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Palliative Care

palliative
Palliative Care is “the active total care of patients whose disease is not responsive to curative treatment.” The goal of palliative care is the achievement of the best possible quality of life for patients and their families.

Symptom Control involves therapies for nausea & vomiting, dry mouth & stomatitis, excessive pulmonary secretions/death rattle, radiation mucositis and proctitis, and wound care.

We work together with prescriber and patient 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.


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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 which target various pathways such as vagal nerve stimulation, the vomiting center, and the CTZ for more severe cases. Researchers at Memorial Sloan-Kettering Cancer Center 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.

Cleri LB, Kris MG, Tyson LB, Pisters KM, Clark RA, Gralla RJ
Department of Medicine, Memorial Sloan-Kettering Cancer Center, Cornell University Medical College, New York, New York 10021

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 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.

Ormrod D, Goa KL.
Adis International Limited, Auckland, New Zealand.

Click here to access the PubMed abstract of this article.


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Therapy for Dry Mouth (Xerostomia)

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.

Cerchietti LC, Navigante AH, Bonomi MR, Zaderajko MA, Menendez PR, Pogany CE, Roth BM.
Supportive Care Division, Department of Medical Oncology, Angel H. Roffo Cancer Institute, University of Buenos Aires, Buenos Aires, Argentina.

Click here to access the PubMed abstract of this article.

A three-drug mouthwash (lidocaine, diphenhydramine and sodium bicarbonate in normal saline) can provide effective symptomatic relief in patients with chemotherapy-induced mucositis.

Support Care Cancer. 2000 Jan;8(1):55-8
Efficacy of treatment to relieve mucositis-induced discomfort.

Turhal NS, Erdal S, Karacay S.
Department of Medicine, Marmara University Hospital, Istanbul, Turkey.

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]

Oda M, Sato M, Yagi N, Ohno K, Miyazaki S, Watanabe S, Takada M.
Faculty of Pharmaceutical Sciences, Health Sciences University of Hokkaido, Japan.

Click here to access the PubMed abstract of this article.


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Anti-Secretory Agents

Excessive Secretions/Death Rattle

Transdermal Anticholinergics for the Treatment of “Death Rattle” and Excessive Secretions

Difficulty 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
J Pain Symptom Manage. 2002 Apr;23(4):310-7
Prescrire Int. 2001 Aug;10(54):99-101

Otolaryngol Head Neck Surg. 1990 Oct;103(4):615-8
Reduction of salivary flow with transdermal scopolamine: a four-year experience.

Talmi YP, Finkelstein Y, Zohar Y.
Department of Otolaryngology, Hasharon Hospital, Golda Medical Center, Petah Tikvah, Israel.

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.

Dreyfuss P, Vogel D, Walsh N.
Department of Rehabilitation Medicine, University of Texas Health Science Center, San Antonio 78284-7798.

Click here to access the PubMed abstract of this article.


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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. Palliative care often involves the use of opioid analgesics. NMDA-receptor antagonists, such as dextromethorphan and ketamine, can block pain transmission in dorsal horn spinal neurons, reduce nociception, and decrease tolerance to and the need for opioid analgesics. [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 prescriber and patient 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.


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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. Ointments may contain polyethylene glycol (PEG), which can be absorbed from open wounds and damaged skin. If the wound is quite large and too much PEG is absorbed, it can lead to renal toxicity. Another useful dosage form is the €œpolyox 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 which 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.

Phenytoin references:

Ann Pharmacother 2001 Jun;35(6):675-81
Click here to access the PubMed abstract of this article.

Biochem Pharmacol 1999 May 15;57(10):1085-94
Click here to access the PubMed abstract of this article.

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

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

Chung Hua I Hsueh Tsa Chih 1997 Jan;77(1):54-7
Click here to access the PubMed abstract of this article.

Burns 1993 Aug;19(4):306-10
Click here to access the PubMed abstract of this article.

Diabetes Care 1991 Oct;14(10):909-11

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 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 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].

Fernandez Vozmediano JM, Alonso Blasi N, Almenara Barrios J, Alonso Trujillo F, Lafuente L
Servicio de Dermatologia, Hospital Clinico Universitario Moreno de Mora, Cadiz.
Click here to access the PubMed abstract of this article.


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Opioids for Dyspnea

Palliat Med. 1997 Jul;11(4):277-81.
Oral morphine as symptomatic treatment of dyspnoea in patients with advanced cancer.

Boyd KJ, Kelly M.
St Christopher’s Hospice, London, UK.

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.

Woodcock AA, Gross ER, Gellert A, Shah S, Johnson M, Geddes DM

Click here to access the PubMed abstract of this article.

EPEC Project, 1999. The Project to Educate Physicians on End-of-life Care from the Institute for Ethics at the American Medical Association.


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Radiation Mucositis/Proctitis

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.

Khan AM, Birk JW, Anderson JC, Georgsson M, Park TL, Smith CJ, Comer GM.
Department of Radiation Oncology, State University of New York Hospital at Stony Brook, 11794-8173, USA.

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.

al-Sabbagh R, Sinicrope FA, Sellin JH, Shen Y, Roubein L.
Division of Gastroenterology, University of Texas Medical School, Houston, USA.

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.

Kochhar R, Sriram PV, Sharma SC, Goel RC, Patel F
Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

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 Management 30;2 (Aug 2005); 107-9


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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
  • Hydrocodone without acetaminophen
  • Lidocaine -Tetracaine spray
  • Metoclopramide- nasal spray and suppository
  • Misoprostol – suppository and oral preparations
  • Morphine transdermal
  • 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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