Tisha B’Av 2020

Most patients with Crohn’s disease and ulcerative colitis take medications either to induce a remission during a flare-up or to maintain their remission and prevent a future attack.

The issue of fasting on Tisha B’Av raises a common enquiry from religious patients as to how best to manage their tablets and whether it is safe to avoid the medication for the 25 hour fast.

I am not going to give Halachic advice which must be sought from a Rabbi, but in general medication is not considered as food and does not have the same stringencies as eating since there is no enjoyment in swallowing tablets.  Rabbis that I have spoken to understand that chronic conditions such as Crohn’s and Colitis require regular medications and would recommend no adjustments are made in respect of Tisha B’av (unlike Yom Kippur).

The issue in managing Crohn’s and Colitis is that the conditions are rarely considered life threatening these days. Nevertheless the impact of missing doses can be devastating in terms of symptoms, so here are my recommendations for those patients who are hoping to minimise their medications on the fast itself.

Mesalazine preparations – patients who take their medications (Pentasa, Mezavant, Asacol, Octasa, etc) 2 or 3 times per day can get just as much response by taking them once daily. Therefore I would advise taking the last dose before the fast starts on Wednesday instead of at bed-time. The Thursday dose can be taken as a once daily dose on Thursday evening after the fast goes out. If you are concerned about waiting until then, you can take half the dose in the morning without water or using a small amount of water, and half in the evening.

Steroids – It is risky to miss steroid medication even for a day, which is why patients are gradually weaned off prednisolone instead of abrupt withdrawals. One way around this is to gradually change the times of your dose as the fast approaches each day for 5 days so that your morning dose is taken a little later each day until the day before the fast when you take the steroids in the evening before the fast. On the fast day itself, you can now take the dose after the fast goes out and revert to your usual morning dose the following day.

Azathioprine and 6-mercaptopurine – drugs such as these have long half lives so won’t have any impact if you simply take the medication after the fast goes out instead of in the morning.

Methotrexate – this is taken weekly, so can be taken after the fast goes out if your day of taking it falls on a Thursday this year.

Loperamide – if patients require regular dosing to prevent diarrhoea, I would support this as you run the risk of becoming dehydrated. One should try to use the minimum amount of water to swallow the tablets.

Humira injections – injections are not an issue on fast days and can be administered as normal.

Fast well and let me know if you have any specific queries.

Please note: These recommendations are the views of the author and individual patients should seek clarification from their own Dr/ IBD Nurse if they wish to make those adjustments.