Transcript Compound Drugs of Value - palliativecare

COMPOUNDED DRUGS
Valuable in Hospice, End-of-Life,
and Palliative Care
George Muller, RPh
Compounding Business Services
and
John P. McNulty, MD, FACP, FAAHPM
The Palliative Care Institute of SE LA
Objectives
• Discuss commonly prescribed drugs in hospice
employed in formats not commercially
available, and modified to a patient’s need:
• Nausea and Vomiting
• Pain and Dyspnea
• Creams, Gels for Local or Systemic Effect
• Infected and bleeding wounds
• Rectal and GU
Drugs
• Haloperidol, Ativan, Benadryl, Reglan
• Morphine, Levorphanol,
Methadone, Oxycodone, Lidocaine
• Ketamine oral, i.m., cream or gel, nasal spray
• Phenytoin paste or cream
• Metronidazole, chloramphenicol, thrombin,
Monsel’s Solution
• Bladder irrigations: acetic acid; KMnO4
• Rectal Rocket
Nausea and Vomiting: HABR
• Effective evidence-based combination used for
refractory nausea and vomiting.
• Haloperidol : acts on vomiting center( CTZ )
and dopamine receptors; Lorazepam: reduces
cortical-induced nausea; Benadry: acts on CTZ
and blocks extrapyramidal side-effects of
haloperidol and metoclorpramide ( Reglan ).
Metoclorpramide: increases GI motility, acts
on CTZ, dopamine and serotonin receptors.
HABR
• Usual combo: Haldol 1 mg; Ativan 1 mg;
Benadryl 25 mg; Reglan 5 mg. Can decrease
Haldol or Ativan to 0.5 mg or add decadron.
• Oral capsule, short-acting: 1 cap q 6 hr prn, or
long-acting: 1 cap q 12 hr. Available as a liquid.
• Rectal suppository ( same doses) 1 q 6-12 hr
rectally as needed.
• Transdermal gel is no longer recommended.
Pain and Dyspnea
• Oral concentrate solutions of morphine,
levorphanol, methadone, and oxycodone are
often used to provide relief of pain or dyspnea
in patients who are unable to swallow safely,
especially in patients who are nearing death.
Used in small doses given buccally or
sublingually, absorption by some is mucosal,
by others via the upper GI tract. Fentanyl and
methadone absorb fastest.
Oral Opioid Concentrate Solution
Morphine
• Morphine is commercially available as a fixed
20mg/ ml oral concentrate in a 30ml dropper
bottle. When smaller or larger concentrations
are desired for a patient, compounded
morphine can be provided at a range from
10mg to 60 mg/ml, in 15ml to 30 ml dropper.
• Standard dose for pain or dyspnea is 5 mg
subling. q 2-4 hr, but depending on the
intensity of symptom distress, dose escalation
at a more frequent time may be needed.
Methadone Oral Concentrate
• Methadone is often the drug needed for
intractable pain. In patients unable to swallow,
a concentrate suspension of methadone
20 mg /ml is most often used, supplied in a 30
ml dropper bottle, and because methadone is
bitter, it is best flavored with chocolate, mint,
and raspberry. Concentrations are available
from 10-60 mg/ml in a 15 or 30 ml dropper.
Levorphanol and Oxycodone
Oral Concentrate Solutions
• Levorphanol is compounded most often as a 4
mg/ml concentrate suspension in a 30 ml
dropper bottle. It is best flavored with pina
colada. Levorphanol is available in 2-8 mg/ml
concentrations. Excellent alternative to
methadone for refractory or neuropathic pain.
• Oxycodone oral concentrate is used when
morphine is not tolerated. 20mg/ml in 30 ml.
0.25 ml q 2-4 hr subling, can titrate as needed.
Nebulized Morphine
• Nebulized Morphine (or Hydromorphone) for
the relief of dyspnea is controversial. It is not
effective in chronic obstructive lung disease
and interstitial pulmonary fibrosis.
• There is evidence that Morphine nebs help
dyspnea in cancer patients, more quickly than
opioids given systemically. It would seem likely
that dyspnea due to CHF would be helped,
based on morphine’s dramatic effectiveness in
acute pulmonary edema.
Nebulized Morphine compounding
and dosing
• Should be prepared under strict aseptic
conditions under a hood in a clean room
enclosure
• Compounded as a 2.5mg or 5mg per vial
concentration
• Concentrated as 2.5mg, normal dosage
utilized, per 1ml or per 3ml vial
• Sterile vial has screw cap enabling simplified
pouring into a nebulizer
Nebulized Lidocaine
for Intractable Cough
• When usual treatments for a persistant cough due to
cancer or chronic lung disease fail:
• Lidocaine 1 ml of 2% sterile solution added to 3 ml
sterile saline can be nebulized every 3-4 hours.
• Should be prepared in a sterile aseptic environment
if compounded
• Alternatively 1ml can be withdrawn via syringe from
a manufactured 20ml vial and placed in a nebulizer
with 3ml of normal saline from a sterile prepackaged
vial
Creams, Gels
• Morphine Cream has been reported to relieve
painful wounds and decubitus ulcers.
• Phenytoin Paste or Cream has evidence-based
studies documenting its value in healing
decubitus ulcers which are healable.
• Ketamine Cream or Gel is being studied and
widely used for local somatic and neuropathic
pain.
• See next slides for more details.
Morphine Cream
for Painful Wounds
• To relieve the pain caused by dressing
wounds, or to relieve chronically painful
wounds, Morphine 1% Cream can be applied
to the wound 15 minutes before dressing, or
every 4 hrs as needed for chronic pain.
Morphine is effective on an open lesion, not
on intact epidermis. There is no systemic
absorption, and no additive effect on other
opioids being given systemically.
Phenytoin to heal Decubitus Ulcers
• Phenytoin was noted years ago in epileptic
children on long-term phenytoin to develop
overgrowth of gingeval tissue. Evidence has
shown that Phenytoin can stimulate the
regrowth of normal tissue in decubiti and
other wounds if the tissue is otherwise
healthy with adequate blood supply.
• Phenytoin 5% Paste 30 Gm is compounded
and widely used in hospice settings.
Ketamine
• Ketamine, an anesthetic given i.v. in subanesthetic doses has been used for years to
relieve neuropathic pain by blocking the nmethyl-d-aspartate receptor (NMDA) in the
spinal cord
• It is possible to use ketamine orally, i.m., in
creams and gels, and by nasal spray for pain
relief, and relief of depression in some cases.
• Ketamine gels or creams, 5-10%, applied
locally to painful body regions are useful.
Ketamine
• Oral and i.m. ketamine are being studied to
confirm its effectiveness in reducing pain and
depression.
• Ketamine nasal spray is being used for
breakthrough pain. It should not be used in
patients with seizures or seizure potential.
• Best reference: Prommer, EE; Ketamine for
Pain: an Update of Uses in Palliative Care,
J Pall Med: 15, no.4 2012: 474-483
Bleeding and Infected wounds in
Hospice Patients
• Large, bleeding, necrotic, purulent, foulsmelling wounds due to head, neck, and
breast neoplasms are difficult to manage, and
cause distress to the patient, family and staff.
• One effective management, after cleansing
the affected area, is to puff a mixture of
powdered Flagyl and chloramphenicol via a
small plastic insufflator, or bellows, to the
wound surface every one or two days.
Control of Bleeding in Wounds of
Body Surface
• Thrombin is commonly used to control
bleeding of oozing necrotic neoplastic lesions.
Thrombin can be added to puffed drugs
applied to control infection. It is expensive.
• Monsel’s Solution, ferris subsulfate, an older
compounded drug, coagulates bleeding from
open wounds when painted or dabbed on the
site, much like a styptic pencil. Used to stop
bleeding from slice biopsies in dermatology .
Urinary catheter clogging
Resistant urinary infection
• Cloudy or turbid urine not due to infection is
often due to amorphous debris and/or
phosphate crystals, which may obstruct
urinary catheters. A simple, often successful
remedy is to irrigate the catheter with 60 ml
of 0.1% acetic acid solution once or twice daily
• An old, seldom used method to clear a lower
GU resistant infection: Irrigate bladder with
1:10,000 KMnO4 sol. twice daily for 30 min.
Rectal Pain
• Pain due to anal fissure or thrombosed
hemorrhoids has been effectively relieved by
inserting a compounded Rectal Rocket into
the anal canal. The Rocket remains overnight,
held in place by flanges, allowing the lidocaine
and hydrocortisone in the suppository base to
be absorbed into the inflamed tissue.
• Morphine cream is effective (slide 11), as is
• Ketamine cream and i.m .(slide 13,14).
Conclusion
• Compounded drugs allow flexibility in dosing,
and access to drugs in delivery systems not
commercially available.
• Contact your local compounding pharmacist
to get more specific information about these
compounded drug uses, the formulas, the
directions for patients, the contraindications
for their use in specific patients, and the cost.