Customized Medications for Pain Management, Symptom Control & Wound Care

Customized Medications Offer Therapeutic Alternatives & Advantages for Palliative Care

Change in Route of Administration – A medication may only be commercially available as an oral or injectable product, but we can often simplify home administration for someone who NPO by compounding an alternate dosage form, such as a transdermal gel.

Combination Preparations – It is often possible to combine several compatible drugs into a single dosage from, such as a capsule, troche, transdermal gel, or suppository.  This can simplify the medication administration schedule, and improve compliance.

Unavailable or Discontinued Medications – When a commercial medication is out of stock or temporarily unavailable, we can usually obtain the needed drug as a bulk powder and compound a suitable preparation.

Flavoring – Often, we find that hospice patients are unable to tolerate sweetness, but would prefer a medication with a bitter flavor – like coffee, for example.  We can flavor each medication to please the individual’s palate, and eliminate aftertastes.

Elimination of Problem-Causing Excipients – Medications can be formulated free of dyes, sugar, lactose, alcohol, and preservatives.

Dosage Modification – We can compound a medication that contains the most appropriate strength of medication to provide therapeutic benefit but avoid adverse effects.  This can be particularly helpful for a patient with kidney failure or liver disease.

Change in Dosage Form – Medications can be altered to meet each patient’s needs.  For Example:

• Alternatives to oral administration when the patient has difficulty swallowing
• A liquid medication can simplify titration when doses need to be gradually increased to control pain or other symptoms.
• Freeze-pop, lozenges, or lollipops are particularly useful when it is desirable to prolong medication contact with the oral mucosa, such as when a patient has “thrush”.

Advantages of Transdermal, Sublingual, Buccal, and Rectal Drug Administration

• 1st-pass liver metabolism is bypassed
• Direct application and absorption
• Elimination of GI side effects
• Avoidance of drug interactions
• NPO medication administration
• Avoidance of injectable therapies
• Rapid onset of action
• More cost effective
• Convenient

Examples:

• Hydromorphone Sublingual Drops
  • Pain control
• Lorazepam Transdermal Gel
  • Anxiety/terminal agitation
• BDR (Diphenhydramine, Dexamethasone, Metoclopramide) Suppositories
  • Nausea & vomiting

Pain Management

Besides mitigating suffering, pain control is crucial because even when the underlying disease process is stable, uncontrolled pain prevents patients from working productively, enjoying recreation, or taking pleasure in their usual role in the family and society.

Individualized Therapy – By combining various agents, which utilize different mechanisms to alter the sensation of pain, physicians have found that smaller concentrations of each medication can be used. 

Adjuvant drugs – including antihistamines and corticosteroids – are valuable during all phases of pain management to enhance pain relief, treat concurrent symptoms, and counteract the side effects.

Trigger Points and Dermatomes – A dermatome is the area of skin supplied by a spinal nerve by way of its dorsal root.  Pain may originate at the spinal level and follow the path along the entire dermatome to the trigger point.  Dermatome maps and trigger point application may be useful when a practitioner chooses to administer medications transdermally.

Topical/Trans-dermal Medications for Chronic Pain Patients, Neuropathic Pain, Pain Management

Hydrocodone without Acetaminophen

IBU Suppositories for Bone Pain

Dextromethorphan in Morphine Tolerance – Dextromethorphan in an NMDA (N-methyl-D-aspartate) receptor antagonist.  Ongoing research indicates that drugs in this class can block pain transmission in dorsal horn spinal neurons and reduce nociception.  However, most commercially available dextromethorphan preparations have drawbacks to use for pain management.  Dextromethorphan is frequently combined in cough/cold preparations with various antihistamines, decongestants, expectorants, or analgesics.  Decongestants may raise concerns for hypertensive patients, and antihistamines may cause problems for those with BPH or glaucoma.  Liquid “cough syrups” often contain sugar and/or alcohol, and have an unpleasant taste.  Our compounding pharmacy can prepare a dosage form containing dextromethorphan as the only active ingredient, in the most appropriate dose and dosage form for each patient – including capsules or a pleasantly-flavored liquid.

LDN (Low Dose Naltrexone) – Recent clinical and preclinical studies have demonstrated that cotreatments with extremely low doses of opiod receptor antagonists (i.e. naltrexone) can markedly enhance the efficacy and specificity of morphine and related opiod analgesics, and simultaneously attenuate opoid tolerance, dependence, and other adverse side-effects such as nausea, vomiting, and pruritis.

Symptom Control

Nausea – Using a combination of medications tailored to meet that individual’s specific needs can often effectively control persistent nausea.  A variety of medications which target various pathways such as vagal nerve stimulation, the vomiting center, and the chemotherapy trigger zone (CTZ) can be used.

• ABHR (lorazepam + diphenhydramine + haloperidol + metoclopramide)
  • Creams, lozenges, suppositories
  • ± Dexamethasone
• High-dose metoclopramide suppositories
• Intranasal metoclopramide
• Oral combination antiemetics
• Transdermal promethazine

Constipation – Carbon Dioxide Evacuant Suppositories encourage bowel movements by forming carbon dioxide.  This gas pushes against the intestinal wall, causing contractions that move along the stool mass.  Results often may be obtained in 5-30 minutes. 

GI Motility Disorders & Emesis

Stomach Pain
   •Sucralfate + Lidocaine + AlOH/MgOH

Side Effects of Chemotherapy

• Mucositis
  • Glutamine suspension – Glutamine is a nutrient for rapidly dividing cells and the major energy source for intestinal epithelium.
• Xerostomia (Loss of saliva)
  • Pilocarpine time-release capsules
• Stomatitis
  • Allopurinol Mouthwashes
• Proctitis
  • Misoprostil Suppositories
• Flavoring

Wound Care

Topical Phenytoin for Wound Healing – Phenytoin may promote wound healing by a number of mechanisms, including stimulation of fibroblast proliferation, facilitation of collagen deposition, glucocorticoid antagonism, and antibacterial activity.  Phenytoin has been used topically in the healing of pressure sores, venous stasis, and diabetic ulcers, traumatic wounds, skin autograft donor sites, and burns.

Benzoyl Peroxide for Treatment of Decubitus Ulcers – Benzoyl peroxide is a powerful oxidizing agent with broad spectrum germicidal activity and good liposolubility.  Therefore, it may represent a good agent for prevention of wound infection in areas with high density of sebaceous glands.

Topical Metronidazole for Malodorous (odor producing) Wounds – Odor from malignant cutaneous wounds, ulcerated tumors, some pressure ulcers, fungating tumors and benign cutaneous ulcers can cause great distress and embarrassment for patients.  Clinical research using topical metronidazole over the past 20 years indicates that metronidazole is effective against the anaerobic bacteria that cause these foul and distressing odors.

Lidocaine ± Tetracaine Spray provides topical anesthesia

Sucralfate in Oral Adhesive Paste – Numerous topical sucralfate preparations have been applied for their protectant properties or for treatment of a variety of dermatologic and mucosal problems, including oral and esophageal ulcers, peristomal and perineal excoriation, decubitus ulcers, radiation-induced rectal and vaginal ulcerations, and second and third degree burns.

Cholestyramine Ointment – If high concentrations of bile acids are contained in the stool, they can irritate the anus and buttocks in a manner similar to the skin irritation experienced by patients with ostomies.  When applied topically, cholestyramine, a bile acid sequestrant, can irreversibly bind the bile and bring relief to the patient.

Ketoprofen may be used to control inflammation and pain

Pentoxifylline may improve microcirculation

Misoprostol to promote wound healing