Pain Management                                                                   

Pharmacy compounding is the art and science of preparing customized medications for patients. Its practice dates back to the origins of pharmacy, yet the presence of compounding throughout the pharmacy profession has changed over the years. The pharmacist's role in preparing medications quickly changed to that of a dispenser of manufactured dosage forms. Within the last two decades, though, compounding has experienced resurgence, as modern technology and innovative techniques and research have allowed more pharmacists to customize medications to meet specific patient needs. Today, an estimated one percent of all prescriptions are compounded daily by pharmacists working closely with physicians and their patients.

In the simplest terms, we help physicians and patients solve medication problems: Unique medication strengths: A medicine may be available only in one or two strengths. However, a physician may find that the best dose is not one of those. We can prepare a dosage that meets the physician and patients needs. Therefore, there is no need to take too much medicine which could cause adverse effects or too little which may not work for you.

Unique dosage forms: Medicines often are available only in tablets or capsules. Certain individuals with swallowing difficulties may need a liquid, suppository or other dosage form. Through compounding, we can make several varieties of dosage forms, including: capsules, topical and vaginal creams, gels, oral and topical liquids, lozenges, troches, rapid dissolving tablets, mini troches, suppositories, injectables and more.

Unavailable medications: Pharmaceutical companies may stop making products for which there is a limited demand. If we can obtain the medicine in its chemical form, we can compound it for you.

Bad tasting medicine: Some individuals will not take a medicine because of bad taste. This is a special problem when a medicine must be taken for several months or years to control a chronic health problem. We can prepare dosage forms in flavors that people like. We have 40 different flavors (from peppermint to orange-guava-melon).

Allergies: Commercial medicines may contain flavors, preservatives, dyes and fillers. If a patient is allergic to any one of these ingredients using that medicine could result in unpleasant or life-threatening reactions. We can prepare medicines that are free of materials to which a patient is known to be allergic.
 

The compounding solution for pain management

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Struggling through chronic pain problems like arthritis, fibromyalgia, migraine, headaches and nerve and muscle pain does not have to be a daily activity. There’s a better solution: pharmacy compounding, a customized option for pain management. Every individual is unique, and the types of pain experienced can be equally diverse. By working with a compounding pharmacist, physicians can prescribe treatments tailored specifically for the patients pain management needs. Many commonly prescribed pain relief medications cause stomach irritation and other unwanted side effects. Compounding can provide alternate methods of delivery by combining the ingredients of traditional oral pain medications in a

• Topical gel/Cream 
• Spray form that can be applied directly to the site of pain
• Application sticks (varied in size)
• Capsules
• Tablet triturates
• Injectables
• Flavored/unflavored troches
• Lozenges

Topical pain relievers A specially prepared compound that combines several medications into a single topical gel ready to be applied directly to affected areas can eliminate these multiple products. Because patients vary in size, symptoms and pain tolerances, commercially available medications often do not provide appropriate dosage strength. Through compounding a physician and pharmacist can customize a medication to the exact amount needed by the patient. Development of transdermal gels capable of supporting multiple classes of drugs while enhancing penetration and subsequent delivery of drug entities across the skin barrier allow for a noninvasive, convenient, and relatively adverse-event free mechanism for accomplishing this tailored care. The recent development of a pluronic gel formulation has expressed significant efficacy over other gel formulations such as the carbopol-based formulation. Variations in absorption depend on numerous factors. As the polymer concentration increases, the diffusion coefficient of Ketoprofen decreases. As temperature increases, the diffusion coefficient of Ketoprofen increases.

The difficulty in transdermal delivery of drugs is in finding a vehicle that is able to solubilize drugs and that still possesses that capacity to allow transdermal delivery. The advantage that the current PLO gel offers is in its constituents that combine the desired properties of several entities to allow for maximal solubilization of drugs and maximal delivery of the drug through the skin. Current PLO gels contain lecithin as a constituent. The strategy involved is that lecithin is thought to disorganize the structure of skin while still leaving it intact and unharmed. Its presence also increases the drug's solubility in the solvents. Lecithin, along with the pluronic constituent, act as surface-active agents to aid in the extraction of lipids from the stratum corneum. This is important because the stratum corneum acts as the principle barrier to the percutaneous penetration and subsequent absorption of topically applied drugs. Water in the PLO gel acts as a penetration enhancer as well. We specialize in working with orthopedic surgeons and pain management clinics.

Back and shoulder problems labelled from P1 which is a simple Ketoprofen 10% cream. P3 is also very popular with orthopedic specialists.

Treatment for shingles:

P7 Lidocaine 5% + Ketoprofen 20% + Ketamine 2% + Carbamezapine 5% + 0.2%2 Deoxy-D-Glucose + 3% Acyclovir
 

Diabetic Neuropathy/ Neuropathic pain/ RSD:

Neuropathic agents applied transdermally to treat pain avoid systemic side effects, efficiently deliver the drug to the site of application and may also be able to administer multiple drugs in one dosage form. Agents used to increase the circulation are:

• Nifedipine transdermal
• Pentoxifylline transdermal
• Alpha lipoic acid: Modulates the nitric oxide within the cell, stimulates the glucose uptake from free radicals and also helps prevent diabetic neuropathy by decreasing lipid peroxidation of nerve tissue.
 

Dr. GH is a rheumatologist, who treats "Trigger Finger" and found P6A cream very helpful in alleviating symptoms associated with that condition. He suggests to use a moist hot soak for 2 to 3 minutes and then use the cream once to 2 times a day on the affected area. The formulation uses the non-greasy lipoderm base.

One physician used a hypertonic cream to improve blood circulation. His favorite ingredients are Morphine + Dextromethorphan and Gabapentin. He finds this very succesful in treating diabetic neuropathy. When applied topically, these everyday agents enable medical practitioners to lower the dose of more potent narcotics. Also, because of the dosage form, one is able to decrease the number of potential, harmful side effects associated with most pain relieving medications.

Other combinations:

Analgesic Capsules

Morphine--The primary drug in the area of pain management. As an analgesic preparation it is virtually irreplaceable. Unfortunately, when given chronically, tolerance always ensues. This is why we have incorporated Dextromethorphan into the formulation. Recently, it has been shown that Dextromethorphan can slow the development of morphine tolerance. It does this by binding to and blocking the NMDA receptor. This is the receptor that is needed for morphine tolerance to develop.

Oxycodone-- A morphine relative, is also a very good analgesic.
Hydrocodone-- Another morphine related medication used to decrease pain.
Dextromethorphan-- Extended release capsules are available so that the patient can continue his or her regular morphine related products and take this to slow the development of tolerance.

(The E.R. stands for extended release)
Morphine SO4 E.R. with Dextromethorphan: 15, 30, 60, 90, 100, 160,or 200 mg
Oxycodone E.R. with Dextromethorphan: 20, 40, 60, or 80 mg
Hydrocodone E.R. with Dextromethorphan: 5, 7.5, 10, 15, 30, 40 mg
Dextromethorphan E.R. 30 or 100 mg
Cyclobenzaprine 10 mg/ Guaifenesin 30 mg/ Dextromethorphan 30 mg

 

Liquid analgesics

As liquids, these analgesic products are used successfully in treating pain in children and the elderly, who may not be able to swallow capsules or tablets. Oxycodone is a semi-synthetic, morphine-related medication used for the management of severe pain. APAP stands for Acetyl-p-aminophenol, in short, Acetaminophen. It is used widely as an analgesic and antipyretic. It is effectively used in treating many types of pain including arthritis and menorrhea.

Aseptic compounding and Intrathecals

Nasal Sprays

For migraine sufferers, pain medication may be administered through nasal sprays, flavored troches, or lozenges. These dosage forms bypass the gastrointestinal tract, providing optimal results with less GI irritation.
 

Intraoral lesions

• Apthous ulcers
• Primary herpetic stomatitis
• Radiation necrosis
• Acute necrotizing ulcerative gingivitis

Aphthous ulcers:

Benign autoimmune condition canker sores (Aphthous ulcers) are very common. Typically, they are a shallow ulcer with a white or whitish/yellow base surrounded by a reddish border. Canker sores (aphthous ulcers) are a common form of mouth ulcer

Misoprostol-- Decreases pain and inflammation. Heals intraoral lesions within 24hours
Tetracycline-- is an antibiotic in the mixture to reduce the bacterial flora in and around the lesion.
Nystatin-- is to stop any fungal growth that might occur and complicate the problem even further. 
Chlorpheniramine-- an antihistamine is included for its local anesthetic action and the temporary relief it can grant from pain and discomfort.
Deoxy-2-glucose-- acts as an antiviral. 
Triamcinolone-- a synthetic steroid is used as anti-inflammatory and antipruritic agents

Topical GTN (Glyceryl Trinitrate) to reduce the discomfort associated with the application of capsaicin:

The burning discomfort associated with the application of capsaicin cream (0.025%) was significantly reduced by the application of GTN cream (1.33%). 

Compounding of medications has allowed us to customize a formulation, upon the request of a physician, to best suit a patient’s need. We are able to compound:
· Drugs, through transdermal route, {found to be of great advantage in situations where in a transdermal 
absorption would provide a therapeutic effect} ex: NSAID, by itself or in combination with muscle relaxants, 
steroids, analgesics, antipruritic, antiviral etc.
· By varying the composition of the gel, cream or the ointment base, the penetration of the active ingredient can 
be controlled to get a desired result. 
· Injectables {preservative free or custom aseptic compounding} ex: pain meds, intrathecal injectables, or eye 
preparations.

We specialize in customizing medications to meet unique patient and unique physicians needs. If you read about something in a medical journal and would like for us to source it or formulate it for your patients, Please call or email for more information. We will work with your Doctor to customize the best pain management solutions for you. We will mail directly to patients or physicians office. Our commitment to our patients and physicians is always our priority. We hope you will allow us to help you to help your patients.