What you don’t know can hurt your patientsBen O’RourkeTed WilliamsChristine Wood Samantha WoodhouseBrian ZacherAtanaz Zargarizadeh

Presentation Outline Patient Care Team/ Site Description

Christine Wood Alternative Hormone Replacement Therapy

Brian Zacher Alternative Anti-Infective Agents

Samantha Woodhouse Alternative Pain Treatments

Atanaz Zargarizadeh Alternative Anti-Emetics

Ted Williams Conclusion

Ben O’Rourke

Lloyd Center Pharmacy

Compounding Pharmacy Provides specialty products for animals

and humans Major focus is on hormone replacement

therapy

Compounding

Compounding is the process of preparing a specialized medication for an individual patient when the standard Rx does not fill the bill.

Nordenberg, Tamar. Pharmacy compounding: customizing prescription drugs. FDA Consumer magazine. 2000.

Why Compound?

Patient may be allergic to inactive ingredients of manufactured drug

Right dose may not be available Patient may need drug in a powder, liquid,

lozenge, suppository, or other form Drugs for certain conditions are not made

Alternative Hormone Replacement Therapy Large portion of business Help meet the individual patients’

specific needs Indications

Siglers Prescription Drug Cards. 21st Ed. SFI Med Publishing Guyton A, Hall J. Textbook of Medical Physiology 10th Ed. WB Saunders Co. Pennsylvania. 2000

Alternative Hormone Replacement Therapy Men: thyroid deficiency, loss of strength/

endurance/ libido/ hair, prostate cancer Women: atrophic vaginitis, osteoporosis,

hypoestrogenism, breast cancer

Siglers Prescription Drug Cards. 21st Ed. SFI Med Publishing Guyton A, Hall J. Textbook of Medical Physiology 10th Ed. WB Saunders Co. Pennsylvania. 2000

Hormones

Progesterone Estrogens:E1, E2, E3

Premarin Testosterone:

SoyWild Yams

www.hormoneprofile.comGuyton A, Hall J. Textbook of Medical Physiology 10th Ed. WB Saunders Co. Pennsylvania. 2000

Chrysin

Stabilizes Testoserone Induces UDP-Glucoronosyltransferase

(UGT)

http://toxsci.oxfordjournals.org/cgi/content/full/82/1/70http://dmd.aspetjournals.org/cgi/content/full/28/9/1077Lacy, J LexiComp Drug Information Handbook 13th Ed. 2005

Baquacil polyhexamethylene biguanide (PHMB) A common swimming

pool biocide Protection against

bacteria and algae without the harsh effects of chlorine

A compound having a broad spectrum activity and low toxicity Ophthalmology

Acanthamoeba Keratitis Acanthamoeba

Small, free-living protozoa commonly found in water

Lives in two forms Trophozoite Cyst form

Patients notice pain, photophobia, and irritation

Clinical characteristics include stromal ring infiltrate, epithelial haze, and radial keratoneuritis

Combination therapy is used to treat

PHMB for trophozoites Eye Drop that is made at Lloyd

Center Pharmacy Chlorhexidine for cysts

Radial Keratoneuritis

Hassanlou, M et.al. Bilteral acanthamoeba ketatitis and treatment strategy based on lesion depth. Can J Ophthalmol, Vol. 41, No 1, 2006.

Other Uses

Bacterial VaginosisMost common vulvovaginal infection

Mouth Rinses Inhibits re-growth of plaqueReduces oral bacterial counts

HIV

Rosin, M et. al. “Effect of a polyhexamethylene biguanide mouthrinse on bacterial counts and plaque.” J Clin Periodontol. 2001 Dec; 28 (12): 1121-6.

Gerli, S, Rossetti, D, and Di Renzo GC. “A new approach for the treatment of bacterial vaginosis: use of polyhexamethylene biguanide. A prospective, randomized study.” Eur Rev Med Pharmacol Sci. 2003 Sep-Oct; 7 (5): 127-30.

Krebs, FC et.al. “Polybiguanides, particularly polyethylene hexamethylene biguanide, have activity against human immunodeficiency virus type 1.” Biomed Pharmacother. 2005 Sep; 59 (8): 438-45.

COMPUNDING FOR PAIN MANAGEMENT Chronic Pain and Compounding Pharmacy Different strength of mixed of compounds including

Morphin Hydromorphone

Which is five times more potent than morphin with lower incidence of side effects

Bupivicaine Local anesthetics block the generation and the conduction of

nerve impulses, presumably by increasing the threshold for electrical excitation in the nerve, by slowing the propagation of the nerve impulse, and by reducing the rate of rise of the action potential

Department of Neurological Surgery. Spinal cord stimulators and Spinal Pumps.http://www.cumc.columbia.edu/dept/nsg/NSGCPMC/specialties/spinestim.htmlPain Management Compounding http://www.bbpharmacy.com/paincompounding.html

METHOD OF DELIVERY Small doses of the opioid are delivered close to their

receptors in the dorsal horn of the spinal cord, resulting in high local concentration.

Fine catheters are placed within the epidural space or within the cerebrospinal fluid in the subarachnoid space.

Catheters may be tunnelled subcutaneously to exit under the skin at an accessible site. They are attached to a bacterial filter for intermittent or continuous drug administration or, alternatively, may be connected to a subcutaneously implanted reservoir or pump delivery system, which can function for weeks or months.

Department of Neurological Surgery. Spinal cord stimulators and Spinal Pumps.http://www.cumc.columbia.edu/dept/nsg/NSGCPMC/specialties/spinestim.htmlPain Management Compounding http://www.bbpharmacy.com/paincompounding.html

Alternative Pain Management

Most important of all, different dosages are prepared in these compounding pharmacies to fit with the patient’s pain characteristics, also with reduce of side effects of opioids in previous form of usage ( non-compounding pills and dosages). Compounding pharmacies prepare the pain medication for effective response that has not been achieved with previous treatments.

Department of Neurological Surgery. Spinal cord stimulators and Spinal Pumps.http://www.cumc.columbia.edu/dept/nsg/NSGCPMC/specialties/spinestim.htmlPain Management Compounding http://www.bbpharmacy.com/paincompounding.html

Case Study Introduction 63 yr old male Avid deep sea fisherman Has used Transderm Scop (scopolamine) patch

every summer weekend for nearly 20 years Has developed a severe, persistent, painful rash

behind both ears due to the adhesive Has tried various other motion sickness

treatments with no comparable effect

Case Study Conundrum

Would rather endure the pain and rash (and possible longer term effects) rather than not use the patch

The patient is a pharmacist

Alternative Solution

Scopolamine Hydrobromide compounded with Pluronic Lecithin Organogel (PLO)

Provides sustained drug delivery similar to the patch

No adhesives Demonstrated effect in as far back as

1992

Pluronic Lecithin Organogel (PLO)

Liquid a refrigeration temperaturesEasy to mix and measure

Cream at room/body temperaturesEasy to applyVery little mess

Conclusions Mass manufactured products target the masses

Not all drugs are right for all patients Not all drug combinations are right for all patient Not all delivery modes are right for all patients

Know what you don’t know Even an experienced pharmacist can be oblivious to

an established solution to a problem

Additional References Student Site Evaluation