmān Mansūrpūrī 6:385 

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