COMPOUNDING FOR PROVIDERS
Chronic Pain Management - Providers
Chronic pain can be very difficult to manage in many patients. Many of the traditional oral drugs used for pain treatment, such as opioids, NSAIDs, and anticonvulsants, can have unwanted systemic side effects. These classes of medications, among others, can be just as effective in managing pain when used topically. Using a multimodal approach to treating symptoms of chronic pain has also been shown to be efficacious, which can be easily accomplished using a topical formulation.
Classes of medications that can be used topically include: NSAIDs, Alpha II Agonists, AMPA-Na+ Channel Blockers, GABA Agonists, NMDA-Ca2+ Channel Blockers, Tricyclic Antidepressants.
• Avoid first pass hepatic metabolism
• Avoid GI tract
• May improve compliance
• Increased drug concentration at site of pain
• Decreased systemic side effects
• Most common side effect is rash
• May not be suitable for large areas
• Absorption may vary from patient to patient depending on the stratum corneum barrier
Dermatology - Providers
Each patient's dermatological condition is unique which can create a challenge for practitioners in regards to finding treatment options. Compounding pharmacists have the ability and experience to compound individualized therapies for numerous dermatological conditions including scarring, acne, rosacea, skin discoloration, psoriasis, and eczema.
Treating these conditions often requires a multidisciplinary approach. Depending on the specific illness, a variety of drugs can be compounded into topical creams, lotions, gels, pastes, and ointments. Common agents used to compound formulations include calcium channel blockers (for circulation), anti-inflammatory agents, antihistamines, antipruritic agents, local anesthetics and many other classes of drugs.
Some of the conditions we help treat include:
• Athlete’s Foot
• Chemical Peels
• Diaper Rash / Incontinence
• Fever blisters
• Head Lice / Scabies
• Hyper-pigmentation Molluscum
• Nail fungus
• Poison ivy
• Radiation burns
• Scarring and Keloids
• Sun Protection / Photoaged Skin / Wrinkles
Hormone Replacement Therapy - Men - Providers
Many men can experience andropause or low-T as they age. As a result of declining free testosterone levels in the body, males can exhibit a variety of debilitating symptoms. Decreased concentration, lethargy, loss of libido, erectile dysfunction, and depression are commonly seen in men with low-T. Low-T is often characterized by total testosterone levels falling below 300 ng/dl. Testosterone supplementation can offer a solution for these patients.
Compounded topical and oral preparations are options to help patients with low-T. Many preparations are commercially available such as AndroGel, Testim, Striant. Injectable testosterone may not provide normal physiological serum levels for patients. In addition, patients may need specific dosing adjustments that may not be managed with these products. A compounded preparation could be an alternative if patients are having issues or concerns with commercially available therapy. Studies have shown that there is increased mortality specifically among patients with cardiovascular risks or history of cardiovascular issues. Complete medical histories should be taken and evaluated to ensure patient safety.
Hormone Replacement Therapy - Women - Providers
Many women have difficulties coping with chronic conditions stemming from menopause. These conditions can often be complicated to manage. Symptoms arise from deficiency or dominance of estrogen, progesterone, or testosterone. Hormone replacement therapy involves three main forms of circulating estrogen: estrone (E1), estradiol (E2), estriol (E3). Other important hormones include progesterone (P4), dehydroepiandrosterone (DHEA), and testosterone (T).
Studies have shown that combinations of E1, E2, E3, P4, and DHEA have been effective in treating various vasomotor symptoms that may be associated with menopausal hormone imbalance. Formulations include topical and vaginal creams, oral capsules and orally disintegrating tablets. Various ratios of these hormones exist in the female body, and in order to mimic these ratios, formulations often have to be compounded to contain some proportion of the three estrogens. Triestrogen or TriEst is a common name given to formulations containing E1, E2, and E3 while biestrogen or BiEst is a common name given to formulations containing E2 and E3. BiEst generally contains 80% estriol and 20% estradiol, while TriEst contains 80% estriol, 10% estrone, and 10% estradiol. A prescription written for 2.5 mg of BiEst will actually contain 2 mg of estriol (E3) and 0.5 mg of estradiol (E2) if using a conventional 80:20 ratio.
Hospice and Palliative Compounding - Providers
Compounded preparations can improve therapeutic outcomes, reduce side effects, and reduce the stress and discomfort associated with end-of-life care. Compounding medications for hospice patients is essential when other therapies fail or commercially manufactured medications are unavailable. If your patient requires alternative dosage forms, has allergies or side effects to commercially available products, or requires the use of multiple therapies combined into one medication, compounding pharmacists have the ability to customize compounded medications to meet these needs.
Compounded preparations can be used to treat a variety of underlying conditions related to hospice and palliative care including:
• Chronic Pain
• Skin Infections
• Breakthrough Pain
• Skin Ulcers
The following delivery forms may be available:
• Topical Gels/Creams
• Transdermal Gels/Creams
• Topical Ointments
• Oral/Sublingual Drops
• Flavored Oral Suspensions
• Rapid Dissolve Tablets
Pediatrics - Providers
Many medications are not available in child-friendly dosage forms. The most common factors that influence medication compliance among children include taste and appearance. The commercial market does not produce many formulations of medications that are easy to use in the pediatric population.
Compounding pharmacies are able to provide clinicians with a variety of options of medication dosage forms for their pediatric patients. Common preparations are seen in liquid and topical forms. Freezer pops, gummy chews, and lollipops can be made containing different medicines depending on patient need. These medications can also be flavored according to patient preference.
• Omeprazole suspension for reflux which is commonly seen in infants
•Topical diaper rash formulations using cholestyramine
Postpartum Care - Providers
After pregnancy, many women are faced with unexpected bodily changes including stretch marks, lactation failure, or sore and cracked nipples during breastfeeding. Treating these issues often becomes complicated as many medications can harm the baby in utero or postpartum, through breastfeeding. Compounded medications may the best solution as they can be customized to meet both the mother’s and the baby's needs.
Compounded medications can help treat many issues that may arise during pregnancy as well as post delivery. In regards to stretch marks, although there is no proven way to prevent stretch marks, certain topical products can be prepared to try to improve the elasticity and appearance of the skin. For some women, breastfeeding is not an option. Problems with milk letdown, which is the inability to lactate due to not having enough of the hormone, oxytocin, is a fairly common problem. If this is the case, oxytocin nasal spray can be compounded to facilitate lactation. As a result, you can give your patient the best chance to be able to breastfeed.
With breastfeeding comes the possibility of sore and cracked nipples. Special ointments can be compounded to soothe sore and cracked nipples. In addition, if a fungal infection develops, certain topical antifungals can be prepared for the infant and mother. Miconazole oral gel, clotrimazole oral gel, and gentian violet preparations can be applied to the mouth of the infant. Miconazole oral gel and clotrimazole oral gel can also be applied to the mother’s nipple(s).
Sports Medicine - Providers
Sports medicine, for athletes ranging from weekend warriors to World-Class Olympians, has proven to be another area where pharmacy compounding has shown to be very useful. For example, compounded medications can be used to treat sports-related pain, inflammation, muscle spasms, bacterial/fungal infections, and neuralgia. In addition, compounded medications can help treat excessive sweating, can be used for pre-game rubs, and can be used with iontophoresis and phonophoresis technologies, which are used to enhance drug penetration through the skin. Compounded medications allow personalized treatment and the options are unlimited as formulations are customizable in terms of dosage, method of administration, the number of active ingredients, absorption, and more.
Many preparations are commercially available to help manage pain, inflammation, and muscle spasms, but they can cause undesirable side effects. However, these medications, when used topically, can provide better therapeutic benefit with fewer unwanted side effects.
Treatment options may include:
• Topical NSAIDs such as ibuprofen
• Topical anesthetics such as LET gel (lidocaine, epinephrine, tetracaine)
• Medications for iontophoresis and phonophoresis such as steroids, dexamethasone, NSAIDS, local anesthetics, salicylates, and individual substances such as zinc oxide, iodine, acetic acid, and calcium chloride
• Medications used for pre-game rubs such as emu oil and anti-spasmodic drugs
• Medications for excessive sweating
• Nutritional Supplements
• Rehydration Drinks
Veterinary - Providers
Veterinary medication therapy often poses unique challenges. Many medications can be compounded to help with administration and treatment of conditions in a variety of animals. Compounded preparations are always prepared from FDA-approved animal or human drugs. These preparations are prepared and evaluated in a manner consistent with current potency, purity and stability standards. Compounding pharmacies want to work with veterinarians to create specialized, effective formulations for their patients.
Depending on the animal and condition, various medications can be compounded into oral liquids, topical preparations, and animal treats.
• Topical methimazole gel for treatment of hyperthyroidism
• Phenobarbital and potassium bromide oral liquid for epilepsy
• Methocarbamol suspension for rhabdomyolysis in horses
•Antibiotic and antifungal liquid formulations for infections with appropriate flavoring to help with administration
Wound Care - Providers
As a provider, when treating wounds or serious injuries, you want to ensure you properly treat the wound in order to obtain the best outcomes. Customized medication becomes important when treating wounds, because the choice of medication as well as the formulation used (e.g., creams, ointments, gels) will affect the healing process.
Examples of compounded medications for wound care may include:
• Topical antibiotic solutions to be used during the healing process
• Papain/Urea Ointment for wound debridement
• Topical Phenytoin for ulcer healing
Topical compounds may include any of the following ingredients: Misoprostol, Metronidazole, Phenytoin, and Lidocaine.
Compounds may be made in a variety of combinations and may depend if there is pain and odor associated with the wound.
Writing a Prescription for a Compounded Medication - Providers
When Writing A Prescription for a Compounded Medication the Following Information Should be Included:
- Patient identification (name, date of birth, address)
- Drug allergies
- Indicate prescription is to be compounded
- Generic name of all active ingredients
- Strength or Dose of medication (for example: %, milligram, grams)
- Formulation desired (cream, gel, troches, capsule, suppository, ODTs, etc.)
- Quantity desired and/or days supply needed
- Directions for use
- Medical condition being treated
- Refills, if any.
If you have any specific questions regarding formulations, do not hesitate to contact our pharmacy.
Contact our pharmacists with questions. We're happy to answer any questions and discuss suitable options to meet your patient's needs.