My query is regarding the use of insulin pumps (e.g., Omnipod) and continuous glucose monitoring systems (CGM) (e.g., Freestyle Libre, Dexcom G6) for use in Type 1 Diabetic patients. These items are only meant for one-time use and are also very expensive to purchase. A needle is inserted through the skin and covered with an adhesive. Removal of the sensor will result in having to discard the sensor or pump item. Can it be considered valid to perform ghusl by passing water over them instead of removing the sensor/pump or catheter insertion requiring it to be permanently discarded?
Both insulin pumps and continuous glucose monitors (CGM) consist of a subcutaneous component covered by an adhesive to secure it in place and to protect the subcutaneous component. In the case of insulin pumps, the subcutaneous component is a needle or cannula that is used for insulin delivery. In the case of CGMs, the subcutaneous component is a sensor that monitors glucose in interstitial fluid. Both stay in place for multiple days (2-3 days for insulin pumps and 7-14 days for CGM sensors).
Performing Ghusl while Using an Insulin Pump or CGM Device
For Muslims, this raises a question regarding the validity of ghusl when using one of these devices. When performing ghusl, a person must wash his entire body[i]. However, the adhesive that secures the infusion set in place prevents water from reaching the underlying skin.
One could either remove the device entirely, which is costly, or temporarily uncover the skin by removing the adhesive. Removing the adhesive would be problematic for several reasons:
- Temporarily removing the adhesive while leaving the needle in place increases the risk of infection at the site and the risk of hematoma/trauma due to movement of the subcutaneous portion.
- This may cause malfunction of the subcutaneous portion, leading to device malfunction.[ii]
- The subcutaneous portion would be dislodged requiring the insertion of a new needle.
Dispensations in Cases of Great Difficulty (al-Ḥaraj)
Having to replace the insertion site prior to its normal expiration period leads to significant difficulty (e.g., prohibitive costs of multiple insertion sets, repeated discomfort of needle insertion, bruising, and infection). The Sharī`ah aims to prevent this type of difficulty (al-ḥaraj). Therefore, wiping over the infusion site would be permitted as mentioned above. In comparable situations, scholars have given similar rulings. For example, in the case of certain professions that unavoidably result in water impermeable substances getting stuck under one’s nails, such as leatherworkers and garment dyers.[iii]
Comparison to Wiping Over a Bandage
Wiping over the adhesive avoids the difficulty described above. This situation is comparable to a puncture wound with a foreign body remaining at the site of puncture. One would then apply an adhesive bandage over the wound and wipe over it. According to the Sharī`ah, a person may wipe over a bandage placed over a wound when removing the bandage would cause harm[iv]. In the query, the wound is self-inflicted for a medical need, i.e., the insulin delivery and glucose measurement.
Is There a Need for Insulin Pumps and CGMs?
The dispensation above only applies when a wound needs to be covered. If a person has an injury that will not be exacerbated or prolonged by the removal of the bandage during ghusl, then wiping over the bandage will not be permitted. This raises the question as to whether there is a medical necessity that would justify wiping over the insulin pump or CGM site in the first place.
For diabetics, maintaining glycemic control and preventing hypoglycemic episodes is a medical necessity. Improved glycemic control, with a goal HgbA1c<7 for most adult patients, has been shown to reduce the risk of micro- and macro-vascular complications and subsequent end-organ damage[v]. Prevention of hypoglycemia is necessary due to its potentially devastating consequences, such as brain death and fatal arrhythmias[vi].
Insulin dependent diabetic patients most commonly use multiple daily insulin injections for insulin delivery. Studies have not shown one method to be significantly superior to the other in glycemic control, although a recent systemic review and meta-analysis found that insulin pump therapy offered a slight decrease in HgbA1c and a reduction of hypoglycemic episodes[vii]. However, the optimal choice is often dependent on the patient’s lifestyle and glycemic patterns. For example, insulin pump therapy can be of particular benefit in patients with variable insulin requirements, unpredictable schedules, and those who have not achieved glycemic goals with multiple daily injections[viii]. If after consultation with one’s doctor or a diabetic care team, an insulin pump has been deemed the optimal choice, a Muslim may wipe over the insertion site during ghusl.
Studies have shown CGM’s to improve glycemic control in type 1 diabetics and to reduce episodes of hypoglycemia in comparison to traditional finger-stick blood glucose monitoring[ix]. For most type 2 diabetics, studies have not shown as clear a benefit. However, CGM has been recommended for type 2 diabetics with multiple daily insulin injections, risk of hypoglycemia, or hypoglycemic unawareness[x]. Therefore, a Muslim with type 1 diabetes may wipe over their sensor insertion sites during ghusl, even if not prescribed by a doctor. On the other hand, a Muslim with type 2 diabetes should only do so if a CGM device is recommended by his doctor and diabetic care team.
- After consultation with a doctor or diabetic care team, a Muslim may wipe over an insulin pump insertion site during ghusl if it is deemed to be the optimal choice.
- A Muslim with type 1 diabetes may wipe over CGM sensor insertion sites during ghusl, even if not prescribed by a doctor.
- A Muslim with type 2 diabetes may wipe over CGM sensor insertion sites during ghusl only if recommended by a doctor or diabetic care team.
And Allah Knows Best
Mufti Adil Farooki, MD
Shaykh Mateen Khan, MD
[i] البحر الرائق , دار الكتاب الإسلامي، 1:48
[ii] Diabetes Care 1985; 8: 367–370.
[iii] االفتاوى الهندية , مكتبة رشيدية ، 1:13
[iv] رد المحتار على الدر المختار، دار الفكر، 1:60
[v] Glycemic Targets: Standards of Medical Care in Diabetes-2020.
[vi] J Clin Invest. 2007;117(4):868.
[vii] Ann Intern Med 2012;157:336–347
[viii] J Diabetes Sci Technol 2013;7: 1567–1574
[ix] Lancet. 2018;391(10128):1367.
[x] Diabetes Care. 2020;43(Suppl 1):S77.