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Did You Know? That treating chronic or acute pain by delivering medication to the right trigger point usually decreases the amount of medication the patient uses?

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Did You Know? That many medications used orally can be prepared for direct topical application to the pain site?

Volume 6, Number 10

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Compounding for Pain Management and Palliative Care

Association, the American Academy of Hospice and Palliative Medicine, the National Hospice and Palliative Care Organization, and the Texas and New Mexico Hospice Organization. In the following interview, Dr. Peralta describes the use of compounded medications in patients suffering from acute or chronic pain. How did you become interested in pain management? In addition to maintaining my office-based practice in internal medicine, I worked for 12 years as a hospitalist in the intensive care and critical care units in several local hospitals, where providing pain control was often an essential part of treatment. In my private practice, I identified three sets of patients who usually do not receive adequate pain management. First are those experiencing an acute

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An Interview with Alexander Peralta, Jr, MD

Alexander Peralta, Jr, MD, a specialist in pain and symptom management, is the director of Palliative Care Services for American Hospice of Texas in Fort Worth, Texas. Dr. Peralta received his undergraduate degree from the College of Pharmacy at the University of Texas at Austin, T exas, in 1968. In 1975, he was chosen as one of 50 national scholarship recipients by the president of Mexico to attend medical school; he subsequently completed his medical education at the Centro de Estudios Universitarios, Instituto de Estudios Biomedicos, Mexico, and New York Medical College in Valhalla, New York. While practicing in internal medicine, Dr. Peralta developed a special interest in and compassion for patients in pain. He is a diplomate of the American Board of Hospice and Palliative Medicine and a member of the American Medical C A S E R E P O R T

Ketoprofen 5% and Gabapentin 5% Gel for Neuropathy

Sam Pratt, RPh Pharmacy Specialists Altamonte Springs, Florida

A 72-year-old white woman presented with significant pain and numbness in her lower legs and feet. She had been given a diagnosis of diabetic neuropathy with associated nerve damage and essential tremors 8 years earlier. Her other medical problems included heart disease, chronic obstructive pulmonary disease, and rheumatoid arthritis. She had been treated for the last 4 years with oral gabapentin (Neurontin). However, the gabapentin did little to ease her pain and numbness, which she described as "like walking on broken glass." compound instead of an oral medication for this patient because she was already taking a number of oral medications.

Outcome

Before using the ketoprofen/gabapentin gel, the patient felt pain from the tops of her calves to the bottoms of her feet. After the first application, she noticed improvement. Within a month, her symptoms were more tolerable; her condition has continued to improve since that time. In view of these results, her physician discontinued the use of the oral gabapentin. She now relies solely on the ketoprofen/gabapentin gel to relieve the symptoms of neuropathy. Today, the pain and numbness have been significantly reduced and are limited to her ankles and feet. For more information, contact Sam Pratt, RPh, Pharmacy Specialists, 650 Maitland Avenue, Altamonte Springs, Florida 32714.

Treatment

Her physician, a neurologist, set up a pharmacy consultation and asked me to prepare a topical gel containing ketoprofen 5% and gabapentin 5%, to be applied 3 or 4 times daily. He was especially interested in trying a topical

Peralta

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Which compounded medications do you prescribe most often? 1. A gel or suppositories of ABH (Ativan [lorazepam] 1 mg, Benadryl [diphenhydramine hydrochloride] 25 mg, and Haldol The second set of patients whose pain is [haloperidol] 1 to 2 mg, to which Reglan inadequately treated includes those with [metoclopramide hydrochloride] 5 to 10 mg conditions such as rheumatoid arthritis, lupus is sometimes added) for administration erythematosus, progressive systemic sclerosis, How did you become interested in prescribing every 4 to 6 hours to relieve anxiety, or other connective tissue disorders. Many delirium, nausea, vomiting, and compounded medications for pain physicians are very reluctant to provide terminal restlessness management? analgesic medications to relieve the severe I began to appreciate the bene ts of com2. Hydromorphone 50 mg or 100 mg in pain caused by such disorders. I found that pounding when I practiced pharmacy for 7 capsules or suppositories for administration treatment with anti-in ammatory drugs, gold years before I pursued a medical career. I every 4 or 6 hours to relieve severe pain therapy, and methotrexate often did not relieve worked as the compounding pharmacist at a 3. Ibuprofenor ketoprofen in Pluronic lecithin the pain caused by rheumatic diseases, which university teaching hospital that included 58 organogel in a variety of strengths for is debilitating and causes the eventual loss of specialty ambulatory care clinics at a remote administration every 4 or 6 hours to relieve functional capacity. Without e ective pain site. We prepared cough syrups, ointments, joint or bone pain relief, performing the activities of daily living creams, lotions, parenterals, and other becomes di cult or impossible. I began to medications very economically on a large scale. 4. Dextromethorphan 60 mg or 90 mg capsules prescribe low-dose opiates (morphine 30 mg One of our British clinicians even asked us to administered every 8 or 12 hours to relieve once or twice daily) for those patients, many make a Brompton's cocktail (a mixture of nociceptive or neuropathic pain of whom were elderly, and found that they morphine, cocaine, chlorpromazine, and 5. Morphine sulfate capsules, suppositories, experienced no therapy-related adverse e ects. Everclear [grain alcohol])! We also comampoules for inhalation, or solution for In fact, they could engage in more functional pounded preparations used in hyperalimentaintravenous or subcutaneous administration activities, such as water aerobics. Their quality tion, which for me is the epitome of comin various strengths to relieve pain of life improved measurably when they were pounding. I was quite content being a and dyspnea not in pain. pharmacist, but the opportunity to study 6. Midazolam and propofol to provide medicine presented itself at the right time. The third set of patients with inadequately palliative sedation treated pain consists of residents of medical Why do you prescribe compounded care facilities such as nursing homes. I provide These preparations are usually e ective within medications for pain management? medical care for many of my elderly patients 10 to 20 minutes after administration. About 10% to 15% of the medications that I who are admitted to a nursing home, and I now prescribe are compounded, and approxiWhat should your colleagues know about have found that their pain often is not su cmately 85% of my patients respond to those the use of compounded medications to iently treated. Sta members often are afraid relieve pain? to administer prescribed opiates routinely, and formulations. That is an excellent rate of response to treatment: therapeutic agents that Compounded analgesics are extremely because such medications are given only as can resolve 70% to 80% of a patient's symptoms e ective in relieving the pain that accompanies needed, true pain relief is never achieved. are considered highly e ective. Analgesic so many life-limiting and life-threatening As I began to understand the needs of those formulations tailored to speci c medical needs diseases. E ective pain management requires three sets of patients, I became more actively bene t individual patients tremendously. I an understanding of the pathogenesis and involved in providing pain management. One cannot emphasize the importance of the neuropathophysiology of pain and of pharmaof my patients is a 42-year-old black woman patient-physician-pharmacist triad enough; it cokinetics and pharmacodynamics. Opioid who had been su ering acute pain crises is the only instance in the healthcare arena in analgesics can be titrated to relieve complex caused by sickle cell anemia. The ischemic pain which providers collaborate to customize and pain syndromes such as nociceptive or caused by that disease can be excruciating. personalize care for patients. That collaboraneuropathic pain. Most opiates do not have a Before she became my patient, she had been tion ensures that each compound is safe, "ceiling e ect," so they can be titrated to hospitalized for treatment of a sickle-cell pain clinically e ective, reproducible, and costachieve comfort for the individual patient. crisis approximately 12 times during a 3-month e ective, and that it produces minimal It's also important to dispel three myths about period. As her pain management consultant, I adverse e ects. Physicians who prescribe a compounding that are still perceived as fact promised her that pain would no longer by some clinicians. The rst myth is that compounded medications are not approved by the Food and Drug Administration [FDA], the second is that compounded medications Ketoprofen 5% and Gabapentin 5% Gel for Carpal have not been subjected to the rigors of Tunnel Syndrome bioavailability testing, and the third is that Sam Pratt, RPh containing ketoprofen 5% and gabapentin 5%. compounds are not prepared properly to achieve the desired e ect. Those assumptions Pharmacy Specialists The gel was to be applied 3 to 4 times daily to are totally untrue. I believe that each time a Altamonte Springs, Florida the patient's hands and left foot. nurse adds an ingredient to an intravenous A 55-year-old white man presented with solution, a pharmacist prepares a formulation Outcome numbness, tingling, and a swelling sensation After 2 weeks of treatment with the ketofor use in total parenteral nutrition, or a in both hands severe enough to waken him physician or nurse mixes chemotherapeutic profen/gabapentin gel, the sensations of at night. After a thorough evaluation, which agents for administration, he or she is comswelling and numbness in the patient's hands included nerve conduction studies, carpal pounding! Those activities do not require were signi cantly reduced (by 50% to 60%, tunnel syndrome was diagnosed. At the time by the patient's estimate). He is no longer approval by the FDA. Pharmacists trained in of diagnosis, symptoms had been present for wakened by the tingling in his hands. His compounding and aseptic technique can 2 to 3 years, aring several times daily. The formulate extemporaneous preparations that physician now believes that surgery to correct patient also presented with numbness and have been elegantly prepared and are e ective. carpal tunnel syndrome is unnecessary. pain in his distal left foot, which were A compounding pharmacist can provide The topical gel only partly reduced the excellent pharmaceutical care for the patients attributed to degenerative disease. Besides swelling and pain in the patient's left foot of the physician who understands the mechadi culty sleeping, these symptoms had (by about 25%, by the patient's estimate) nisms of pain, so that complete pain relief is caused partial incapacitation of his hands but has considerably increased his comfort provided with minimal adverse e ects, even in and discomfort when walking. when walking. the most di cult cases. His physician, a neurologist, concluded Overall, the patient's use of the ketoprofen/ Note: The American Medical Directors that the carpal tunnel syndrome could be gabapentin gel has provided signi cant relief Association has provided excellent guidelines corrected through surgery, but the degenerafrom the symptoms of carpal tunnel syndrome for the management of chronic pain in nursing tive disease could not be cured. No medicaand degenerative disease that he had at the home patients. tion was commercially available with an approved indication to treat either condition. beginning of this topical therapy. For additional information, contact Alexander For additional information, contact Sam Pratt, Peralta, Jr, MD, director of Palliative Care Treatment RPh, Pharmacy Specialists, 650 Maitland Services, American Hospice, 3124 Southeast His physician set up a pharmacy consultation Avenue, Altamonte Springs, Florida 32714. Loop 820, Fort Worth, Texas 77140. Website: and asked me to prepare a topical gel www.americanhospice.info.

pain crisis caused by a myocardial infarction, a pulmonary embolus, sickle cell anemia, or a traumatic injury. Physicians have been taught that providing analgesia for these patients obscures the cause of the disease, but experience in the acute care setting and researching the literature have shown me that treating an acute pain crisis doesnotmask the origin of a patient's pain.

control her life. She did not believe me initially, but e ective therapy made that promise a reality. During the subsequent 2 years, she was hospitalized only twice for the treatment of pain caused by her sickle cell disease. She was able to visit family members who lived in distant areas of the country and could continue activities that were once prohibited by her disease-related pain. She even entertained the possibility of re-enrolling in college. Providing that type of care is what pain management is all about.

compounded analgesic ensure that their patient receives the right dosage, in the right form, in the right strength, and at the right frequency to provide consistent pain control.

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RxTriad - A publication of the International Journal of Pharmaceutical Compounding. © 2003 IJPC. All rights reserved.

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