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Pain Management Compounding

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 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
� Suppository
� 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

P1Ketoprofen 10 %Gel60g Apply 2 to 3 times a day
P1AKetoprofen 20%Gel60g Apply 2 to 3 times a day
P1BKetoprofen 1.5% + Piroxicam 2.5%Gel60g Apply BID
P3Diclofenac 5% + Lidocaine 4% + Prilocaine 2% + Gabapentin 3% + Baclofen 1%Gel60g Apply 2 to 3 times a day
P2 Ketoprofen 10% + Cyclobenzaprine 1% + Lidocaine 4% Gel60g Apply 2 to 3 times a day

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

P7Lidocaine 5% + Ketoprofen 20% + Ketamine 2% + Carbamezapine 5% + 0.2% 2-Deoxy-D-Glucose + 3% AcyclovirGel60g Apply 2 to 3 times a day

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.

P6PLidocaine 10% + Ketoprofen 10 % + Ketamine 10% + Gabapentin 10%Gel 60g Apply 2 to 3 times a day
P6P1Lidocaine 10% + Ketoprofen 10 % + Ketamine 10% + Gabapentin 10% + Nifedipine + Pentoxyfylline + Alpha lipoic acid Gel 60g Apply 2 to 3 times a day
P5Lidocaine 5% + Ketoprofen 20% + Ketamine 2% + Carbamezepin 5%Gel60g Apply 2 to 3 times a day
P6Lidocaine 5% + Ketoprofen 10 % + Ketamine 2% + Gabapentin 10% Gel60g Apply 2 to 3 times a day
P6ALidocaine 5% + Diclofenac 10% + Ketamine 3% + Gabapentin 10% + Dexamethasone 0.1% Gel 

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:

P3EDiclofenac 5% + Lidocaine 4% + Prilocaine 2% + Gabapentin 3% + Baclofen 1% + Tramadol 1%Gel 60gApply 2 to 3 times a day
P3F Gabapentin 3% + Ketamine 2% + Baclofen 1%Gel 60gApply 2 to 3 times a day
P4Lidocaine 4% + Menthol 1% + Camphor 0.5%Gel 60gApply 2 to 3 times a day
P4A Lidocaine 5% + Ketoprofen 20% + Ketamine 2% + Carbamazepine 5%Gel 60gApply 2 to 3 times a day
P5Lidocaine 5% + Ketoprofen 20% + Ketamine 2%Gel 60gApply 2 to 3 times a day
P5ALidocaine 5% + Ketoprofen 20% + Ketamine 2% Gel 60gApply 2 to 3 times a day
P5BLidocaine 5% + Ketoprofen 20% + Ketamine 2% + Carbamezepine 5% + Dexamethasone 0.1%Gel 60gApply 2 to 3 times a day
P15Amitriptylline 2 % + Ketamine 5 % + Gabapentin 6 %Gel 100gApply 2 to 3 times a day

Analgesic Capsules

P11Diclofenac 25mg + Glucosamine 333mgCap901C TID
P11ATramadol 30mg + Glucosamine 333mgCap901C TID
P11BDiclofenac 25mg + Tramadol 30mg + GlucosamineCap901C TID
APAP + Hydrocodone Cap
APAP + Hydrocodone + DextromethorphanCap
Morphine 10mgCap

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

Hyaluronic acid/Bupivacaine 40mg/10mg2ml syringeInj
Hyaluronic acid/Bupivacaine/Betamethasone 40mg/10mg/2mg2ml syringeInj
Hyaluronic acid Bupivacaine free 20mg 2ml syringeInj
Hyaluronic acid Bupivacaine free 40mg2ml syringeInj
Morphine + Clonidine 20mg/1mg/ml intrathecalInj
Morphine 8mg/ml intrathecalInj
Hydromorph + Bupivicaine + ClonidineInj

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

Lidocaine + PhenyephrineSpray

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

DexamethasoneIs a corticosteroid that can be used as an anti-inflammatory and anti-pruritic.
DiclofenacIs a non-steroidal anti-inflammatory drug (NSAID).
PiroxicamA member of the oxicam family, is able to inhibit edema, erythema, tissue proliferation, fever and pain.
KetoprofenIs a non-steroidal anti-inflammatory agent (NSAID) whose use is best indicated for pain involving torn muscles and like injuries.
PhenylbutazoneIs a pyrazolone derivative that exhibits anti-inflammatory, anti-pyretic, analgesic, and uricosuric property. It is primarily used for the treatment of all types of arthritis, including gout and osteoarthritis, and is also indicated for the treatment of painful shoulder and superficial thrombophlebitis
CyclobenzaprineIs a muscle relaxant and anti-spastic agent that affecting muscle function. 
LidocaineIs a local anesthetic, which, applied topically, is able to numb the area
KetamineTypically used for reflex sympathetic dystrophy, is for nerve pain that may not be responsive to other medications. This topical application allows practitioners to reduce the dose of more potent narcotic painkillers.
NaproxenIs a non-steroidal anti-inflammatory drug (NSAID) with anti-pyretic and analgesic properties
GuaifenesinHas been shown in several veterinary studies to be an effective muscle relaxant. Its mechanism of action is unclear.
AmitriptylineHas been shown to reduce nerve pain when used topically. Its mechanism of action is unknown.
CapsaicinIs effective for relieving neurologic, neuropathic, and arthritic pain.
Baclofen Is a very effective muscle relaxant and anti-spastic agent. It possibly works by decreasing excitatory neurotransmitter release.
CarbamazepineIs effective for treating trigeminal neuralgia. It decreases polysynaptic responses and blocks post-tetanic potentiation. This topical formulation is good for relieving nerve pain.
GabapentinHas been shown to be effective in relieving nerve pain. Gabapentin acts by mimicking GABA, an inhibitory neurotransmitter. Carbamazepine is also a good treatment for nerve pain.
ClonidineStimulates alpha-adrenoreceptors in the brain, resulting in reduced sympathetic outflow from the central nervous system.
Methadone Methadoneis a synthetic opioid agonist that has been shown to be effective in the treatment of chronic malignant and non-malignant pain. It has a great oral and rectal absorption, no active metabolites, prolonged duration of action resulting in longer administration intervals, and lower cost than other opioids.
LoperamideLoperamide, an opioid agonist produced an antihyperalgesic effect through peripheral opioid receptors in inflamed tissue.

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.

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 feel free to call one of our compounding pharmacist at (626) 960-4723 or fax at (626) 813-7648. 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.

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