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Guide to Prescribing Topical Formulations for Chronic Pain Chronic nociceptive or neuropathic pain are extremely common. Both frequently co-exist. The topical administration of pain relievingagents provides specific patient benefits, including better localised effect, less systemic side effects compared to oral drug administrationand improved patient compliance. MyCompounder uses a patented and proven transdermal base called Lipoderm® which can deliver arange of active ingredients simultaneously through the skin to assist manage a range of common pain conditions. Commonly Used Topical Pain Relieving Agents
Decide on the aetiology
of the chronic pain
Amitriptyline
Tricyclic anti-depressant. Applied topically, it attenuates pain transmission to promote analgesia. • For peripheral sensitisation, start with a Ideal for neuropathic pain and combines well with Ketamine and GABA agonists.
Baclofen
GABA agonist. Inhibits transmission at spinal level to depress the transmission of pain and to relax muscles. Ideal for all types of neuropathic pain and spasm. Interchange with gabapentin for affect.
• For central sensitisation, start with a Capsaicin
Depletes presynaptic Substance P in pain and heat sensing neurones and reduces the sensation of pain. Ideal for peripheral neuropathy (e.g post-herpetic neuralgia caused by shingles, headache) and for both arthritis and neuropathic pain in joints. Add Lignocaine 1-2% if topical irritation is problematic.
Clonidine
Applied topically, it blocks the release of noradrenaline via activation of alpha-2 receptors on • For muscle spasm related pain, start with peripheral sympathetic terminals. Ideal for symptoms of hyperalgesia, allodynia, diabetic neuropathy and sympathetically maintained pain (SMP).
cyclobenzaprine. MgCl can also beadded.
Cyclobenzaprine Broad antagonist of H1, 5-HT and ACH receptors and topically it promotes muscle relaxation and
• For arthritis, trial capsaicin, ketoprofen analgesia. Often combined with Baclofen, Ketoprofen and Lignocaine in BCKL cream. Gabapentin
GABA agonist/AMPA antagonist. Inhibits transmission at spinal level and depresses the transmission of pain. Ideal for all types of neuropathic pain. Interchange with baclofen and pregabalin for affect.
Guaifenesin
Promotes muscle cell relaxation via Nitric Oxide activation. Topically, it’s ideal for fibromyalgia, trigger point pain, muscle spasm pain and stress headaches. Can also be taken orally for Fibromyalgia.
Ketamine
NMDA antagonist. Dosed topically, it promotes localised anaesthesia. Highly potent. Combines well with tricyclic agents, GABA agonists and Clonidine for neuropathic pain. Ketoprofen
Potent NSAID. Apply 2-3 times daily. Ideal for nociceptive pain and for neuropathic pain where Fine-tune the formulation
Piroxicam
Long acting NSAID. Add to Ketoprofen regimens when longer periods of pain relief are required.
(peripheral/central pain, muscle spasm,arthritis formulations) for extra strength.
Pregabalin
GABA analogue which blocks central voltage dependent calcium channels to block neurotransmitter release. Use when response to gabapentin has been ineffective. Can also be used with other agents Lignocaine
Rapid onset, short acting local anaesthetic. Effective for peripheral neuropathy and can also be added to formulations to reduce topical irritation from active ingredients such as Capsaicin. Amethocaine
Also known as ‘Tetracaine’ – longer acting local anaesthetic. Use as for Lignocaine.
157 Scoresby Rd, Boronia Vic 3155 ■ 1300 78 98 78 fax 03 9839 3378 ■ scripts@mycompounder.com.au ■ www.mycompounder.com.au MyCompounder Pty Ltd December, 2012 Examples of Topical Pain Formulations in Transdermal Base Arthritis
Start with Ketoprofen and capsaicin at a range of strengths. Then add Piroxicam then Ketamine with titration. If capsaicin sensitivity occurs, exclude it or Peripheral or nociceptive symptoms
Substitute any ingredients as necessary for effect. Add Lignocaine for Capsaicin intolerance as required. neuropathy and sympathetically maintained Ketamine can be boosted to 10%. Add Piroxicam 3% if longer NSAID duration is required.
Neuropathic symptoms
Substitute any ingredients as necessary for effect. e.g neuropathic pain, post herpetic neuralgia, Add peripheral agents (see above) if hyperalgesia reflex sympathetic dystrophy (nerve trauma), or allodynia are present. Add muscle relaxants as cancer pain, phantom limb pain, entrapment necessary. Substitute Gabapentin with pregabalin Both nociceptive & neuropathic symptoms
Substitute any ingredients in (B) or (C) as necessary for effect or titrate to max concentrations. Add combinations are possible following patient Lignocaine for Capsaicin intolerance as required.
Trigger Point pain with Muscle spasm or
Substitute any ingredients as necessary for effect. muscle tension
Magnesium Chloride up to 10% can also be added for problematic muscle cramps. Ketamine or NSAID’s can be added for additional analgesia effect.
Fibromyalgia or widespread pain
• Guaifenesin – 300mg orally bd for 7 days orally bd as tolerated after 8-12 weeks.
Useful information
• Nociceptive pain is caused by actual or potential damage to body tissue and usually described as a sharp, aching, or throbbing pain. Examples include sprains, bone fractures, bumps, bruises and inflammation (infection or arthritis). Usually responsive to oral NSAIDS and/or analgesics (pain killers). • Neuropathic pain is the result of an injury or malfunction in the peripheral or central nervous system – the injury may or may not involve actual damage to the nervous system. People often describe this pain as a burning or heavy sensation, or numbness along the path of the affected nerve. Responds well to adjuvant analgesics.
157 Scoresby Rd, Boronia Vic 3155 ■ 1300 78 98 78 fax 03 9839 3378 ■ scripts@mycompounder.com.au ■ www.mycompounder.com.au MyCompounder Pty Ltd December, 2012

Source: http://mycompounder.com.au/sites/default/files/Chronic%20Pain%20Guide.pdf