What you dont know can hurt your patients

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What you dont know can hurt your patients

• Ben ORourke
• Ted Williams
• Christine Wood
• Samantha Woodhouse
• Brian Zacher
• Atanaz Zargarizadeh

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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 ORourke

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Lloyd Center Pharmacy

• Compounding Pharmacy
• Provides specialty products for animals and
  humans
• Major focus is on hormone replacement therapy

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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.
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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

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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
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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
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Hormones

• Progesterone
• EstrogensE1, E2, E3
• Premarin
• Testosterone
• Soy
• Wild Yams

www.hormoneprofile.comGuyton A, Hall J. Textbook
of Medical Physiology 10th Ed. WB Saunders Co.
Pennsylvania. 2000
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(No Transcript)
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Chrysin

• Stabilizes Testoserone
• Induces UDP-Glucoronosyltransferase (UGT)

http//toxsci.oxfordjournals.org/cgi/content/full/
82/1/70http//dmd.aspetjournals.org/cgi/content/f
ull/28/9/1077Lacy, J LexiComp Drug Information
Handbook 13th Ed. 2005
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Baquacil polyhexamethylene biguanide (PHMB)

• A compound having a broad spectrum activity and
  low toxicity
• Ophthalmology

• A common swimming pool biocide
• Protection against bacteria and algae without
  the harsh effects of chlorine

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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.
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Other Uses

• Bacterial Vaginosis
• Most common vulvovaginal infection
• Mouth Rinses
• Inhibits re-growth of plaque
• Reduces 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.
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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.colu
mbia.edu/dept/nsg/NSGCPMC/specialties/spinestim.ht
mlPain Management Compounding http//www.bbpharma
cy.com/paincompounding.html
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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.colu
mbia.edu/dept/nsg/NSGCPMC/specialties/spinestim.ht
mlPain Management Compounding http//www.bbpharma
cy.com/paincompounding.html
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Alternative Pain Management

• Most important of all, different dosages are
  prepared in these compounding pharmacies to fit
  with the patients 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.colu
mbia.edu/dept/nsg/NSGCPMC/specialties/spinestim.ht
mlPain Management Compounding http//www.bbpharma
cy.com/paincompounding.html
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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

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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

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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

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Pluronic Lecithin Organogel (PLO)

• Liquid a refrigeration temperatures
• Easy to mix and measure
• Cream at room/body temperatures
• Easy to apply
• Very little mess

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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 dont know
• Even an experienced pharmacist can be oblivious
  to an established solution to a problem

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Additional References

• Student Site Evaluation