Pharmacy Specialists Compounding Pharmacy

PALLIATIVE CARE

Palliative care aims to relieve and manage symptoms – such as nausea and vomiting, pain, dry mouth, oral pain or inflammation, wound care, fatigue, loss of appetite, radiation mucositis, constipation, and shortness of breath – without causing unwanted side effects such as excessive drowsiness, GI upset, and constipation. Our compounding pharmacy is an important part of the patient care team, as we have resources that are not available at traditional pharmacies. Our patients’ options are not limited to one-size-fits-all medications.

Here are some of the ways that our compounding pharmacy can help patients nearing the end of life:

We can customize pain medications to control pain that has not responded to commercially available drugs.
When a medication is only commercially available as an oral or injectable form, it can often be compounded as a different dosage form such as a topical or transdermal gel, suppository, troche, or lollipop.
We can combine compatible drugs into a single dosage form to make it easier to take medications and manage schedules.
When a patient is unable to tolerate the taste of a medication, we can compound oral preparations and flavor them specifically for each patient, masking bitterness.
If a patient is suffering from dry mouth (common after head and/or neck radiation), or has mouth tenderness or an infection, medicated dosage forms can be compounded which may enable the patient to enjoy eating again.
Pressure sores (decubitus ulcers) can be very difficult to manage. Our professional compounding pharmacist can work with physicians and other members of the health care team to prepare the best formulation for each patient and relieve pain and speed healing.
Wound odor can be extremely embarrassing for patients. Topical preparations can be compounded to reduce odor.

Life can be very challenging for those suffering from chronic illness and their families and caregivers. Adding the resources of our professional compounding pharmacy offers a greater spectrum of treatment options and allows the patient to live life more comfortably. Various types of medications have been compounded to relieve problems that affect patients who are receiving palliative care or who have received chemotherapy or radiation therapy.

Palliative Care is “the active total care of patients whose disease is not responsive to curative treatment.”

The skill and caring of a knowledgeable compounding pharmacist can complement a physician’s abilities. Patients with chronic illnesses or who are nearing the end of life frequently require symptom control and pain relief. While every individual is unique, common symptoms and problems include:

Pain Management
Nausea and Vomiting
Severe Constipation
Diarrhea
Decubitus Ulcers
Shortness of Breath
Anxiety

Compounded medications are available to help with all of the above problems. We work closely with practitioners and caregivers to customize a personal solution that meets the needs of each patient so that patients can enjoy precious time with loved ones. Please contact our compounding pharmacist to discuss the dosage form, strength, and medication or combination that is most appropriate.

Compounded Medications for Palliative Care

Among the greatest therapeutic challenges faced by both patients and caregivers is the treatment required by individuals who have a terminal condition. It is difficult to find evidence-based studies on the management of end-of-life situations because each patient’s medical case is unique. In addition, maintaining a controlled environment for such patients is difficult. End-of-life care is multifaceted and people with a terminal illness are among the most vulnerable patients in need of effective and compassionate care. When those patients suffer in spite of commercially available therapies, the innovation and experience of clinicians and compounding pharmacists can often yield a solution to the most challenging treatment problems.

Int J Pharm Compd. 2014 May-Jun;18(3):190-200.
Compounded drugs of value in outpatient hospice and palliative care practice.
Click here to access the PubMed abstract of this article.

Anti-Emetics

Nausea & Vomiting

Persistent nausea can often be effectively controlled by using a combination of medications tailored to meet that individual’s specific needs. Dosage forms include transdermal gels, suppositories, lollipops, and more.

Promethazine is commonly compounded for topical or transdermal application to treat nausea, vomiting, and vertigo, but this preparation may be used as an antiemetic for cases ranging from chemotherapy to motion sickness. The dose is typically 25mg for adults, and the dose is decreased for children. The gel is applied to an area of soft skin, such as the inside of the wrist or arm, the side of the torso, or the inside of the thigh. For children, doses are often applied to the inside of one wrist, and then the wrists are rubbed together.

US Pharmacist, August 1999; 74-5

Lorazepam, diphenhydramine, haloperidol, and metoclopramide (known in combination as “ABHR”) have been prepared as a rectal suppository and in other transdermal dosage forms. The rationale is to use a variety of medications that target various pathways such as vagal nerve stimulation, the vomiting center, and the CTZ for more severe cases. Researchers at Memorial Sloan-Kettering Cancer Centre have studied the antiemetic activity and safety of the antiemetic regimen of metoclopramide, dexamethasone, and diphenhydramine in patients receiving standard outpatient chemotherapy programs. Vomiting was prevented in over 70% of patients.

Cancer 1995 Sep 1;76(5):774-8

Oral combination antiemetics in patients with small cell lung cancer receiving cisplatin or cyclophosphamide plus doxorubicin.

Click here to access the PubMed abstract of this article.

Intranasal metoclopramide may significantly reduce the frequency of acute vomiting in patients receiving highly emetogenic chemotherapy, such as cisplatin-induced delayed emesis. Intranasal metoclopramide caused minor irritation of the nasal membrane and unpleasant taste in some patients but was otherwise well tolerated, with no report of serious extrapyramidal effects.

Drugs 1999 Aug;58(2):315-22; discussion 323-4
Intranasal metoclopramide.
Click here to access the PubMed abstract of this article.

ABH Transdermal Gel for Chemotherapy-Induced Nausea/VomitingChemotherapy-induced nausea and vomiting (CINV) is commonly cited by patients as being among the “most unpleasant and distressing” side effects associated with chemotherapy. CINV may impair quality of life significantly and necessitate chemotherapeutic dose reductions, treatment delays, and discontinuation of therapy. Finally, it may cause a substantial number of lost workdays for patients and considerable costs to the healthcare system, resulting in a substantial economic burden. Bleicher et al. of the Haematology/Oncology Division, Creighton University Medical Centre, Omaha, NE, investigated the efficacy of “ABH,” a topical gel containing lorazepam (Ativan®), diphenhydramine (Benadryl®), and haloperidol (Haldol®), in reducing breakthrough CINV. Adults receiving standard recommended prophylactic antiemetics as outpatients were instructed to apply 0.5 mL of a transdermal gel (containing lorazepam 2 mg, diphenhydramine 25 mg, and haloperidol 2 mg) when they experienced significant CINV. When the severity of CINV was quantified on a scale of 0-10, the mean CINV score decreased significantly from a 6.1 before gel application to a 1.7 as evaluated 30 minutes following gel application. Topical use of ABH gel appears to be a promising and safe rescue therapy for breakthrough CINV that occurs despite prophylactic antiemetic therapy.

Weschules noted that of 11,181 ABHR (ABH plus metoclopramide [Reglan®]) prescriptions provided for patients, 6,529 (58.4%) were for a topical gel, and 4,312 (38.6%) were for a rectal suppository.
Less than 0.5% of patients discontinued treatment due to adverse side effects. Another retrospective study reported the use of an ABHR gel to be 98% effective in hospice patients.
There were no adverse reactions; however, problems arose when patients with bowel obstructions were treated.

Lorazepam, diphenhydramine, and haloperidol transdermal gel for rescue from chemotherapy-induced nausea/vomiting: results of two pilot trials.
Click here to access the PubMed abstract of this article.

J Palliat Med 2008;8:1135–1143.
Tolerability of the compound ABHR in hospice patients.
Click here to access the PubMed abstract of this article.

Int J Pharm Compounding 2006;10:95–99.
ABHR Gel in the Treatment of Nausea and Vomiting in the Hospice Patient
Click here to access the abstract of this article.

Therapy for Dry Mouth (Xerostomia)

Pilocarpine Mouth Rinse for Xerostomia

Xerostomia (dry mouth) is a common condition that can significantly impair quality of life. Therapy with oral pilocarpine tablets can relieve dry mouth symptoms, but produces numerous adverse effects. Mouth rinsing with pilocarpine solutions at concentrations of 1 to 2% induced a significant objective and subjective dose-dependent increase in salivary flow, similar to the results reported for oral 5 mg pilocarpine, but with fewer side effects. A systematic review and meta-analysis of 20 studies involving 1732 patients with xerostomia showed that pilocarpine should be one of the first lines of therapy in head and neck cancer survivors who had radiotherapy-induced xerostomia and reduced salivation.

Oral Oncol. 2017 Mar;66:64-74.
Interventions for the management of radiotherapy-induced xerostomia and hyposalivation: A systematic review and meta-analysis
Click here to access the PubMed abstract of this article.

Braz J Med Biol Res. 2002 Jan;35(1):105-10.
Effect of pilocarpine mouthwash on salivary flow
Click here to access the PubMed abstract of this article.

Spec Care Dentist. 2015 Jul-Aug;35(4):164-9.
Efficacy and safety of pilocarpine mouthwash in elderly patients with xerostomia
Click here to access the PubMed abstract of this article.

Dry Mouth & Stomatitis

There are many factors that can interfere with the ability to eat when a person is receiving chemotherapy. Malnutrition may result, yet it is often preventable. Our pharmacy can compound medications to help combat mouth tenderness and infections, which may enable patients to enjoy eating again.

Cancer. 2002 Nov 15;95(10):2230-6
Effect of topical morphine [mouthwash] for mucositis-associated pain following concomitant chemoradiotherapy for head and neck carcinoma.
Click here to access the PubMed abstract of this article.

Loss of saliva (xerostomia) is one of the most common complaints among patients who have received radiation therapy of the head and neck. Xerostomia contributes to radiation-induced periodontal infection, dental caries, osteoradionecrosis, and poor digestion of carbohydrates. Ask us about sialogogues (saliva stimulants) in customized dosage forms. The following article discusses the benefits of using pilocarpine in a sustained release dosage form to treat xerostomia.

Yakugaku Zasshi. 1997 Jan;117(1):59-64
[Preparation and evaluation of solid dispersions of pilocarpine hydrochloride for alleviation of xerostomia]
[Article in Japanese]
Click here to access the PubMed abstract of this article.

Anti - Secretory Agents

Transdermal Anticholinergics for the Treatment of “Death Rattle” and Excessive SecretionsDifficulty clearing upper airway secretions (death rattle) is a problem for half of all dying patients. Treatment often includes the use of anticholinergic drugs, such as scopolamine (also known as hyoscine) or atropine. Transdermal scopolamine has several indications for symptom control in patients with end-stage disease: control of excess salivary secretions, management of terminal secretions, and control of nausea.

Palliat Med. 2002 Sep;16(5):369-74
Using anti-muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative care.
Click here to access the PubMed abstract.

J Pain Symptom Manage. 2002 Apr;23(4):310-7
Death rattle: prevalence, prevention and treatment.
Click here to access the PubMed abstract.

Prescrire Int. 2001 Aug;10(54):99-101
Scopolamine: new preparations. Reference treatment for death rattle.
Click here to access the PubMed abstract.

Otolaryngol Head Neck Surg. 1990 Oct;103(4):615-8
Reduction of salivary flow with transdermal scopolamine: a four-year experience.
Click here to access the PubMed abstract of this article.

Drooling is a serious social handicap experienced by some neurologically impaired patients. No one method has been identified to control drooling for all patients, however, anticholinergic drugs have been utilized. In the following case study, transdermal scopolamine was found to be effective for controlling drooling in a traumatic brain-injured patient for whom more conservative methods failed. From a baseline saliva flow rate, saliva flow decreased up to 59%. No significant side effects were observed with treatment, and the decrease in drooling was maintained for a 4-month period. Although transdermal scopolamine may represent one acceptable facet of long-term treatment, it must be stressed that efficacy is variable across patient populations and that treatment approaches must be individualized.

Am J Phys Med Rehabil. 1991 Aug;70(4):220-2
The use of transdermal scopolamine to control drooling. A case report.
Click here to access the PubMed abstract of this article.

Pain Management

Pain management is essential because, even when the underlying disease process is stable, uncontrolled pain prevents patients from working productively, enjoying recreation, or taking pleasure in their usual roles in the family and society. Chronic pain may have a myriad of causes and perpetuating factors, and therefore can be much more difficult to manage than acute pain, requiring a multidisciplinary approach and customized treatment protocols to meet the specific needs of each patient. Optimal treatment may involve the use of medications that possess pain-relieving properties, including some antidepressants, anticonvulsants, antiarrhythmics, anesthetics, antiviral agents, and NMDA (N-methyl-D-aspartate) antagonists. NMDA-receptor antagonists, such as dextromethorphan and ketamine, can block pain transmission in dorsal horn spinal neurons and reduce nociception. [Anesth Analg 2001 Mar;92(3):739-44] 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. Topical and transdermal creams and gels can be formulated to provide high local concentrations at the site of application (e.g., NSAIDs for joint pain), for trigger point application (e.g., combinations of medications for neuropathic pain), or in a base that will allow systemic absorption. Side effects associated with oral administration can often be avoided when medications are used topically. Studies suggest that there are no great restrictions on the type of drug that can be incorporated into a properly compounded transdermal gel. When medications are administered transdermally, they are not absorbed through the gastrointestinal system and do not undergo first-pass hepatic metabolism.We work together with prescribers and patients to solve problems by customizing medications that meet the specific needs of each individual. Please contact our compounding pharmacist to discuss the dosage form, strength, and medication or combination that is most appropriate for your patient.

J Pain Symptom Manage. 2009 May;37(5):913-7.
Effectiveness of topical administration in palliative care: a systematic review.
Click here to access the PubMed abstract of this article.

Wound Care

Per a prescription order, a formulation can be compounded to contain the proper combination of active ingredients, in the most appropriate base, to treat a specific type of wound. We customize medications to meet each individual’s specific needs. For example, the choice of cream, ointment, or gel can be clinically significant. Each time a wound needs to be cleaned, there is the potential for disruption of new tissue growth. Gels, which are more water-soluble than creams or ointments, may be preferable for wound use because a gel can be rinsed from the wound by irrigation. Another useful dosage form is the “polyox bandage” – which can be puffed onto a wound and will adhere even if exudate is present. A polyox bandage can be compounded to contain the active ingredient(s) of your choice.

Decubitus Ulcers

Phenytoin has been used topically to speed the healing of decubitus ulcers, pressure sores, venous stasis and diabetic ulcers, traumatic wounds, skin autograft donor sites, and burns. Ketoprofen may be used to control inflammation and pain, lidocaine provides topical anesthesia, and pentoxifylline may improve microcirculation at the wound margins and promote healing of the injured area. Misoprostol, a prostaglandin analog, is often included in wound care formulations to promote healing. Debridement of necrotic eschar with 40% urea paste may also speed healing. Medications that improve capillary blood flow can be added to a compounded medication to enhance circulation at the wound margins and promote healing of the injured area.

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. Rhodes et al compared the healing of stage II decubitus ulcers with topically applied phenytoin and two other standard topical treatment procedures in 47 patients in a long-term care setting. Ulcers were examined for the presence of healthy granulation tissue, reduction in surface dimensions, and time to healing. Topical phenytoin therapy resulted in a shorter time to complete healing and formation of granulation tissue when compared with DuoDerm dressings or triple antibiotic ointment applications. The mean time to healing in the phenytoin group was 35.3 +/- 14.3 days compared with 51.8 +/- 19.6 and 53.8 +/- 8.5 days for the DuoDerm and triple antibiotic ointment groups, respectively. Healthy granulation tissue in the phenytoin group appeared within 2 to 7 days in all subjects, compared to 6 to 21 days in the standard treatment groups. The phenytoin-treated group showed no detectable serum phenytoin concentrations. Anstead et al. described a patient with a massive grade IV pressure ulcer that was unresponsive to conventional treatment, yet responded rapidly to treatment with topical phenytoin. Song and Cheng reported phenytoin improved wound breaking strength in normal and radiation-impaired wounds. The results of their study indicated that topical phenytoin accelerated normal and irradiation-impaired wound healing by increasing the number of wound macrophages and improving the macrophage function. Pendse et al evaluated the effectiveness of topical phenytoin in healing chronic skin ulcers in a controlled trial of 75 inpatients. At the end of the fourth week, 29 of 40 phenytoin-treated ulcers had healed completely versus 10 of 35 controls. They concluded: “topical phenytoin appears to be an effective, inexpensive, and widely available therapeutic agent in wound healing.”The effectiveness of topical phenytoin as a wound-healing agent was compared with that of OpSite and a conventional topical antibiotic dressing (Soframycin) in a controlled study of 60 patients with partial-thickness skin autograft donor sites on the lower extremities. Mean pain scores were lower and mean time to complete healing (complete epithelialization) was best in the phenytoin-treated group (6.2 +/- 1.6 days). Topical phenytoin compared very favorably with, and in some aspects was superior to, occlusive dressings.No study reported any significant adverse effects secondary to topical phenytoin therapy.

Ann Pharmacother 2001 Jun;35(6):675-81
Topical phenytoin treatment of stage II decubitus ulcers in the elderly.
Click here to access the PubMed abstract of this article.

Biochem Pharmacol 1999 May 15;57(10):1085-94
Role of phenytoin in wound healing–a wound pharmacology perspective.
Click here to access the PubMed abstract of this article.

Ann Pharmacother 1996 Jul-Aug;30(7-8):768-75
Phenytoin in wound healing.
Click here to access the PubMed abstract of this article.

Int J Dermatol 1993 Mar;32(3):214-7
Topical phenytoin in wound healing.
Click here to access the PubMed abstract of this article.

Chung Hua I Hsueh Tsa Chih 1997 Jan;77(1):54-7
[The effect of systemic and local irradiation on wound macrophages and the repair promoting action of phenytoin sodium]
Click here to access the PubMed abstract of this article.

Diabetes Care 1991 Oct;14(10):909-11
Topical phenytoin in diabetic foot ulcers.
Click here to access the PubMed abstract of this article.

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 the prevention of wound infection in areas with a high density of sebaceous glands. Topical treatment of pressure sore with 20% benzoyl peroxide in O/W emulsion yielded very satisfactory results. In another study, 10% benzoyl peroxide gel was used prophylactically once a day for 7 days before surgery. The researchers concluded that topical benzoyl peroxide is an efficacious, harmless, and inexpensive agent for the prevention of wound infections in seborrheic regions.

Med Cutan Ibero Lat Am 1988;16(5):427-9.
[Benzoyl peroxide in the treatment of decubitus ulcers]
Click here to access the PubMed abstract of this article.

Topical Tranexamic Acid to Reduce Bleeding in Advanced BCC

Tranexamic acid (TXA) is a synthetic derivative of the amino acid lysine. Conventionally used orally or intravenously, when administered topically, TXA has the ability to reduce bleeding with minimal systemic absorption and, in turn, a reduction in the risk of systemic side effects. A case study discussed an elderly female with locally advanced basal cell carcinoma (BCC) of the scalp that was managed conservatively. The primary aim, in this case, was palliative wound care, and successful hemostasis of the large bleeding malignancy was achieved using topical TXA. After a month of applying topical tranexamic acid 500 mg daily, the scalp tumor remained stable in size. Vascularity and bleeding of the tumor were significantly reduced. Wound dressings were continued, and topical TXA 500 mg was eventually decreased to every other day with continued good hemostatic effect. No systemic side effects were encountered during the course of the treatment. Topical TXA is a promising therapeutic option for the hemostasis of locally advanced BCC or other skin malignancies, especially as part of palliative care for patients who are unsuitable for surgery or radiotherapy.

JAAD Case Rep. 2016 Mar; 2(2): 162–163.
Role of topical tranexamic acid in hemostasis of locally advanced basal cell carcinoma
Click here to access the PubMed abstract of this article.

Dyspnea

When illness is incurable or the cause is irreversible and the goal is palliation.

Palliat Med. 1997 Jul;11(4):277-81.
Oral morphine as symptomatic treatment of dyspnoea in patients with advanced cancer.
Click here to access the PubMed abstract of this article.

N Engl J Med. 1981 Dec 31;305(27):1611-6.
Effects of dihydrocodeine, alcohol, and caffeine on breathlessness and exercise tolerance in patients with chronic obstructive lung disease and normal blood gases.
Click here to access the PubMed abstract of this article.

Education for Physicians on End-of-life Care (EPEC) Participant’s Handbook
EPEC Project, 1999. The Project to Educate Physicians on End-of-life Care from the Institute for Ethics at the American Medical Association.

BMJ. 2003 Sep 6;327(7414):523-8
Randomized, double-blind, placebo-controlled crossover trial of sustained-release morphine for the management of refractory dyspnoea
Click here to access the PubMed abstract of this article.

Prevention / Treatment of Radiation Mucositis / Proctitis

Bupivacaine Lozenges for Reducing Pain from Oral Mucositis

Oral mucositis which results in severe pain is primarily due to cancer treatment but can also be related to immune-deficiency caused by infections and systemic inflammatory diseases. “The vast majority of patients undergoing radiation therapy with or without high-dose chemotherapy for head and neck cancer will develop oral mucositis in degrees ranging from minor erythema of the oral mucosa to large debilitating and painful ulcers.” A pilot study investigated the location of anesthetic effect and duration of pain relief after a single dose administration of a 25 mg bupivacaine lozenge to reduce pain in the oral cavity and pharynx in patients with head and neck cancer (HNC) and oral mucositis. The lozenge was compounded and included a sweetener and licorice powder to mask the taste. There was a significant reduction in pain in both the oral cavity and pharynx immediately after the lozenge was completely dissolved in the mouth. The mean time for maximal pain reduction after the lozenge was dissolved was 42 minutes. There was still a significant reduction in mean pain in the oral cavity after 180 minutes. “Results indicate that the bupivacaine lozenge has a clinically significant and long-lasting pain-relieving effect on pain because of oral mucositis in patients with HNC.”

Pain Rep. 2016 Sep; 1(3): e571.
A novel lozenge containing bupivacaine as topical alleviation of oral mucositis pain in patients with head and neck cancer: a pilot study
Click here to access the PubMed abstract of this article.

Radiation proctitis is a known complication of radiation therapy for prostate cancer. Commercially available treatments are often ineffective and have focused on relieving symptoms after damage has occurred, although options exist for prevention.

A prospective, randomized, placebo-controlled, double-blinded trial concluded that misoprostol rectal suppositories significantly reduce acute and chronic radiation proctitis symptoms in patients receiving radiation therapy for prostate cancer.

Am J Gastroenterol 2000 Aug;95(8):1961-6
A prospective randomized placebo-controlled double-blinded pilot study of misoprostol rectal suppositories in the prevention of acute and chronic radiation proctitis symptoms in prostate cancer patients.
Click here to access the PubMed abstract of this article.

Seven patients with radiation proctitis completed an open pilot study to evaluate the effectiveness of short-chain fatty acid (SCFA) enemas. Four weeks of treatment resulted in clinical improvement in all patients and modest changes in endoscopic and pathological parameters.

Am J Gastroenterol. 1996 Sep;91(9):1814-6
Evaluation of short-chain fatty acid enemas: treatment of radiation proctitis.
Click here to access the PubMed abstract of this article.

Oral Viscous Sucralfate Gel for Post-Procedural Treatment of Barrett’s Esophagus & Other Problems Solved with Topical Sucralfate Preparations

Barrett’s esophagus (BE) is an abnormal change in the cells of the lower portion of the esophagus, characterized by the replacement of the normal stratified squamous epithelium lining of the esophagus by columnar epithelium cells which are usually found lower in the gastrointestinal tract. Patients with BE have approximately an 0.5% risk of developing esophageal adenocarcinoma. In general, high-grade dysplasia and early stages of adenocarcinoma can be treated by endoscopic resection and/or endoscopic ablative therapy, whereas advanced stages (submucosal) generally require surgical treatment. Patients who undergo endoscopic resection and/or endoscopic ablative therapy might suffer from retrosternal discomfort and transient dysphagia, adverse effects that sometimes accompany these procedures. One of the common post-procedural treatments is oral sucralfate suspension or viscous gel, 1 gram four times daily for two weeks after the procedure. The rationale for this treatment is to enhance the wound-healing process in the esophageal tissues and to coat the wounded tissues with sucralfate, a cytoprotective agent.

Population studies suggest that gastroesophageal reflux disease (GERD) is increasing in prevalence, both in the U.S. and worldwide. The diagnosis of GERD is associated with a 10% to 15% risk of BE. Other risk factors associated with the development of BE include:

• Long-standing GERD
• Male gender
• Obesity
• Age over 50 years

Thirteen peer-reviewed articles have described the use of 5 mL of sucralfate suspension (200 mg/mL) 4 times a day for a period of 2 weeks after each endoscopic treatment of BE to ease the retrosternal discomfort and transient dysphagia that accompanies this procedure.

Randomized clinical trials (RCTs) have shown the benefit of topical sucralfate therapy for the treatment of:
• chronic venous leg ulcers
• burn wounds
• chronic radiation-induced proctitis (A sucralfate enema was chosen as a first-line treatment for this pathology by the Mucositis Study Group of Multinational Association of Supportive Care in Cancer in collaboration with the International Society of Oral Oncology).

RCTs have shown the benefit of sucralfate preparations to enhance wound-healing following:
• Hemorrhoidectomy
• Fistulotomy
• Tonsillectomy

However, less success has been noted for oral mucositis, radiotherapy-induced skin tissue damage and radiotherapy-induced esophagitis.

Pharmaceutics. 2018 Sep; 10(3): 159
Mucosal Applications of Poloxamer 407-Based Hydrogels: An Overview
Click here to access the PubMed abstract of this article.

Int J Pharm Compd. 2019 Sep-Oct;23(5):376-381.
Oral Viscous Sucralfate Gel for Post-procedural Treatment of Barrett’s Esophagus
Click here to access the PubMed abstract of this article.

Topical sucralfate may induce a lasting remission in a majority of patients with moderate to severe rectal bleeding due to radiation proctosigmoiditis.

Dig Dis Sci 1999 May;44(5):973-8
Natural history of late radiation proctosigmoiditis treated with topical sucralfate suspension.
Click here to access the PubMed abstract of this article.

Topical morphine is effective in relieving mucositis-associated pain following concomitant chemoradiotherapy in head and neck carcinoma. Three patients, who had been treated previously with oral morphine with no relief from esophagitis pain, swallowed from 2 to 10 mL of 0.1% morphine viscous gel three times a day, 5 to 60 minutes before eating. The gel covered esophageal surfaces and produced topical anesthesia. Benefit continued to increase over several days of use. In prior studies, relief of oral mucositis pain was obtained by a topical 0.1% morphine solution. The major advantages of topical morphine administration are simplicity, low incidence of side effects, and low cost.

J Pain Symptom Manage. 2005 Aug;30(2):107-9.
Chemoradiotherapy-induced esophagitis pain relieved by topical morphine: three cases.
Click here to access the PubMed abstract of this article.

“Mucositis is a common adverse event related to many antineoplastic regimens… Ketamine is a potent N-methyl-D-aspartate (NMDA) receptor channel blocker that can lead to decreased nocioception and inhibit the inflammatory cascade… Also, ketamine acts on a number of other pathways that may attenuate pain.”Ketamine mouthwash (20 mg/5 ml) administered using the “swish and spit” technique may be a viable treatment option in refractory mucositis pain.

J Palliat Med. 2009 Nov;12(11):989-91.
Ketamine mouthwash for mucositis pain.
Click here to access the PubMed abstract of this article.

Systemic doxepin, a tricyclic antidepressant, has been used for pain management of patients with chronic pain. Practitioners at major US universities and in private practice assessed pain reduction after topical doxepin rinse in fifty-one patients with painful oral mucositis attributable solely to cancer therapy. A significant reduction of oral pain was recorded after doxepin was administered. At 5 minutes, on average, patients reported a 41% decrease in pain, and the median duration of pain reduction lasted for almost 2½ hours. Taste was acceptable and discomfort/burning with use was minimal. These findings are in contrast to typical complaints of taste and discomfort/burning associated with topical application of local anesthetics.

Anesth Analg 2006;103:465–70
Oral Doxepin Rinse: The Analgesic Effect and Duration of Pain Reduction in Patients with Oral Mucositis Due to Cancer Therapy
Click here to access the PubMed abstract of this article.

Examples of Compounded Medications

The following list is just a few of the preparations that we can compound for palliative care. All formulations are customized per prescription to meet the unique needs of each patient. Please call us to discuss the dosage form, medication, and strength which are most appropriate for your patient.

ABHR – gel and troche
Cholestyramine ointment
Dextromethorphan
single agent and oral modified release preparations
Lidocaine -Tetracaine spray
Metoclopramide- nasal spray and suppository
Misoprostol – suppository and oral preparations
Transdermal pain medications
Pilocarpine – gel, lollipop, or oral modified release preparations
Promethazine gel
Scopolamine gel
Short-chain fatty acid enemas
Sucralfate oral adhesive paste, cream, and enema

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