Hospice & Palliative Care in Developing Countries
Compounding End of Life Medications
WHO Recommendations to Developing Countries
Russ Zakarian, Pharm.D. FASCP
What is Compounding?
Compounding is the method of preparing customized medications to help meet unique physician and patient needs.
Pharmacy
The art or profession of preparing and preserving drugs, and of compounding and dispensing medication according to the prescriptions of physicians.
– Early 20th Century Webster Dictionary
Also known as a problem solver, a compounding pharmacist’s ultimate goal in preparing customized
medications is to help the physician and patient achieve a more positive therapeutic outcome.
Hospice
Alternative routes of administration Individualized pain management Nausea & vomiting Inhalation therapy Emergency kits Mouth ulcers Saliva stimulants Adjunctive therapies
Meeting Unique Needs In:
Hospice Pain Management Bio-identical Hormone Replacement Therapy Veterinary applications
– Household pets– Equine– Zoos– Exotics
Dental Dermatology
Compounded Dosage Forms
Oral capsules and liquids Transdermals Lollipops and popsicles Troches, tablet triturates and sublingual
drops Rapid dissolve tablets Suppositories, enemas and rectal rockets
Compounded Dosage Forms
Nasal and otic preparations Topical creams, ointments, gels, powders
and sprays Oral adhesives, mouthwashes and rinses Sterile products
– Inhalation solutions, injections, ophthalmics, TPNs
Compounded Capsules
Medications formulated in capsules enable the patient to get the exact dosage needed, while avoiding unwanted dyes and fillers.
Compounding for Pain Management
Capsules– Morphine Sulfate SR caps up to
900mg/cap– Oxycodone SR caps
Compounded Oral Liquids
Preparing medications in a liquid form allowathe patient who can’t swallow pills to get the appropriate medicine in a vast range of flavors, such as tutti-frutti or vanilla butternut.
Compounded Oral Liquids
Difficulty swallowing
Avoid unwanted ingredients
Increased compliance
Anhydrous formulations
Compounding for Pain Management
Oral Liquids– Magic Mouthwash
Morphine oral solutions 50mg/ml(commercial dose is 20mg/ml)
Transdermal Drug Delivery
Drug Classes Used in Transdermals NSAIDS Muscle relaxants Antinausea agents Antiviral agents Anti-inflammatory agents Anesthetics Anti-anxiety agents
Transdermal Drug Delivery
Drug Classes Used in Transdermals Anti-diabetic agents Antidepressant / anti-psychotic agents Anti-hypertensive agents Thyroid medication Antihistamines Anti-infective agents
Compounding for Pain Management
Transdermal Gels– ABHR– Alprazolam– Dexamethazone– Diazepam– Gabapentin– Haloperidol– Ketamine
Compounding for Pain Management, cont
Transdermal Gels– Hydroxyzine– Metochlopramide– Oxycodone– Promethazine– Temazepam– Diphenhydramine
Medicated Lollipops
Local effects– Anesthetic– Antifungal– Antiviral– Anti-inflammatory– Saliva stimulant– Healing agents
Troches
Soft gelatin-flavored troches, such as those prepared in the 24 and 30-count molds, provide medication in an easy-to-take and pleasant-tasting form.
Compounded Sterile Products
USP <797> standard compliant Infusion pain management with CADD infusion
pumps Routes of infusion: SQ, MediPort, PICC MS 50mg/cc Hydromorphone 10mg/cc Fentanyl 50mcg/cc Lorazepam 2mg/cc Midazolam 5mg/cc
Suppositories and Enemas
Rectal or vaginal use Helpful to patients who
have difficulty in swallowing, nausea/vomiting
Injections cause pain, anxiety
Rapid local affect
Compounding for Pain Management
Suppositories– ABHR– Chloral Hydrate– Diazepam– Morphine– Phenytoin– Gabapentin
IAHPC Meds for Palliative Care –Pharmacist Prospective
List includes 33 medications of which 17 already included in WHO list.
Medications were rated on effectiveness and safety profile.
Final list was approved by panel of 28 professional organizations.
Refer to handout for list of meds.
Anti-depressants
TCA local anesthetic type properties due to its “sodium channel blockade.”
Not shared by SSRI anti-depressants. Decreasing depression can de-amplify the
sensation of pain. Plasma steady state takes 2 weeks.
Adverse Drug Effects
Amitriptyline (TCA)– Dose related Anti-cholinergic effects– Co-morbidities such as CV disease and drug interactions
limits its use. Desipiramine (TCA)
– Lowest risk of anti-cholinergic effects Mirtazapine/Trazadone
– Dual action of NaSSA and Tetracyclic Cymbalta (not on the IAHPC list)
– FDA approved for nerve injury pain
OPIOID ANALGESICS
Opioids classifies as full morphine-like agonists.– Do not exhibit dose-ceiling expect when limited by
toxicities. Antagonize NMDA receptors mu, kappa, delta receptors are target
molecules for analgesia
MORPHINE
Gold standard IAHPC list both IR and SR forms WHO only list IR forms Highest dose list for SR is 30mg tabs MSIR sol dose listed is 10mg/5ml
SPECIAL CONSIDERATIONS
Neurotoxicity– Opioid Induced Hyperalgesia (OIH)
… more pain with more drug Tolerance
– Neuronal excitotoxicity via cell death– Changes in glutamate availability– NMDA receptor excitability– Ratio of M6G/M3G– NMDA blockers – ketamine, clonidine, methadone– Signal of disease progression
OXYCODONE
mu & kappa receptor agonist Metabolized CYP 2D6 pathway
– Dose adjustments necessary with drugs that inhibit CYP 2D6 (Haldol,Paxil,Prozac)
10-20% metabolized to oxymorphone. Oxycodone IR 5mg on IAHPC list
– Oxycodone SR not included
FENTANYL
Potent mu agonist PO conversion to patch
– Convert oral opioid to equivalent dose of oral morphine– Half this dose and convert to mcg for appropriate patch size– Reverse should not be used
Metabolized CYP 450 3A4 25mcg for Opioid Naïve patients
METHADONE
Elimination half-life (8-59 hours) is longer than its duration of action (4-5 hours)
High dose and prolonged QT intervals a marker for deadly cardiac problems
Dose conversion is challenging Not a first line drug DEA restricts distribution to 10mg tabs
LIST OF ESSENTIALMEDICATIONS, CONT
Bisacodyl/Senna/Mineral Oil Prednisone/Dexamethasone Acetaminophen Valium/Lorazepam Midazolam/Zolpidem Haldoperidol Gabapentin
GETTING PAST THE STIGMA
Reasons Pharmacist stock inadequate supplies of opiods– Concerns with DEA monitor usage– Illicit use and fraud– Fear of theft
Questions???
For more information Russ Zakarian,Pharm.D. Model Drug Pharmacy 1-800-585-3785 [email protected]