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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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Novel Anti-inflammatory Gel for Transdermal Delivery
When compounding medications, we have a continually expanding armamentarium of bases, from which we select the most appropriate base for the intended use of a compounded preparation. We follow the science such as the following report. The efficacy of PLO gels used in pain management may be enhanced by using ricinoleic acid instead of isopropyl palmitate as an oil phase. Studies by Boddu et al. of the Department of Pharmacy Practice, The University of Toledo, Ohio and the Department of Pharmaceutical Sciences, Washington State University, Spokane, showed that the use of ricinoleic acid as an oil phase in a pluronic lecithin organogel (PLO gel) resulted in the formation of a stable base with higher permeation of ketoprofen than the isopropyl palmitate PLO gel. They evaluated and compared the in vitro and in vivo anti-inflammatory effects of ketoprofen in the ricinoleic acid PLO gel system with isopropyl palmitate PLO gel. The results from the in vitro study showed that the ricinoleic acid PLO gel possessed significantly higher anti-inflammatory activity than isopropyl palmitate PLO gel. Further in vivo testing of the formulation showed that the ricinoleic acid PLO gel formulation was significantly more effective in reducing pain and edema when compared to the isopropyl palmitate PLO gel. In addition, the ricinoleic acid PLO gel formulation markedly inhibited the synthesis of prostaglandin E2. Note: Ricinoleic acid is contained in Poloxamer 407 which we can use as a base when appropriate for the medication. |
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Topical and Transdermal Drug Administration
Topical drug treatment aims at providing high concentrations of drugs at the site of application so as to avoid adverse systemic effects associated with oral administration. Smart polymers, or stimuli-responsive polymers, are able to respond to a stimulus by showing physical or chemical changes in the delivery of the drug carried by them. The thermo-responsive nature of certain gels such as Pluronic® F-127 and pluronic lecithin organogels (PLO), makes them excellent candidates for the delivery of drugs at various application sites. These bases have attracted particular interest in the formulation of topical and transdermal delivery systems with regard to promoting, improving or retarding drug permeation through the skin, bearing in mind that for topical delivery systems, accumulation in the skin with minimal permeation is desired, while for systemic delivery, the opposite behavior is preferred. Our compounding professionals will select the best base for each compound after considering the intended use of each medication.
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Rectal Propranolol Controls Paroxysmal Sympathetic Hyperactivity Post Brain Injury
Paroxysmal sympathetic hyperactivity (PSH) affects approximately 10% of survivors of acquired brain injury and is associated with substantial morbidity. The most effective maintenance therapies include oral β-blockers and α-2 antagonists. May et al. of the University of Kentucky HealthCare reported the use of rectal propranolol for symptomatic control of PSH in a critically ill patient with an altered gastrointestinal tract for whom oral intake was contraindicated. A 15-year-old Caucasian male with no past medical history was admitted status post all-terrain vehicle rollover with multiple intra-abdominal injuries. On hospital day 40, the patient experienced cardiac arrest with a subsequent anoxic brain injury, which was complicated by the development of PSH on post-arrest day 1. Because of his altered gastrointestinal tract, he was symptomatically managed with propranolol 40 mg per rectum every 6 hours in the form of specially prepared suppositories, intravenously infused morphine and dexmedetomidine, and a transdermal clonidine patch. The patient improved clinically during this treatment and was transferred to a rehabilitation facility. This is the first case report to describe successful use of propranolol suppositories in a clinical environment. This case supports the use of propranolol suppositories as a potential alternative route when oral administration is not possible.
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Novel Formulations that Potentiate Antifungal Activities
Terbinafine, an orally and topically active antifungal agent, has been available for the treatment of dermatophytic infections and onychomycosis for more than a decade. Oral administration has been shown to be associated with drug-drug interactions, hepatotoxicity, low concentration at the infected sites, gastrointestinal and systemic side effects and other adverse effects. Since topical drug delivery can provide higher patient compliance, allow immediate access to the infected site and reduce unwanted systemic drug exposure, an improved topical drug delivery approach with high permeability, sustained release and prolonged retention at the site could overcome the limitations and side effects caused by oral administration. Conventional topical formulations cannot keep the drug in the targeted sites for a long duration of time. To overcome this limitation, our compounding pharmacy utilized a novel drug delivery system based on polymers and nanostructure carriers for the topical delivery of terbinafine and other medications.
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Topical Amitriptyline Combined with Ketamine for the Treatment of Erythromelalgia: a Mayo Clinic Study
Erythromelalgia is an uncommon neurovascular disorder characterized by redness, increased skin temperature, and pain that usually occurs in the extremities. Treatment remains challenging because of its varying response to medical therapy. The objective of a study by Poterucha et al. of College of Medicine, Mayo Clinic, Rochester was to assess the response of erythromelalgia to compounded topical amitriptyline-ketamine. They retrospectively evaluated 36 patients with erythromelalgia who were treated with compounded topical amitriptyline-ketamine from January 1, 2004, through January 31, 2011. Thirty-two patients (89%) were female. Mean (standard deviation) age was 44.7 (15.8) years (range, 5-74 years). Patients applied the medication 1 to 6 times per day (median, 5 times). One patient (3%) had complete relief from symptoms, 14 (39%) had substantial relief, 12 (33%) had some relief, 7 (19%) had no relief, and 2 (6%) had local worsening of symptoms. No patients had systemic adverse effects.
CONCLUSIONS:
A majority of patients with erythromelalgia (75%) reported improvement in pain with topical application of a compounded amitriptyline-ketamine formulation. The medication was well tolerated.
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