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Compounding for Hospice Patients


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Compounding for Hospice Patients

  1. 1. Compounding for Hospice Patients Pain & Symptom Management Alan Brown RPh – Dana Noblett RPh – Joel Jarman RPh 195 Main Street - Chatham, NJ 07928 P (973) 635-6200 / F (973) 635-6208
  2. 2. The Importance of Compounding for Hospice Patients <ul><li>Each individual patient has unique needs </li></ul><ul><li>Every patient has different end of life experiences </li></ul><ul><li>Compounding allows a pharmacist to customize </li></ul><ul><li>medication to the specific needs of each hospice patient </li></ul>
  3. 3. The Effects of Long Term Illness on Hospice Patients Hospice patients can have abnormal physiologies as a result of long- term illness that require different treatments <ul><li>Different approaches are required for end result </li></ul><ul><ul><li>PO fails, TDG works </li></ul></ul><ul><li>Receptors are often damaged and fewer in number </li></ul><ul><ul><li>- standard anti-nausients are no longer effective </li></ul></ul><ul><ul><li>opiates require higher doses more frequently </li></ul></ul><ul><ul><li>Fatty tissues breaks down in cancer patients </li></ul></ul><ul><ul><ul><li>pain patches on chest and arms provide inadequate relief </li></ul></ul></ul><ul><ul><li>Patients don’t sleep well and food intake is decreased </li></ul></ul><ul><ul><ul><li>- results in increased pain and restlessness </li></ul></ul></ul>
  4. 4. Methods of Medication Administration to Hospice Patients Compounded medications presents nurses with more treatment options to alleviate pain, control adverse symptoms, and to provide the best quality of life for their patients <ul><li>Sublingual </li></ul><ul><li>Transdermal </li></ul><ul><li>Rectal </li></ul><ul><li>Intra-nasal </li></ul>
  5. 5. FDA Guidelines for Pharmacy Compounding The FDA recognizes the need for compounded medications and has thus created legal requirements in order to ensure the safety and effectiveness of these medications <ul><li>A compounded medication must be individually prescribed for a patient </li></ul><ul><li>Bulk drug substance qualifies for use in compounds by any of three qualifications </li></ul><ul><ul><li>Found in an FDA approved drug </li></ul></ul><ul><ul><li>Listed in USP </li></ul></ul><ul><ul><li>Listed as acceptable for pharmacy compounding by FDA rule </li></ul></ul>
  6. 6. The Health Care Triad
  7. 7. Types of Compounds and Criteria Limitations Transdermal Gels – Suppositories (short acting or sustained release) – Capsules – Suspensions – Injections/IV <ul><li>pH </li></ul><ul><li>Solubility </li></ul><ul><li>Use By Date </li></ul><ul><li>Suppositories </li></ul><ul><ul><li>Phenytoin 3:1 </li></ul></ul><ul><li>Transdermal gels </li></ul><ul><ul><li>Gel can hold a limited amount of powder drug </li></ul></ul>
  8. 8. Compounds for Pain Management <ul><li>Transdermal Morphine- with or without Hydroxyzine Pamoate </li></ul><ul><li>Fentanyl Sublingual </li></ul><ul><li>Dextromethorphan Capsules </li></ul><ul><li>Morphine/Oxycodone with DM capsules (SR) </li></ul><ul><li>Morphine/Oxycodone suppositories (IR and SR) </li></ul><ul><li>Dexamethasone 8-10 mg TID- due to bone metastases </li></ul><ul><li>Hydromorphone capsules (SR) </li></ul><ul><li>Methadone </li></ul><ul><li>Ketamine </li></ul>
  9. 9. Topical Compounds for Painful Sites, Joints, and Neuropathies <ul><li>Ketoprofen 20% Ibuprofen 2.5% PLO gel </li></ul><ul><li>Ketoprofen 10% Ketamine 10% Guiafenesin 10% Lidocaine 2% Speed Gel </li></ul><ul><li>Ketamine 10% Gabapentin 6% Lidocaine 2% PLO gel </li></ul><ul><li>Ketoprofen 10% Ketamine 10% Guiafenesin 10% Lidocaine 2% Dexamethasone 2% Speed Gel </li></ul>
  10. 10. Compounds for Symptom Management <ul><li>Shortness of Breath/ </li></ul><ul><li>Chronic Obstructive Pulmonary Disease </li></ul><ul><ul><li>Morphine Sulfate 2-4mg/3mL </li></ul></ul><ul><li>Wet Respirations </li></ul><ul><ul><li>Scopolamine (single or double strengths) </li></ul></ul><ul><ul><li>Hyoscyamine sublingual </li></ul></ul><ul><li>Nausea & Vomiting </li></ul><ul><ul><li>Prochloperazine TDG </li></ul></ul><ul><ul><li>ABR or ABHR TDG/suppositories </li></ul></ul>
  11. 11. <ul><li>Restlessness/Anxiety </li></ul><ul><ul><li>Lorazepam </li></ul></ul><ul><ul><li>Diazepam </li></ul></ul><ul><ul><li>Haloperidol </li></ul></ul><ul><ul><li>Thorazine </li></ul></ul><ul><li>Sleeplessness </li></ul><ul><ul><li>Chloral Hydrate 500mg Suppositories </li></ul></ul><ul><ul><li>Temazepam TDG </li></ul></ul><ul><li>Cachexia </li></ul><ul><ul><li>Hydrazine Sulfate 60mg capsules </li></ul></ul>Compounds for Symptom Management
  12. 12. Compounds for Wounds <ul><li>Wound Anesthesia </li></ul><ul><li>(painful wounds that require dressings) </li></ul><ul><li>Ketamine/Bupivicaine Topical Spray </li></ul><ul><li>Wound Treatment </li></ul><ul><ul><li>Nifedipine </li></ul></ul><ul><ul><li>Misoprostol </li></ul></ul><ul><ul><li>Pentoxyfylline </li></ul></ul>
  13. 13. Compounds for Specific Diseases and Conditions <ul><li>Decubitis Ulcers </li></ul><ul><ul><li>Ketoprofen </li></ul></ul><ul><ul><li>Lidocaine </li></ul></ul><ul><ul><li>Phenytoin </li></ul></ul><ul><ul><li>Nifedipine </li></ul></ul><ul><ul><li>Misoprostol </li></ul></ul><ul><li>Shingles </li></ul><ul><ul><li>Deoxy-D-Glucose with Lidocaine Topical Spray </li></ul></ul><ul><li>Oral/Esophogeal Tissue Destructions </li></ul><ul><li>(burns from Chemotheraphy or Radiation) </li></ul><ul><ul><li>Misoprostol mouth rinse </li></ul></ul>
  14. 14. <ul><li>Maintenance </li></ul><ul><li>(transdermal or rectal) </li></ul><ul><ul><li>Phenytoin </li></ul></ul><ul><ul><li>Valproic Acid </li></ul></ul><ul><ul><li>Immediate Relief (transdermal or rectal) </li></ul></ul><ul><ul><li>Diazepam </li></ul></ul>Compounds for Seizure Control
  15. 15. Case Study 1 <ul><li>Your hospice patient with metastases to the brain and bone is currently experiencing good symptom control with PO </li></ul><ul><ul><ul><li>Morphine Sulfate 60mg SR Q8h </li></ul></ul></ul><ul><ul><ul><li>Lorazepam 1mg Q4-6h </li></ul></ul></ul><ul><ul><ul><li>Phenytoin 100mg TID </li></ul></ul></ul><ul><ul><ul><li>Dexamethasone 8mg Q8h </li></ul></ul></ul><ul><ul><ul><li>Prochlorperazine 10mg Q8-12h </li></ul></ul></ul><ul><li>But at 4pm you are contacted by family member who informs you that your patient is no longer taking PO medications. </li></ul><ul><li>What do you do? </li></ul>
  16. 16. Case Study 2 Your critical care hospice patient with metastasis to spine and a history of drug abuse arrives from the hospital on MS pump 100mg/hr with 15mg/hr bolus. He/she is complaining of pain in the sacral area of the lower spine where the patient had an open wound. In 3 days, her MS infusion rate was increased 3 times. The patient is still complaining of pain in the sacral area. What would you do?
  17. 17. Your 76 old patient with pancreatic cancer has uncontrollable nausea/wretching/vomiting and is at the end of life. All family members gathered around her. All traditional PO anti-nausients have failed. What would you do? Case Study 3
  18. 18. Case Study 4 Your patient’s pain is being controlled with Hydromorphone 2mg Q4h, however she wakes up with pain every morning. What would you do?
  19. 19. What You Need to Know Liberty Drug is committed to helping you improve the quality of life for your patients at the end of life. We recognize the range of medical conditions that your patients experience and our compounding services are readily available and customized for each individuals’ personal needs. <ul><li>Many hospice patients continue to suffer from pain and unresolved symptoms </li></ul><ul><li>We hope to raise awareness to more health professionals about the benefits of compounded prescriptions so that these treatments are available to all in need of such medications </li></ul>
  20. 20. Questions/Notes 195 Main Street - Chatham, NJ 07928 P (973) 635-6200 / F (973) 635-6208 Thank you for your time