Rxtriad

This Issue:
◆ Ativan, Benadryl, and Haldol (ABH) Gel and Ativan, Benadryl, Haldol, and
Metoclopramide (ABHM) Gel in the Treatment of Nausea
◆ DermaZinc-Plus with Clobetasol for the Treatment of Psoriasis
◆ Intranasal Fentanyl Citrate and Cancer-Related Breakthrough Pain
◆ Compounding Law Rescinded
March 2001
was still experiencing some nausea. I sug- a 10-mg/mL concentration to the gel; thedose (a topical application of 1 mL every 4 to 6 hours) was to remain unchanged.
After 2 doses of treatment with this for- mulation, the patient’s nausea was relieved.
She continued this protocol and experi-enced relief from nausea until her death in John Herr, RPh
John Farkus, MD
cally applied medication to be very effec- Town and Country Pharmacy,
tive in decreasing the anxiety and nauseaproduced by some diseases during the end- Ridgewood, New Jersey
1. Carling MA. Hospice and the role of the palliative therapy for a 78-year-old woman compounding pharmacist. IJPC. 2000;4:247- who was dying of cancer of the stomach.
2. Allen LV. Hospice care and the pharmacist.
sea than from pain. Her physician had pre- scribed antiemetic trimethobenzamidesuppositories (Tigan) 200 mg to be usedevery 6 to 8 hours as needed, but this medi- hospice care interdisciplinary team for thepurposes of assessing and determining David Holloway, RPh
treatments for terminally ill patients. At Trail Creek Pharmacy, Euless Texas
our meeting on March 15, 2000, I sug-gested that a topical Ativan, Benadryl, and became the patient of a physician located had been added be prescribed to alleviate this patient’s nausea, and her physician tient had been diagnosed as having psoria- sis, for which he had been treated by sev- mixed in a Pluronic lecithin organogel in eral physicians. When the patient received his diagnosis, his family history indicated that no other relatives had psoriasis, but SAMPLE (to enhance absorption)
the patient’s elbow as a scaling sore that The patient was instructed to apply 1 mL did not heal, and in 1997 the lesions ap- of this gel to her wrist every 4 to 6 hours At the time of our interdisciplinary team The patient’s primary complaint was that cause of that pain in the remaining subjects.
the subjects had been receiving oral mor- The average number of daily pain episodes his scalp. His physician prescribed a zinc was five, and 50% of the subjects rated the pyrithione formula with clobetasol propi- eight patients (66.6%), the pain lasted 30 mL spray bottle. The medication was to be may occur several times per day for short applied twice daily. DermaZinc is an over- At the time of the study, all subjects had periods, the effects of short-acting mor- been receiving morphine in various proto- cols (listed in Table 2 of the article) as continue beyond the duration of pain; re- peated dosing can result in adverse effects.
twice per day) for breakthrough pain. Re- many disadvantages for the patient: Their morphine was rated as “good” by four pa- administration is invasive and uncomfort- tients (33%), “fair” by five (42%), and mula when clobetasol is added. Our patient, like many others with psoriasis, required At the initiation of the study, each pa- multiple therapies in order to restore his tient began a protocol of receiving 20 µg toxic effect on local tissue, it can be used of intranasally administered fentanyl cit- as long-term therapy. It is delivered as a In addition to treatment with the spray, bottle with a 0.2-mL reservoir. Each spray bottle delivered a 0.2-mL bolus dose with other day, and the patient was to receive to replace treatment with short-acting oral the treatment of neuropathic pain and dur- morphine, which had been used as the res- ing painful treatment procedures. Because minutes from a tanning bed 2 times a week.
INFC was well-tolerated and well-received After 5 months of following this regimen, breakthrough pain was completely relieved the patient was doing well and his psoria- that additional studies be conducted to de- sis had completely resolved. When he used with that dosage. If partial relief or no pain termine the role of that therapy in the man- relief resulted, each patient was given a second bottle to provide sufficient drug to the time of this writing, he is continuing spray both nostrils. All patients required Legal Update
were asked to use the INFC spray for five and the ultraviolet light therapy and is do- 1. Fenrich J, Vidaurri V. Psoriasis. IJPC 2000; challenged for its constitutionality during 3. Allen, LV. Environmental sensitivities. IJPC taken before the trial were continued with- government’s restrictions that prohibit Literature Summary
sion of the trial, the subjects were asked In Western States Medical Center v. Shalala, a case brought by a group of li- was also asked to list the advantages and censed pharmacies, the court found that the disadvantages of taking medication to con- An assessment of the safety,
efficacy, and acceptability of SAMPLE
After treatment with INFC, eight patients intranasal fentanyl citrate in the
(66%) demonstrated a reduction in the VAS management of cancer-related
score. Four of those patients noted a re- In its opinion, the Court stated that the breakthrough pain: A pilot study.
duction in pain 5 minutes after having used FDA failed to prove that they have a sub- Source: Zeppetella G. J Pain
INFC, and seven patients noticed pain re- stantial interest in preventing widespreadcompounding. They stated that FDA fails Symptom Manage 2000;20:253-258.
lief after 10 minutes. Those eight patients to support the opinion that increased dis- rated the efficacy of INFC as “good” or “very good.” Nine patients (75%) indi- ous because of the health risks associated ing treatment for cancer. This type of pain, cated that INFC was as effective as or bet- with large numbers of patients taking such which afflicts patients despite the use of drugs. The decision states that most evi- the effectiveness of INFC as “moderate” dence runs to the contrary noting that com- curs frequently and is brief in duration and or “bad.” According to the author, patients pounding is legal under state law and that doses of morphine showed a decline in the above, an analgesic with the following at- tributes would be of benefit in treating pa- those who had been receiving a daily mor- rapid absorption, an “individual and epi- not. During the study, two patients required sodic titration,” a rapid onset of action, and have laws specifically setting forth param- a short-to-moderate duration. Intranasally morphine in spite of taking INFC, and two eters for pharmacy practice. In addition, the drug was used repeatedly. No systemic practice and the United States Pharma-copeia has created an entire chapter on experiencing one type of nociceptive can- were noted. At the conclusion of the study, Although the implication of the court’s continue treatment with INFC, and the re- decision is unclear from regulatory stand- maining subjects were dissatisfied with the point, the practice of compounding as nec- those patients (75%), the site of the break- effectiveness of the preparation rather than RxTriad-Literature watch of the International Journal of Pharmaceutical Compounding. 2001 International Journal of Pharmaceutical Compounding. All rights reserved.

Source: https://www.ijpc.com/RxTriad/pdf/RxTriad_V04_N03_Sample.pdf