What you don’t know can hurt your patients

1. What you don’t know can hurt your patients Ben O’Rourke Ted Williams Christine Wood Samantha Woodhouse Brian Zacher Atanaz Zargarizadeh

2. 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 O’Rourke

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

4. 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.

5. 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

6. 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

7. 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

8. Hormones • Progesterone • Estrogens:E1, E2, E3 • Premarin • Testosterone: • Soy • Wild Yams www.hormoneprofile.comGuyton A, Hall J. Textbook of Medical Physiology 10th Ed. WB Saunders Co. Pennsylvania. 2000

10. Chrysin • Stabilizes Testoserone • Induces UDP-Glucoronosyltransferase (UGT) http://toxsci.oxfordjournals.org/cgi/content/full/82/1/70http://dmd.aspetjournals.org/cgi/content/full/28/9/1077Lacy, J LexiComp Drug Information Handbook 13th Ed. 2005

11. A common swimming pool biocide Protection against bacteria and algae without the harsh effects of chlorine A compound having a broad spectrum activity and low toxicity Ophthalmology Baquacil polyhexamethylene biguanide (PHMB)

12. 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.

13. 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.

14. 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.columbia.edu/dept/nsg/NSGCPMC/specialties/spinestim.htmlPain Management Compounding http://www.bbpharmacy.com/paincompounding.html

15. 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.columbia.edu/dept/nsg/NSGCPMC/specialties/spinestim.htmlPain Management Compounding http://www.bbpharmacy.com/paincompounding.html

16. Alternative Pain Management • Most important of all, different dosages are prepared in these compounding pharmacies to fit with the patient’s 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.columbia.edu/dept/nsg/NSGCPMC/specialties/spinestim.htmlPain Management Compounding http://www.bbpharmacy.com/paincompounding.html

17. 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

18. 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

19. 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

20. Pluronic Lecithin Organogel (PLO) • Liquid a refrigeration temperatures • Easy to mix and measure • Cream at room/body temperatures • Easy to apply • Very little mess

21. 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 don’t know • Even an experienced pharmacist can be oblivious to an established solution to a problem

22. Additional References • Student Site Evaluation