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Sports Medicine

podiatry

 

Athletes, coaches, trainers, team physicians, physical therapists, and even the “weekend warrior” are faced with problems including inflammation and muscle spasms. We work together with these individuals and other health care professionals to customize medications which meet specific needs. Our compounding specialists can help to solve medication problems using customized preparations that contain the most appropriate ingredients in the best vehicle to most efficiently provide the needed drug to the affected area. Please contact our compounding pharmacist for more information.


Topical vs. Transdermal Drug Delivery – a function of formulation

Topical
Peripheral tissue activity
Systemic side effects less likely
If analgesic, applied directly over painful site
Insignificant serum levels

Transdermal
Systemic activity
Potential for adverse effects
If analgesic, may be applied away from painful site
Serum levels necessary for effect

Medications that relieve pain, reduce inflammation, and relax muscles can have side effects that are detrimental to athletic performance, such as drowsiness. However, when these medications are administered topically, the therapeutic benefit can be enhanced while significantly reducing the risk of adverse effects.

For example, research has shown that topically-applied ketoprofen provides a high local concentration of drug below the site of application but decreases systemic exposure and significantly reduces the risk of gastrointestinal upset or bleeding. When properly compounded into an appropriate base, tissue concentrations of ketoprofen were found to be 100-fold greater below the application site (knee) compared to systemic concentrations. Muscle relaxants can be similarly prepared to minimize the risk of drowsiness.


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NSAID Therapy

To avoid the risks of COX-2 inhibitors, our pharmacy can compound topically applied NSAIDs such as ibuprofen and ketoprofen. Topical NSAIDs have a safety profile which is superior to oral formulations. Topical NSAID administration offers the advantage of local, enhanced delivery to painful sites with a reduced incidence of systemic adverse effects.

Topical preparations can be customized to contain a combination of medications to meet the specific needs of each patient.

Topical NSAIDs for Acute Pain
Topical non-steroidal anti-inflammatory drugs have a lower incidence of gastrointestinal adverse effects than the same drugs when they are taken orally. The low incidence of systemic adverse effects for topical NSAIDs probably results from the much lower plasma concentration from similar doses applied topically to those administered orally. Topical application of ibuprofen resulted in measurable tissue concentrations in deep tissue compartments, more than enough to inhibit inflammatory enzymes. Topical NSAIDs have not been associated with renal failure.

BMJ. 1995 Jul 1;311(6996):22-6

Topical non-steroidal anti-inflammatory drugs and admission to hospital for upper gastrointestinal bleeding and perforation: a record linkage case-control study.

Evans JM, McMahon AD, McGilchrist MM, White G, Murray FE, McDevitt DG, MacDonald TM.
Department of Clinical Pharmacology, Ninewells Hospital and Medical School, Dundee.

Free full text article available at bmj.com:
http://bmj.bmjjournals.com/cgi/content/full/311/6996/22

2QJM 1995;88:551-557
Click here to access the PubMed abstract of this article.

The following article concludes: “Topical non-steroidal anti-inflammatory drugs are effective in relieving pain in acute and chronic conditions.”

BMJ. 1998 Jan 31;316(7128):333-8

Quantitative systematic review of topically applied non-steroidal anti-inflammatory drugs.

Moore RA, Tramer MR, Carroll D, Wiffen PJ, McQuay HJ.
University of Oxford, Oxford Radcliffe Hospital, Headington, UK

Click here to access the PubMed abstract of this article.

Free full text article available at bmj.com:
http://bmj.bmjjournals.com/cgi/content/full/316/7128/333

The following article reports “The systemic concentrations of ketoprofen have also been found to be 100 fold lower compared to tissue concentrations below the application site in patients undergoing knee joint surgery. Topically applied ketoprofen thus provides high local concentration below the site of application but lower systemic exposure.”

Pharm Res. 1996 Jan;13(1):168-72

Percutaneous absorption of ketoprofen from different anatomical sites in man.

Shah AK, Wei G, Lanman RC, Bhargava VO, Weir SJ.

Pfizer Inc., Central Research Division, Groton, Connecticut 06340

Click here to access the PubMed abstract of this article.


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Topical Anesthetics

Analgesic gels and sprays can be compounded to reduce pain and bleeding secondary to lacerations. The search for a “topical anesthetic that affords painless, safe application, does not contain narcotics or controlled substances, and has a maximum safety with complete anesthesia” revealed that LAT gel (lidocaine, adrenaline, tetracaine) is superior to preparations containing cocaine for topical anesthesia in laceration repair. Epinephrine (adrenaline) in the gel helps to stop bleeding secondary to injury.

Pediatrics 1995 Feb;95(2):255-8
Lidocaine adrenaline tetracaine gel versus tetracaine adrenaline cocaine gel for topical anesthesia in linear scalp and facial lacerations in children aged 5 to 17 years.

Ernst AA, Marvez E, Nick TG, Chin E, Wood E, Gonzaba WT
Department of Medicine, Louisiana State University, New Orleans.

Click here to access the PubMed abstract of this article.


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Iontophoresis & Phonophoresis

Iontophoresis facilitates delivery of medications into the tissues beneath the skin by electronic transport of ionized drugs in solution. Acetic acid iontophoresis is effective in the treatment of heel pain. Iontophoresis of dexamethasone for plantar fasciitis should be considered when more immediate results are needed. Iontophoresis has also been used to successfully treat plantar hyperhidrosis.

Phonophoresis is a technique that combines topical drug therapy with ultrasound to achieve therapeutic drug concentrations in muscle and other tissues beneath the skin. Ultrasound gels can be formulated to contain medications such as anti-inflammatories and/or anesthetics.

J Am Podiatr Med Assoc. 1999 May;89(5):251-7
Management of heel pain syndrome with acetic acid iontophoresis.

Japour CJ, Vohra R, Vohra PK, Garfunkel L, Chin N.
Department of Surgery, Veterans Affairs Medical Center, Brooklyn, NY 11209, USA.

Click here to access the PubMed abstract of this article.

Am J Sports Med 1997 May-Jun;25(3):312-6
Treatment of plantar fasciitis by iontophoresis of 0.4% dexamethasone. A randomized, double-blind, placebo-controlled study.

Gudeman SD, Eisele SA, Heidt RS Jr, Colosimo AJ, Stroupe AL.
Specialty Centers for Orthopaedic & Rehabilitative Excellence, Indianapolis, Indiana, USA.

Click here to access the PubMed abstract of this article.


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Pregame Rubs

Pregame rubs can be compounded to contain substances such as emu oil and anti-spasmodic drugs. Emu oil is a moisturizer that can improve healing of injured skin.

Plast Reconstr Surg 1998 Dec;102(7):2404-7


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Hemorrhoids

Hemorrhoids are particularly problematic for catchers, coaches, and others who are regularly in a squatting position. Treatment often involves use of a novel dosage form known as the “rectal rocket”, a suppository that permits simultaneous internal and external application of anti-inflammatories, anesthetics, antibiotics, or other medications.


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Excessive Perspiration

Hyperhidrosis therapy

Excessive perspiration is a concern for many athletes, as well as members of dance teams and marching bands. Numerous topical treatment options exist.

Primary hyperhidrosis (excessive perspiration) is a physically and emotionally distressing condition which involves mainly the palms, soles, and axillae. Oral anticholinergic agents and beta-blockers may be effective for controlling or reducing profuse sweating, but also carry significant side effects. Topical therapies may be the most practical and most common treatment for hyperhidrosis, but many agents that have proven useful in clinical trials are not commercially available.

Placebo-controlled trials have shown that topically applied 20% aluminum chloride hexahydrate significantly reduces the symptoms of hyperhidrosis in 60%-100% of patients. Skin irritation can be minimized with 1% hydrocortisone cream or by compounding 20% aluminum chloride in a 4% salicylic acid gel base, instead of in anhydrous alcohol base (as is the commercial product Drysol®).

Luh and Blackwell of the Dept. of Internal Medicine, University of Texas Medical Branch at Galveston describe a healthy, active 27-year-old male resident physician who had excessive facial sweating with minimal exertion or stress. The sweating was especially pronounced on the forehead, nose, and upper lip. Daily topical application of a 0.5% glycopyrrolate solution to the face and forehead significantly reduced facial sweating after the first treatment, without any discomfort to the skin. No loss of efficacy was seen after multiple face washings. Facial hyperhidrosis recurred after withdrawal of the glycopyrrolate for 2 days, confirming its therapeutic effect. Two years later, he continues to use glycopyrrolate as needed.

Mayo Clin Proc 1986 Dec;61(12):951-6
South Med J 2002 Jul;95(7):756-8
Ann Pharmacother 1995 May;29(5):489-92
Intl J Pharm Comp 2001 Jan/Feb;5(1):28-9


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Transdermal Medications

Transdermal therapy to decrease side effects

Medications that relieve pain, reduce inflammation, and relax muscles can have side effects that are detrimental to athletic performance, such as drowsiness. However, when these medications are administered transdermally, the therapeutic benefit can be enhanced while significantly reducing the risk of adverse effects.

For example, research has shown that topically applied ketoprofen provides a high local concentration of drug below the site of application but decreases systemic exposure and significantly reduces the risk of gastrointestinal upset or bleeding. When properly compounded into an appropriate base, tissue concentrations of ketoprofen were found to be 100-fold greater below the application site (knee) compared to systemic concentrations. Muscle relaxants can be similarly prepared to minimize the risk of drowsiness.


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Examples of Compounded Medications

The following list is just a few of the preparations that we can compound for sports medicine. All formulations are customized to meet the unique needs of each individual; therefore, we can consider the athlete’s lifestyle and environmental factors when formulating medications. Our compounding professionals can choose the best base to administer the active ingredients, or consult with the prescriber to determine the most appropriate route of administration to solve a specific problem.

  • Clotrimazole in DMSO solution
  • Cyclobenzaprine/Ketoprofen transdermal gel
  • Dexamethasone iontophoresis solution
  • Fluconazole/Ibuprofen topical gel
  • Ketamine/Gabapentin transdermal gel
  • Ketoprofen 10% transdermal gel
  • LAT topical gel
  • Lidocaine/Hydrocortisone “rectal rocket” suppository
  • Nutritional Supplements
  • Rehydration Drinks

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