Islamic Ruling on Heparin

Prepared by Mawlana Dr. Mateen A. Khan MD and Dr. Ramzan Judge, PharmD

Summary

Generally, heparin is impermissible when alternatives are available. Permission exists within the Sharī`ah for heparin if the treating practitioner in consultation with a pharmacist determines that only heparin is a viable medication for the current medical need.

Introduction

Anticoagulants derive their pharmacologic effect by acting at different sites of the coagulation cascade. Some act directly by enzyme inhibition, while others indirectly, by binding to antithrombin.

Heparin is a naturally occurring anticoagulant indicated for the prevention and treatment of thrombotic events such as deep venous thrombosis (DVT), pulmonary embolism (PE), acute coronary syndrome (ACS), and atrial fibrillation. It binds antithrombin to inactivate thrombin leading to decreased fibrin. Thus, it prevents the formation of clots and prolongs clotting time. It is commonly used in medical settings as two formulations, unfractionated and low molecular weight heparin (LMWH). Unfractionated heparin is available in intravenous and subcutaneous formulations. LMWH’s (enoxaparin and dalteparin) are available only in a subcutaneous formulation. Medical contraindications to heparin include patients with active bleeding, patients unable to have routine aPTT monitoring, or patients with a history of heparin-induced thrombocytopenia.[i]

Shar`ī Assessment

Heparin is sourced only from animal tissue. The primary sources across the globe are porcine or bovine. Currently, the only FDA-approved source of heparin in the US is from porcine intestinal mucosa.[ii] Given its common use in the inpatient and outpatient setting, unfractionated and fractionated heparin poses a significant problem for Muslim patients.

Allah, the Exalted, states:

He has only prohibited for you carrion, blood, the flesh of swine and that upon which a name of someone other than ‘Allah’ has been invoked. (2:173, 5:3, 16:115)

Say, “I do not find, in what has been revealed to me, anything prohibited for anyone who eats it, unless it be carrion, blood that pours forth, or flesh of swine – because it is impure – or there be an animal slaughtered sinfully by invoking on it the name of someone other than Allah. (16:115)

Generally, best-practice medical care requires having competency in religious beliefs and restrictions. This includes informed consent for treatments that may contradict religious beliefs. Medical practitioners, whether Muslim or not, should strive to accommodate these restrictions whenever possible for Muslim patients.[iii] Further, when something is impermissible in the Sharī`ah, it necessarily entails some level of harm, although the type of harm may be unknown to us. Some Muslim organizations have given blanket approval for the use of heparin. However, their assessment appears to be shallow and lacking due consideration of actual need (ḍarūrah) and available alternatives.[iv] Rather, the intake of porcine-derived products is categorically impermissible (ḥarām). Permissibility is found only when there is strong need and no viable alternative exists, either due to local unavailability or prohibitive cost.[v]

What follows is a list of the available medicinal alternatives to unfractionated heparin/LMWH for consideration when anticoagulation or DVT prophylaxis is needed.

Alternative medications to heparin:

Oral preparations:

Direct oral anticoagulants (DOACs) – This class of drugs include apixaban, dabigatran, rivaroxaban, and edoxaban.

Subcutaneous preparations:

Fondaparinux

Intravenous preparations:

Argatroban

Bivalirudin

Table 1: Lexicomp app. UpToDate Inc. Accessed March 16, 2022
Table 2: Lexicomp app. UpToDate Inc. Accessed March 16, 2022

Conclusion

Muslim practitioners and patients should open dialogues about religious restrictions and preferences regarding their medical treatment. The reader should clearly note that appropriate indication and correct usage of any medication should always be done in consult with the treating physician. Generally, heparin is impermissible while alternatives exist for it. Permission exists within the Sharī`ah for heparin if the treating practitioner in consultation with a pharmacist determines that only heparin is a viable medication for the current medical need.


Additionally, Muslim healthcare practitioners should take appropriate steps with their Pharmacy and Therapeutics (P&T) committees to include protocols to accommodate Sharī`ah guidelines.


[i] Warnock LB, Huang D. Heparin. [Updated 2021 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538247/

[ii] van der Meer JY, Kellenbach E, van den Bos LJ. From Farm to Pharma: An Overview of Industrial Heparin Manufacturing Methods. Molecules. 2017;22(6):1025. Published 2017 Jun 21. doi:10.3390/molecules22061025

[iii] Swihart DL, Yarrarapu SNS, Martin RL. Cultural Religious Competence In Clinical Practice. [Updated 2021 Nov 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493216/

Sadat-Ali, M, Al-Turki, H. The use of porcine derived low molecular weight heparins in Muslims. Saudi Med J 2013; Vol. 34 (8). Available from: https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.832.54&rep=rep1&type=pdf

Easterbrook C, Maddern G. Porcine and Bovine Surgical Products: Jewish, Muslim, and Hindu Perspectives. Arch Surg. 2008;143(4):366–370. doi:10.1001/archsurg.143.4.366

[iv] https://imana.org/resources/imana-brochure-use-of-heparin/

[v] رد المحتار على الدر المختار، ابن عابدين، دار الفكر (الشاملة)، 1:210

وقيل يرخص إذا علم فيه الشفاء ولم يعلم دواء آخر كما رخص الخمر للعطشان وعليه الفتوى

السابق، 6:389

وفي التهذيب: يجوز للعليل شرب البول والدم والميتة للتداوي إذا أخبره طبيب مسلم أن شفاءه فيه، ولم يجد من المباح ما يقوم مقامه

السابق، 1:233

(قوله أو قول حاذق مسلم) أي إخبار طبيب حاذق مسلم غير ظاهر الفسق، وقيل عدالته شرط

المحيط البرهاني في الفقه النعماني، أبو المعالي برهان الدين، دار الكتب العلمية (الشاملة)، 5:373

فإن الاستشفاء بالمحرم إنما لا يجوز إذا لم يعلم أن فيه شفاءً؛ أما إذا علم أن فيه شفاء، وليس له دواء آخر غيره فيجوز الاستشفاء به؛ ألا ترى إلى ما ذكر محمد رحمه الله في كتاب الأشربة إذا خاف الرجل على نفسه العطش، ووجد الخمر شربها إن كان يدفع عطشه؛ لكن يشرب بقدر ما يرويه ويدفع عطشه، ولا يشرب للزيادة على الكفاية.

البحر الرائق شرح كنز الدقائق، بابن نجيم المصري، دار الكتاب الإسلامي (الشاملة)، 1:122

الاستشفاء بالحرام يجوز إذا علم أن فيه شفاء ولم يعلم دواء آخر اهـ. وفي فتاوى قاضي خان معزيا إلى نصر بن سلام معنى قوله – عليه السلام – «إن الله لم يجعل شفاءكم فيما حرم عليكم» إنما قال ذلك في الأشياء التي لا يكون فيها شفاء فأما إذا كان فيها شفاء فلا بأس به ألا ترى أن العطشان يحل له شرب الخمر للضرورة اهـ.

رد المحتار على الدر المختار، ابن عابدين، دار الفكر (الشاملة)، 6:457

أقول: هذا غير ظاهر، لأن ما يخل العقل لا يجوز أيضا بلا شبهة فكيف يقال إنه مباح: بل الصواب أن مراد صاحب الهداية وغيره إباحة قليله للتداوي ونحوه ومن صرح بحرمته أراد به القدر المسكر منه، يدل عليه ما في غاية البيان عن شرح شيخ الإسلام: أكل قليل السقمونيا والبنج مباح للتداوي، ما زاد على ذلك إذا كان يقتل أو يذهب العقل حرام اهـ فهذا صريح فيما قلناه مؤيد لما سبق بحثناه من تخصيص ما مر من أن ما أسكر كثيره حرم قليله بالمائعات، وهكذا يقول في غيره من الأشياء الجامدة المضرة في العقل أو غيره، يحرم تناول القدر المضر منها دون القليل النافع، لأن حرمتها ليست لعينها بل لضررها.

فتاوی محمودیہ، جامیہ فاروقیہ کراچی، 18:380-386

امداد الفتاوى جديد، دوا میں افیعون، زكريا بك ڈپو انڈیا الھند، 9:257

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