The Best Possible Quality of Life
Symptom control during this sensitive time is CRITICAL. Genesis Pharmacists recognize the need for expedient, therapeutic solutions for various medical needs which may become prevalent such as:
- nausea & vomiting
- dry mouth & stomatitis
- excessive pulmonary secretions
- radiation mucositis
- proctitis
- wound care
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.
Speak with a pharmacist to ensure the most effective treatment options are available for your family.
PREVENTION/TREATMENT OF RADIATION MUCOSITIS/PROCTITIS
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.
DYSPNEA
When illness is incurable or the cause is irreversible and the goal is palliation, systemic opioids are the first-line therapy for symptomatic management of dyspnea.
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 "polyox 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.
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.
ANTI-SECRETORY AGENTS
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.
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.
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.
A three-drug mouthwash (lidocaine, diphenhydramine and sodium bicarbonate in normal saline) can provide effective symptomatic relief in patients with chemotherapy-induced mucositis.
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.
Pilocarpine Troches for Xerostomia
Pilocarpine is indicated for the treatment of xerostomia secondary to radiation therapy of the head and neck. Pilocarpine is a cholinergic agent that stimulates residual-functioning exocrine glands. In a study by Vivino et al., pilocarpine at oral doses of 2.5mg and 5mg four times daily significantly increased saliva production and alleviated symptoms of dry mouth when compared to placebo. The higher dose produced the most improvement but also the highest incidence of adverse effects, such as sweating, diarrhea, and urinary frequency.
Topical Oral Solutions for the Treatment of Chemo-Induced Oral Mucositis
“Magic mouthwashes” are topical solutions or suspensions prepared to relieve symptoms of various oral pathologies. As compounding pharmacists, we recognize the need for practitioners to have the ability to prescribe customized preparations to meet specific patient needs. We can compound various medications into a stable, pleasantly-flavored, alcohol-free suspension.
Misoprostol: Mucosal Protectant and Anti-Secretory
Misoprostol is a synthetic prostaglandin E1 analogue, with mucosal cytoprotectant and antisecretory properties. A mouthrinse containing misoprostol and lidocaine in a non-irritating neutral vehicle can be used to provide immediate pain relief and aid in the healing of the oral cavity.
A mucoadhesive powder containing misoprostol can be used to aid in the healing of mucosal ulcers and irritations. It is applied by using a powder "puffer" or by direct application of the powder to the affected area. The carriers will hydrate and adhere to the mucosal surface, keeping the misoprostol in prolonged contact with the area.
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.
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.
ABH Transdermal Gel for Chemotherapy-Induced Nausea/Vomiting
Chemotherapy-induced nausea and vomiting (CINV) is commonly cited by patients as being among the “most unpleasant and distressing” side effects associated with chemotherapy. CINV may impair quality of life significantly and necessitate chemotherapeutic dose reductions, treatment delays, and discontinuation of therapy. Finally, it may cause a substantial number of lost work days for patients and considerable costs to the healthcare system, resulting in a substantial economic burden.
Bleicher et al. of the Hematology/Oncology Division, Creighton University Medical Center, Omaha, NE, investigated the efficacy of "ABH," a topical gel containing lorazepam (Ativan®), diphenhydramine (Benadryl®), and haloperidol (Haldol®), in reducing breakthrough CINV. Adults receiving standard recommended prophylactic antiemetics as outpatients were instructed to apply 0.5 mL of a transdermal gel (containing lorazepam 2 mg, diphenhydramine 25 mg, and haloperidol 2 mg) when they experienced significant CINV. When the severity of CINV was quantified on a scale of 0-10, the mean CINV score decreased significantly from a 6.1 before gel application to a 1.7 as evaluated 30 minutes following gel application. Topical use of ABH gel appears to be a promising and safe rescue therapy for breakthrough CINV that occurs despite prophylactic antiemetic therapy.
Weschules noted that of 11,181 ABHR (ABH plus metoclopramide [Reglan®]) prescriptions provided for patients, 6,529 (58.4%) were for a topical gel, and 4,312 (38.6%) were for a rectal suppository. Less than 0.5% of patients discontinued treatment due to adverse side effects. Another retrospective study reported use of an ABHR gel to be 98% effective in hospice patients. There were no adverse reactions; however, problems arose when patients with bowel obstructions were treated.
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