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Compounding for Palliative Care
As patients near the end of life, the need for alternate routes of medication administration increases, with up to 70% of patients who receive palliative care requiring a non-oral route. In order to optimize patient care, it is imperative that physicians and other clinicians are aware of available options and their respective advantages and disadvantages.
A major goal of palliative care is to provide comfort. As pain and many other causes of suffering in patients with advanced disease (especially cancer) can be treated, clinicians need a full range of options to adapt to the changing conditions of these patients. Transdermal, topical, sublingual, buccal, and rectal administration can be helpful. Our compounding pharmacist can work together with each practitioner, patient and caregiver to customize therapies that are best to treat each specific problem.
Traditionally, when patients have been unable to swallow or are not permitted to have oral intake, medications have been administered by IV, IM or SC injection.
- Intravenous (IV) therapy generally requires a higher level of patient and nursing involvement, training, and education and can limit patient freedom/mobility. Skilled nursing may be required if the patient/family is unable to care for a catheter and there is a risk of infection.
- Subcutaneous (SC) therapy should be avoided or used with caution in immunocompromised patients and in those patients with bleeding disorders. Local complications are rare but can occur, especially in people with diabetes.
- Intramuscular (IM) injections can be painful, may cause sterile abscesses and muscle fibrosis, have variable absorption and produce wide variances in blood levels, and have no pharmacokinetic advantage over other parenteral routes.
Transdermal administration is particularly useful for patients with dysphagia, nausea and vomiting, or bowel obstruction. Transdermal therapy can facilitate systemic absorption, does not require a port or catheter to be placed, and is easy for almost any caregiver to administer; in addition, the rate limited absorption of the transdermal route can be advantageous in unsupervised settings.
Transdermal creams and gels do not have the disadvantages of patches. Patches:
- Can cause local irritation at patch site.
- Are contraindicated in patients with acute or uncontrolled pain.
- Require a longer period of time for titration.
- Used by a patient with a fever may result in an increased rate of absorption and toxicity or symptoms such as pain can appear after the medication in the patch reservoir is depleted.
Topical gels used to treat painful wounds provide peripherally acting analgesia without central side effects that are common with systemic medications. Topical therapy is reliable and for application, requires only gloves and occlusive dressings. In the case where every effort is being made to avoid IV or SC administration per the family's wishes, no tubing is connected to the patient, and the patient does not need to be able to swallow. Thus, there is no chance of the patient reflexively clamping his jaw on an oral syringe or application stick (e.g., as in sublingual or buccal administration), nor does the patient have to be rolled (e.g., as in rectal administration).
Troches or lozenges and powders can be compounded to treat infections or pain in the mouth. Medicated powders can be moistened to create a "mucosal bandage" that covers an ulcerated area. Antibiotics and topical anesthetics can be added to troches and lozenges which can be placed at the site of the problem for high local concentrations of the needed medication.
Rectal suppositories, suspensions, solutions or gels can be custom made by our compounding pharmacy. When acceptable to the patient and caregiver, rectal administration can be:
- Simple.
- Useful in patients with nausea and vomiting, dysphagia, GI obstruction, malabsorption, or impaired neuromuscular function.
Disadvantages of rectal administration:
- Should not be used in patients with impaction, constipation, or diarrhea
- Should not be used if placement of the suppository will cause pain (e.g., inflamed hemorrhoids, fissures, or lesions of the anus or rectum)
- Avoid in patients with neutropenia or thrombocytopenia due to risk of bleeding or infection.
Intranasal administration can be helpful in some cases and offers the following benefits:
- High vascularity of the nasal mucosa facilitates quick absorption.
- Rapid onset of action
- Convenient
- Easy to administer
- No first-pass hepatic metabolism
Disadvantages of the intranasal route include the potential for side effects such as nasal congestion, nasal irritation, rhinitis, upper respiratory infection, sinus congestion, and local irritation.
References are available upon request.
In addition to compounding medications into dosage forms that are not commercially available, we can flavor medications to make them more pleasing to patients receiving palliative care. We consider the physical properties of each drug, including whether it is lipophilic or hydrophilic, when formulating customized dosage forms. We welcome your questions and medication problems! |
