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Progesterone Cream: Effects and Side-effects on Skin of Peri- and Postmenopausal Women

For many years topical progesterone has been prescribed as an anti-aging and skin-firming treatment. To evaluate the effects of 2% progesterone cream on function and texture of the skin in peri- and postmenopausal women, a double-blind, randomized, vehicle-controlled study was conducted in 40 subjects. Objective methods for measuring skin elasticity and epidermal hydration, and determination of blood hormone levels (luteinizing hormone, follicle-stimulating hormone, oestrogen and progesterone) were used to determine effects and side-effects of this treatment at four visits over a 16-week period. The study demonstrated a significant increase of the elastic skin properties in the women who used the 2% progesterone cream, whereas in the control group no such effect was observed. The 2% progesterone cream showed consistent superiority over vehicle in counteracting different signs of aging in the skin of peri- and postmenopausal women. Clinical monitoring showed a greater reduction in wrinkle counts (29.10% vs. 16.50%) and wrinkle depth (9.72% vs. 7.35%) around the right eye, a greater decrease in nasolabial wrinkle depth (9.72% vs. 6.62%) and a significantly higher increase in skin firmness (23.61% vs. 13.24%) in the treatment group. Progesterone was well absorbed in the systemic circulation, but this concentration increased mean blood levels of progesterone only minimally by 0.53 ng/mL. No serious side-effects of the treatment were observed. This study demonstrates that topical 2% progesterone increases elasticity and firmness in the skin of peri- and postmenopausal women. These effects in combination with good tolerability make progesterone a possible treatment agent for slowing down the aging process of female skin after the onset of menopause.

Br J Dermatol. 2005 Sep;153(3):626-34.

Relieving Pain From Head to Toe: Iontophoresis, Phonophoresis, and Transdermal Therapy

Iontophoresis and phonophoresis are technologies that are capable of enhancing drug penetration through the skin. Phonophoresis uses ultrasonic waves to transmit molecules of drug through the skin, as opposed to iontophoresis, which uses low level electric current. Both techniques are used to treat inflammatory conditions such as arthritis, plantar fasciitis, tendonitis, bursitis, and carpal tunnel syndrome.

Iontophoresis is becoming popular as an alternative to oral and injectable medications because it is non-invasive, non-traumatic, and painless. Many ionic drugs are available including several antivirals, various antibiotics, and other specific drugs. Iontophoresis of ionized drugs provided a 20-60 fold increase in penetration over topical application. Examples of successful applications of iontophoresis include:

treatment of inflammation/pain of muscles and tendons, including the Achilles tendon
rapid, noninvasive local anesthesia, particularly for children
relief of heel pain from bone spurs
controlling the pain of tennis elbow
relief of pain from rheumatoid arthritis of the knee
relief of pain associated with plantar fasciitis
improvement of jaw function in patients with temporomandibular joint (TMJ) disorders
management of hip pain in patients with sickle cell disorders (SCD)
an alternative to steroid injections for therapy of Carpal Tunnel Syndrome

Iontophoresis can be an important healing component that will allow physical therapists to move into hands-on treatment modalities for conditions such as sciatica. By relieving pain, therapy can progress to other techniques that address specific problems so patients can resume higher levels of functional ability. Dexamethasone sodium phosphate is often the drug of choice, but ketoprofen is an alternative non-steroidal anti-inflammatory drug (NSAID) that treats many of the same conditions, including tendonitis, bursitis, arthritis, spinal stenosis, acute sprains and strains. Effective for acute and chronic inflammation, ketoprofen can be used when patients don’t respond well to dexamethasone or have plateaued in treatment.

Potassium iodide solution has been used to treat scar and tendon adhesions. Potassium iodide can soften and remove collagen, allowing an area to be molded and stretched, so that a patient can increase range of motion and strengthen the overloaded muscle.

Phonophoresis (or sonophoresis) combines ultrasound with topical drug therapy to achieve therapeutic drug concentrations at target sites below the skin. A cream or gel containing medications such as corticosteroids, local anesthetics, electrolytes, or antibiotics is applied to the treatment area and then massaged with a transducer head. The technique has been widely used in sports medicine since the 1960s by podiatrists, orthopedists, and physical therapists.

The method of preparation and quality of ingredients used for solutions or gels for iontophoresis or phonophoresis are key to the success of the therapy and minimizing side effects. Drugs must be compounded into the appropriate base and must be reduced to a particle size that that is small enough to be absorbed through the skin. Preparations should be free from grit and bubbles. Optimal preparation requires specialized equipment such as an ointment mill.

Please call our compounding pharmacy for customized preparations for iontophoresis, phonophoresis, or transdermal drug delivery.

Is the FDA more interested in your health or Big Pharma’s wealth?

There are many references in the medical literature that describe the benefits and potential advantages of “natural” hormones, which are often prepared by compounding pharmacies. Yet, in response to pressure from drug companies who manufacture commercially available hormones, the FDA has indicated concerns about the term “bio-identical” and the use of estriol as a component of HRT. However, estriol has a USP monograph and has been used for many years in Europe (where it was marketed by Wyeth) with no reported safety issues, and many articles in peer-reviewed medical journals describe the benefits of estriol. Additionally, estriol is in Phase III clinical trials for treatment of Multiple Sclerosis and no side effects have been reported. And, pharmaceutical manufacturers are allowed to use “bio-identical” in their marketing programs.

U.S. House Resolution Deems FDA's Policy on Estriol "Not in the Public Interest"

On May 6, 2008, Representatives Mike Ross (D-AR) and Jo Ann Emerson (R-MO) introduced a Sense of the Congress resolution that raises direct concerns over this move by FDA. The resolution, co-sponsored by Tammy Baldwin (D-WI), Michael Burgess (R-TX), John Carter (R-TX), Sam Farr (D-CA) and Gabrielle Giffords (D-AZ), deems FDA's policy “improper” and urges for its reversal. The resolution also affirms that physicians are in the best position to determine which medications are most appropriate for their patients and that FDA should respect this important physician-patient relationship. Encourage your Senator or Representative to support H. Con. Res. 342.

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Autism Spectrum Disorder: Customized Medications and Supplements

Autism is characterized by impairments in social relatedness and communication, repetitive behaviors, abnormal movements, and sensory dysfunction. Although autism spectrum disorder (ASD) is diagnosed on the basis of behavioral parameters, there are many underlying biomedical factors which can contribute to these symptoms. Therapies directed at these underlying factors may be helpful in decreasing symptoms of autism.

The Autism Research Institute asked parents to rate the effectiveness of numerous biomedical treatments. As of 2008, over 26,000 parents had evaluated more than 80 interventions. Detoxification was considered helpful by 74% of parents. Other highly rated therapies and the percentage of children that “got better” included: gluten/casein-free diet, 66%; food allergy treatment, 64%; methylcobalamin, 56% (nasal) and 67% (subcutaneous); and essential fatty acid therapy, 56%. Interestingly, parents reported that more children “got worse” with conventional drug therapy (including amphetamines, methylphenidate, antipsychotics, and antidepressants) than with biomedical/non-drug treatment, nutritional supplements, or special diets. It is thought that the earlier treatment is started, the better the results.

Gluten-Free and Casein-Free Preparations

Children with autism may benefit from a gluten-free and casein-free diet. Gluten is a protein found in wheat and other grains such as rye, oats and barley. Casein is the main protein found in dairy products. Many commonly used medications contain gluten. We can compound preparations that are free of gluten and casein to solve problems for sensitive individuals. For example, we can formulate suspensions using an agent that does not contain gluten or casein and does not feed yeast.

Therapy for Gut Dysbiosis

Autistic children frequently have abnormalities in gut permeability, defects or deficiencies in intestinal enzymes, and/or abnormal intestinal flora. Yeast overgrowth can be prevented or treated by oral administration of Lactobacillus or other probiotics. If response is insufficient, oral antifungals may be needed.

Compromised digestive function, often secondary to inflammation of the bowel, may lead to the absorption of toxins (“leaky gut”). Children can benefit from balanced nutrition, treatment of imbalanced gut flora, and enhancement of immune function.

Nutritional Therapy for Autism

Most children with autism have a need for increased amounts of vitamins, minerals, and some amino acids. Once the physician has determined the specific nutrients that are needed by the individual, numerous compatible supplements can be combined into a flavored suspension to simplify administration.

Many children with autism are zinc deficient. Zinc deficiency affects taste perception and children then become averse to eating certain foods and taking supplements. In this case, transdermal preparations can be very helpful by completely bypassing the oral route of administration.

Detoxification (including chelation)

Some children with autism may suffer from heavy metal toxicity, and may potentially benefit from detoxification. Some may also benefit from chelation (removal of heavy metals).

Please note: These therapies have not been approved by the FDA for the treatment of autism, and should be used only under direct supervision of an experienced and knowledgeable health care professional after parents or guardians have received adequate information and given consent.

References: http://www.autism.com/treatable/form34qr.htm (accessed April 2008)
Ann Neurol 2005;57:67–81
J Child Neurol. published on-line 2008 Jan 8
Ann N Y Acad Sci. 2007 Jun;1107:92-103.
Cell Mol Neurobiol. 2004 Apr;24(2):219-41
Neuroendocrinology Letters 2002;23:303-8
Dev Brain Dysfunction 1997;10:40-43
J Inherit Metab Dis.1993;16(4):762-770
Pediatrics 1995;95:255-8
J Nutr Env Med 2000;10:25-32
Children with Starving Brains, 2nd Edition, by Jaquelyn McCandless, M.D.

Boric Acid Therapy for Chronic Vaginitis

Recalcitrant vaginal infections caused by Trichomonas are extremely distressing for patients and frustrating for physicians. Numerous studies have shown that an increase in vaginal pH (a shift toward a less acidic environment) creates a better environment for the growth of Trichomonas vaginalis. Vaginal acidification using boric acid has resulted in resolution of recalcitrant trichomoniasis.1

Patients with diabetes mellitus (DM) are at increased risk of vulvovaginal candidiasis (VVC), a fungal infection caused by Candida glabrata. Diabetic patients with C. glabrata VVC respond poorly to the most common antifungal drugs that are contained in over-the-counter creams. Women with DM and VVC showed an overall superior cure rate (74% versus 51%) at day 15 with boric acid suppositories given daily for 14 days as compared to the prescription drug fluconazole as a single oral dose of 150 mg. 2, 3

A study done at New York Hospital-Cornell University Medical Center reported the “ineffectiveness of conventional antifungal agents appeared to be the main reason for chronic [fungal] infections. In contrast, boric acid was effective in curing 98% of the patients who had previously failed to respond to the most commonly used antifungal agents and was clearly indicated as the treatment of choice for prophylaxis.”4 Another study concluded “in non-Candida albicans infections, boric acid suppositories achieved the best mycologic cure rate (85%).”5

1 J Obstet Gynaecol Can. 2008 Jan;30(1):55-8
2 J Infect. 2007 Oct;55(4):374-7
3 Diabetes Care. 2007 Feb;30(2):312-7
4 J Reprod Med. 1991 Aug;36(8):593-597
5 Am J Ob Gyn. 1995 Sep;173(3 Pt 1):820-823

Compounded Topical Metronidazole 10% Decreases Post-hemorrhoidectomy Pain and Improves Healing

Metronidazole is an antibiotic used to treat many types of infections, but has recently been found to have other uses. Oral metronidazole has been demonstrated to decrease postoperative pain after open diathermy hemorrhoidectomy. A prospective, randomized trial at the Georgia Colon and Rectal Surgical Clinic in Atlanta, Georgia found that topical metronidazole 10%, when applied to the surgical site, significantly reduced postoperative pain as reported on postop days 7 and 14. Postoperative edema (swelling) was also reduced and overall healing improved compared with placebo.¹

A separate double-blind, randomized trial evaluated the effect of topical metronidazole 10% versus placebo, applied to surgical site, in reducing postoperative and post-defecation pain after hemorrhoidectomy. Up to day 14, patients treated with topical metronidazole had significantly less postoperative pain than those who received a placebo. In the metronidazole group, post-defecation pain was ranked significantly lower at day 2 and patients required fewer additional analgesics postoperatively on days 2 and 7. These findings indicate that topical 10% metronidazole significantly reduces post-hemorrhoidectomy discomfort. ²

¹ Dis Colon Rectum 2004 May;47(5):711-6

² Dis Colon Rectum 2008 Jan 4

Contact our compounding professionals for more information about this preparation and other customized medications to meet specific patient needs.

Medications with a Personal Touch

“Before the advent of multi-billion dollar drug companies, pharmacists were compounders by definition. It has been estimated that ‘a broad knowledge of compounding’ was still essential for 80 percent of all prescriptions dispensed in the 1920’s.” ¹

Industrialization meant that many of the medications that the pharmacist prepared could be mass-produced more economically, and in some cases, more elegantly, due to the equipment possessed by manufacturers. Specialties made locally by the compounding pharmacist were replaced by patented drugs which were widely marketed by the drug companies. But, many health care professionals now realize that bigger is not always better, and that one size does not fit all, and once again, realize the advantage of prescribing compounded medications that can be customized by the local compounding pharmacist to solve problems that have not responded to commercially available medications, or to facilitate treatment of patients who are unable to take commercially available medications. Certainly, improved technology and new discoveries in chemistry and physiology have enhanced the modern pharmacists’ ability to formulate unique preparations to meet specific patient needs. A pharmacist who has received advanced training in the art and science of extemporaneous compounding and who possesses the proper equipment and quality ingredients, can work together with the patient and his/her physician, dentist, or veterinarian (and other health care professionals who are licensed to prescribe) to customize a medication containing the proper dosage of the needed drug(s) in the most appropriate dosage form for administration by the preferred route. Now, approximately 2 to 5% of all prescriptions in the U.S. are for compounded medications.

In addition to providing medications in strengths, flavors, and dosage forms that are not commercially available, compounding pharmacists can also prepare medications that are temporarily unavailable or have been discontinued for non-safety issues such as decreased usage or short shelf life which makes the medications unprofitable to mass produce.

Compounding pharmacists are regulated by their State Boards of Pharmacy and are required to follow federal guidelines known as USP chapters 795 (for non-sterile) and 797 (for sterile compounding). Compounds can be assayed for potency, and in the case of sterile preparations, for sterility. In addition, professional organizations have established rigorous accreditation standards, and excellent continuing education courses and international seminars are available, allowing compounding pharmacists to network with their colleagues and discuss novel preparations that meet specific patient needs.

1 Dentaltown, July 2007; 8(7):62-66.

Selecting Quality Supplements

Over the last five years, there has been a significant increase in the number of dietary supplements. Unfortunately, the quality of many remains in question due to the lack of regulatory provisions requiring the evaluation of the actual content of active ingredients. The use of validated analytical methods for the raw materials and finished products is the only mechanism to verify purity; hence, consumers have limited ways to judge the quality of the products they are purchasing. Obviously, quality of the supplement is highly correlated with the potential for therapeutic benefits. But, independent analysis of many supplements, including calcium, glucosamine, St. John’s wort, carnitine, Ginkgo biloba, and super oxide dismutase, has shown that many marketed brands contain subpotent content, including some with zero active ingredients. The lowest priced supplements tend to be poorer in content and formulation, although it is not always true that the highest priced products are the best. One report showed that many patients are not benefiting from glucosamine and chondroitin sulfate supplements due to variation in the content of active ingredients as well as the formulation used by some manufacturers. This has prompted the Arthritis Foundation to recently recommend “when a supplement has been studied with good results, find out which brand was used in the study, and buy that”.

How can consumers be sure they are using quality supplements? Buy from a source (like our pharmacy) that carries supplements from reputable companies and evaluates specific products for content, purity, batch consistency, and quality -which includes bioavailability or body’s ability to absorb and utilize the active ingredients. Consumers should not purchase through the mail or internet unless they know the vendor, and should shy away from products that are backed only by testimonials and not scientific research.

References

None.

Itching Relieved with Topical Naltrexone

Pruritus (itching) is a very common and distressing skin problem. Currently available therapies are not very effective, so there is a need for new effective topical drugs against itching. Two studies used a topical formulation of 1% naltrexone (or placebo) for 2 weeks to treat patients with localized and generalized atopic dermatitis with severe itching. More than 70% of the patients using the 1% naltrexone cream experienced a significant reduction of pruritus. The cream containing naltrexone had an overall 29.4% better effect than placebo. The naltrexone formulation required a median of 46 minutes to reduce itching by 50%; the placebo, 74 minutes. The antipruritic effects of the placebo formulation emphasizes the importance of rehydration therapy for dry skin. Naltrexone, a medication known as an opiate antagonist, can modify pruritus by influencing the peripheral and central sensation of itch. Naltrexone has been found to be successful in suppressing the perception of pruritus from many diverse origins including aquagenic pruritus (an intense prickling sensation that develops in affected individuals immediately after contact with water at any temperature).

References

None.

Nervous about an MRI? Nasal Spray of Midazolam Prevents MRI Claustrophobia

Up to 37% of patients undergoing MRI (magnetic resonance imaging) examinations experience moderate to severe levels of anxiety, necessitating the termination of the procedure in 5-10% of patients. Although the use of MRI has increased, effective procedures to handle claustrophobia are lacking. A nasal spray containing the sedating anti-anxiety medication midazolam has been effective in preventing claustrophobic responses in patients undergoing MRI. In a randomized, double-blind study, patients who received midazolam spray were more sedated and less anxious immediately before entering the MRI. No cancellations occurred with patients who received midazolam, whereas some patients receiving placebo panicked and terminated the scanning procedure. The quality of the MRI was higher in the midazolam group. With the exception of transient burning of the mucosal lining of the nose, no adverse effects were reported. The study concluded that this simple and safe method is useful in sedating patients for MRI and other minor procedures.

References

None.

Changing the Route of Drug Administration:
The Advantages of a Compounded Medication versus “Off-Label Use”

Many medications are prescribed for "off-label" use or an alternate route of administration in order to improve the therapeutic response, provide an economical alternative to solve a medication problem, or minimize the incidence of side effects, because the desired dosage form is not commercially available (for example, eye drops may be used to treat ear infections). In some cases (e.g., terminal illness), alternate routes of drug administration are used because patients simply cannot take needed medication by the intended route.

It is essential that consideration is given to the formulation and excipients as well as active ingredients, particularly when prescribing a route of administration that is different than the labeled use. For example, patients have been instructed to instill tablets and syrups rectally. Because syrups contain sugar, they can be very messy and sticky, and syrups may need to be diluted with water since their high sorbitol concentration may cause bowel evacuation (a problem that can be avoided by prescribing a properly compounded rectal formulation). Patients should always check with our pharmacist before making assumptions: for example, although eye drops may be used in the ears, ear (otic) drops can not be used in the eyes because otic preparations may not be isotonic, which means that significant problems can occur due to differences in concentration gradients, and ear drops may also contain preservatives that can be harmful to the eyes.

Many anticonvulsants, analgesics, and sedatives are given rectally when patients can't take oral meds. The dosage of medication must be individualized as drug absorption via the rectum can be highly variable, i.e., delayed or almost as fast as an intravenous bolus. Therefore, the dose or dosing interval may need to be adjusted when the route of administration is changed.

Our compounding pharmacy can obtain the necessary drug as a bulk chemical and prepare a customized medication in the most appropriate strength and dosage form to solve each patient´s specific medication problems. Please contact us for more information.

References

None

Preventing and Treating Dry Skin

Dry skin usually results from controllable environmental factors, such as exposure to hot or cold weather with low humidity levels, long-term use of air conditioning or central heating, and excessive bathing. Other factors - including diseases like psoriasis, thyroid disorders, alcohol and caffeine, medications (antihistamines, diuretics, and isotretinoin) and dehydration - can significantly alter the skin’s function and appearance. Damage from ultraviolet (UV) radiation may lead to collagen and elastin fibers breaking down much more quickly than they should, resulting in deep wrinkles and loose, sagging skin.

If not cared for, dry skin can progress to red, cracked and inflamed skin, and even cellulitis, a potentially serious bacterial infection that may enter the lymphatic system and blood vessels. These complications are most likely to occur when your skin's normal protective mechanisms are severely compromised. For example, severely dry skin can cause deep cracks or fissures, which can open up and bleed, opening the way for invading bacteria.

Moisturizers help to keep water from escaping. Oils prevent the evaporation of water from the surface of the skin. Hot water and long showers or baths remove oils from your skin. Bath or shower time should be limited to about 15 minutes or less, using warm rather than hot water. Avoid harsh, drying soaps. After washing or bathing, gently pat or blot your skin dry with a towel so that some moisture remains on the skin. Immediately moisturize your skin with an oil or cream. For very dry and scaly skin, creams containing lactic acid and/or urea may be beneficial. If dry skin progresses to dermatitis (red, itchy skin), corticosteroid-containing preparations may be helpful. If skin cracks open, wet astringent dressings may reduce secretions and prevent infection. Use a cool steam humidifier in your home, and choose clothing made from natural fibers such as cotton and silk that allow your skin to breathe.

Our compounding pharmacist will work with you to provide customized therapies for dry skin and related problems.

Treatment for Vulvodynia

Vulvodynia is discomfort of the external female genitalia (vulva) “most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurologic disorder”. The pain can be generalized or localized; and provoked or unprovoked, or both. Treatments include general vulvar care; topical, oral, and injectable medications; biofeedback and physical therapy; low-oxalate diet and calcium citrate supplementation; acupuncture, hypnotherapy, and surgery. “No one treatment is clearly the best for an individual patient.”

Long-term overnight use of the topical anesthetic lidocaine may minimize feedback amplification of pain and may allow for healing. In one report, patients applied a significant amount of 5% lidocaine ointment to the affected area at bedtime and placed a cotton ball generously coated with the 5% lidocaine ointment at the entrance to the vaginal canal to assure overnight contact with the area. After a mean of 7 weeks, 76% were able to have intercourse after therapy as compared with 36% at baseline. There was a significant decrease in pain with sexual activity. However, it is important to use caution in using excessive amounts of lidocaine, because reports of lidocaine toxicity exist. For some patients with localized pain and vaginismus (painful, involuntary spasms of the vagina), a combination of topical amitriptyline 2% and baclofen 2% in a water washable base has been useful for localized tenderness. Topical nitroglycerin has been reported temporarily to improve vulvar pain and dyspareunia; however, headache was a limiting side effect. Topical therapies NOT shown to benefit vulvodynia include topical corticosteroids, topical testosterone, and topical antifungal medications. The anesthetic benzocaine and topical diphenhydramine should be avoided. Choosing the proper vehicle for these medications is as important as choosing the proper medications or combinations. In general, creams contain more preservatives and stabilizers and often produce burning on application, whereas ointments are usually better tolerated. “A compounding pharmacy is used to formulate these topical medications.”

Gabapentin appears to be very effective in the treatment of unprovoked generalized vulvodynia, and has a very low side effect profile.2 Lori Boardman, MD, ScM, associate professor in the Department of Obstetrics and Gynecology at Women and Infants’ Hospital of Rhode Island, Brown Medical School, notes that sedation and dizziness associated with oral gabapentin can limit its clinical applicability. “Topical therapy can circumvent these side effects for at least two reasons. First, the topical route of delivery reduces systemic absorption of the medication, and second, the amount of active drug in topical preparations is significantly less than that administered orally. Although there is little data on using topicals with vulvar pain patients, studies of topical preparations in the treatment of other forms of chronic neuropathic pain suggest beneficial outcomes with minimal side effects.” Dr. Boardman is the director of the Colposcopy and Vulvar Clinics, where patients with both generalized and localized vulvodynia have responded favorably to 2% gabapentin cream (applied three times daily) prepared by local compounding pharmacists.3 In 2005, Johns Hopkins’ Bayview General Clinic Research Center funded a protocol by Anne Burke, M.D. entitled “A Pilot Study of 6% Topical Gabapentin Cream for Vestibulodynia.”4 When using a topical preparation to treat vulvodynia, it may be appropriate to try a “test dose” of the base to determine tolerance before adding the active ingredients.

Call our compounding professionals to discuss customized medications to meet specific needs.

References

1 Journal of Lower Genital Tract Disease 2005;9(1):40–51

2 J Reprod Med 2007 Feb;52(2):103-6

3 National Vulvodynia Association News, Winter 2005

4 Bayview GCRC Newsletter, Summer 2005

Acetaminophen with Codeine: Oral vs. Rectal Administration in Postoperative Pediatric Patients

12/04/2007

Physicians in the Department of Otolaryngology/HNS at Columbia- New York Presbyterian Hospital examined whether acetaminophen with codeine administered as a rectal suppository is an effective alternative for pain control compared with oral administration after an adenotonsillectomy. In a prospective, randomized control study, 75 children aged 1 to 5 years were assigned randomly to receive postoperative pain medication either orally or as a rectal suppository. A journal with eight questions was kept for 10 days after the operation, and an overall survey of five questions was filled out at the first postoperative visit. Equivalent postoperative pain control was achieved with suppositories and oral medication, with few side effects and good tolerance. Total number of doses given per day was similar. Many parents preferred the suppositories to oral medication in maintaining postoperative pain control because of ease of administration. If given the choice for future surgeries, many parents would switch or consider switching from oral pain medication to suppositories.

Cyclic natural progesterone use has been an effective treatment for catamenial and non-catamenial seizures in women. Progesterone is efficiently absorbed after administration as lozenges and rectal suppositories. Progesterone was given at 100 to 200 mg, three times daily on days 15 to 28 of the menstrual cycle. In a 3 month trial, average monthly seizure frequency was reduced by 54% to 68%. A 3 year follow-up report found that 15 of the women continued on the same AED and progesterone protocol and continued to have a very substantial (62% to 74%) reduction in seizure frequency.

References

Laryngoscope 2006 Aug;116(8):1485-8

Mirtazapine for Appetite Stimulation in Dogs and Cats

12/04/2007

The development of anorexia or loss of appetite can complicate management of any disease in an animal. For years veterinarians have struggled to identify effective appetite stimulants for both dogs and cats. Historically, veterinarians have employed mostly steroids and B vitamins to stimulate appetite for dogs, and have used benzodiazepines and cyproheptadine for cats. All of these agents were variably effective and all have the potential to cause adverse drug reactions to further complicate management. The cause of anorexia in animals is complex and may be due to direct physiological causes or may be due to nausea.

Mirtazapine is approved as an antidepressant for use in humans and a side effect noted in humans taking this drug was appetite stimulation. When pharmacy faculty at the Mississippi State College of Veterinary Medicine attempted use of mirtazapine in a dog after all other attempts at appetite stimulation had failed, they were very pleased to find that mirtazapine restored appetite almost immediately in this dog. In another case, a physician used mirtazapine to treat anorexia and nausea in his Boston Terrier with chronic renal failure. Due to the vast improvement in the animal´s quality of life for one month preceding its death, the dog´s primary care veterinary clinic conducted a series of uncontrolled field trials using mirtazapine over the next 4 years in 24 dogs and 17 cats with GI symptoms that were marginally responsive or refractory to standard remedies. “Mirtazapine therapy led to a robust response in 12 animals, improvement compared with standard treatment in 16 cases, and an equivocal response in 13 animals. The most vigorous responses were observed in patients in chronic renal failure or receiving concurrent chemotherapy for neoplastic disease.’1

Many veterinarians have started using mirtazapine to stimulate appetite in both dogs and cats. Commercially available tablets do not permit veterinarians or owners to administer the most appropriate doses to a dog or cat. Compounding pharmacists have formulated flavored oral suspensions upon the request of veterinarians and have anecdotally reported success with this dosage form. For cats that are vomiting as well as anorectic and cannot swallow or retain oral medications, veterinarians have instructed compounding pharmacists to formulate transdermal gels of mirtazapine. Obviously, further studies are needed to determine stability, safety and efficacy of these compounded dosage forms, but until such evidence is available, veterinarians may wish to try these dosage forms in cases that are refractory to traditional methods of appetite stimulation.

References

1 Veterinary Forum, February 2006, pages 34-36.

Seizures Corresponding to the Menstrual Cycle

11/01/2007

Catamenial epilepsy refers to seizures that occur or worsen around menstruation. The exact cause of catamenial seizures remains unclear, and despite the availability of several standard and newer antiepileptic drugs (AED), there is no specific and effective therapy. During this seizure-prone state, the activity of conventional antiepileptic drugs, including diazepam and sodium valproate, is reduced, possibly accounting for the clinical impression that catamenial seizures are unusually drug resistant. Researchers at North Carolina State University evaluated the hypothesis that neurosteroid "replacement" is an effective and a rational therapy for catamenial epilepsy. It is well known that progesterone possesses anticonvulsant properties. The clustering of seizures around the beginning of menstruation corresponds with a significant drop in the levels of progesterone circulating in the body and an increase in the estrogen:progesterone ratio. Generally, estrogens are found to be proconvulsant, whereas progesterone reduces seizures. Recent studies have shown that progesterone is metabolized to the neurosteroid allopregnanolone which plays a crucial role in seizure protection. Declining levels of allopregnanolone, which occur during the menstrual cycle, can provoke seizures. Alternations in seizure activity may also be seen during changes in reproductive status (i.e., while entering puberty, during pregnancy, or after menopause).

Indian Journal of Pharmacology 2005; 37(5):288-293 Neurology 1995;45:1660-2

Ask our compounding pharmacist for more information about natural bio-identical progesterone in customized dosage forms.

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Compounding Pharmacy News

Article Library

Progesterone Cream: Effects and Side-effects on Skin of Peri- and Postmenopausal Women

Relieving Pain From Head to Toe: Iontophoresis, Phonophoresis, and Transdermal Therapy

Is the FDA more interested in your health or Big Pharma’s wealth?

Autism Spectrum Disorder: Customized Medications and Supplements

Boric Acid Therapy for Chronic Vaginitis

Compounded Topical Metronidazole 10% Decreases Post-hemorrhoidectomy Pain and Improves Healing

Medications with a Personal Touch

Selecting Quality Supplements

Itching Relieved with Topical Naltrexone

Nervous about an MRI? Nasal Spray of Midazolam Prevents MRI Claustrophobia

Changing the Route of Drug Administration: The Advantages of a Compounded Medication versus “Off-Label Use”

Preventing and Treating Dry Skin

Treatment for Vulvodynia

Acetaminophen with Codeine: Oral vs. Rectal Administration in Postoperative Pediatric Patients

Mirtazapine for Appetite Stimulation in Dogs and Cats

Seizures Corresponding to the Menstrual Cycle

Changing the Route of Drug Administration:
The Advantages of a Compounded Medication versus “Off-Label Use”