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Thank you for entrusting in the compounding services at MD Custom Rx to help meet the unique medication needs of your patients. We are excited to share with you our monthly newsletter and look forward to continuing to be your medication problem solvers. Please don't ever hesitate to let us know how we can be of further assistance to you and your practice.
Sincerely,
John, Dan and Monica |
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Topical NSAIDs for Chronic Musculoskeletal Pain and Hand and Knee Osteoarthritis in Adults
In a review of 32 publications, 23 studies compared a topical NSAID with placebo. Topical NSAIDs were significantly more effective than placebo for reducing pain due to chronic musculoskeletal conditions. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly taken orally, but they can also be compounded as topical preparations to be applied to the skin over a painful joint with the aim of relieving pain locally. Topical NSAIDs were first licensed in the USA by the Food and Drug Administration in 2007, and were recommended as a first line treatment for osteoarthritis by the National Institute of Clinical Excellence (NICE) in 2008. Multiple systematic reviews have examined topical NSAID use in hand and knee osteoarthritis and have in general found their use favorable. Two negative meta-analyses appear to have been a result of the limited availability of studies of adequate duration at the time of writing, and the inclusion of agents such as topical felbinac which failed to show any therapeutic benefit.
A recent review by Derry et al. established that topical NSAIDS are an effective treatment for hand and knee osteoarthritis after having examined high quality, larger, longer duration studies (up to 12 weeks). This review supports the decision by NICE to recommend topical NSAIDS as the first-line therapy for osteoarthritis.
Topical NSAIDS should be considered in preference to oral NSAIDs due to their equivalent efficacy (formulation dependent) and improved safety profile. In the Derry review, although minor skin reactions occurred, there was no increase in serious adverse events including GI bleeding, a well-recognized and potentially life-threatening complication of oral NSAIDs. Gastrointestinal adverse events with topical NSAID did not differ from placebo, and were less frequent than with oral NSAIDs.
Future studies are required to further evaluate the role of topical NSAIDs in the treatment of other musculoskeletal conditions.
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Options in Topical Therapies for Management of Patients with Acute Pain
The traditional cornerstones of analgesic therapy for patients with acute pain have been oral therapies; however, oral agents exhibit a variety of potentially dose-limiting or intolerable adverse effects in patients. Elderly patients and those with concomitant conditions who are taking multiple systemic drugs may be particularly susceptible to toxicities with oral analgesics. Topical agents can effectively treat patients with acute pain while offering lower systemic absorption and conferring little risk of systemic toxicity. Topical NSAID therapy has been useful in reducing pain of acute-phase herpes zoster pain and other conditions. Topical analgesics represent an alternative treatment modality for patients experiencing acute pain who cannot or choose not to take oral therapies.
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Topical NSAIDs for Treating Acute Ankle Sprains in Adults: Benefits Outweigh Adverse Events
In a meta-analysis of 22 studies, topical NSAIDs provided superior results compared with placebo for pain at rest (short term), persistent pain (intermediate term), pain on weight bearing (short- and intermediate term) and for swelling (short and intermediate term).
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Topical Analgesics for Neuropathic Pain
Topical analgesics applied locally "modify pain by actions on sensory nerve endings and/or adjacent cellular elements. With this approach, there are low systemic drug levels, good tolerability and few drug interactions, and combination with oral formulations is feasible," according to Dr. Jana Sawynok. Controlled trials and case reports of vasodilators, glutamate receptor antagonists, α2-adrenoreceptor agonists, antidepressants, and centrally acting drugs, including combinations of several agents, indicate that these produce pain relief in neuropathic pain. Her review concluded: "Topical analgesics have the potential to be a valuable additional approach for the management of neuropathic pain."
Ask our compounding pharmacist for more information about topical NSAIDs and other medications and combination preparations.
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Topical Amitriptyline-Baclofen Cream for the Treatment of Provoked Vestibulodynia
A retrospective evaluation of patients with provoked vestibulodynia (PV) who were treated with a topical cream containing amitriptyline 2% and baclofen 2% assessed their response using verbal reports, visual analog scales of discomfort with daily and sexual activities, and 5-point numerical scales rating extent of interference with social activities, intercourse frequency, sexual desire, difficulty in lubrication, frequency and overall level of discomfort during sex, and satisfaction with overall sexual life. Data were available for 38 patients, with a median follow-up of 33 weeks. Overall, 71% of women with symptoms that were refractory to previous treatment responded. 53% reported much (>60%) improvement, 18% reported moderate (30-60%) improvement, and 29% patients reported no or little (<30%) improvement. On self-administered questionnaires, patients reported a decrease in the extent to which vulvodynia interfered with sexual activity. No systemic side effects were reported.
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Topical Amphotericin B for Treatment of Burn Wounds Infected with Candida spp.
Candida spp. infection in the context of burn wounds leads to invasive disease with a 14-70% mortality rate. Amphotericin B is an important therapeutic demonstrating minimal resistance, but it is only commercially available via potentially cytotoxic IV infusions. In order to circumvent these sequelae, Sanchez et al. investigated the efficacy of nanoparticle encapsulated (AmB-np) as a topical therapeutic against Candida spp. using a drug release equilibrated solubilized AmB (AmB-sol) as a control. Clinical strains demonstrated equal or enhanced killing efficacy with 72.4-91.1% growth reduction by 4 hours. AmB-nps resulted in statistically significant reduction of fungal biofilm metabolic activity ranging from 80% to 95% viability reduction. Using a murine full-thickness burn model, AmB-np exhibited a quicker efficiency in fungal clearance versus AmB-sol by day three, although wound healing rates were similar. These data support the concept that AmB-np can function as a topical antifungal in the setting of a burn wound.
Note from the Clinical Editor of Nanomedicine:
"This may become a viable alternative to the potentially toxic intravenous formulations."
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