Compounding for Hospice Patients

Pain & Symptom Management

Alan Brown RPh – Dana Noblett RPh – Joel Jarman RPh

195 Main Street - Chatham, NJ 07928P (973) 635-6200 / F (973) 635-6208

The Importance of Compoundingfor Hospice Patients

• Each individual patient has unique needs

• Every patient has different end of life experiences

• Compounding allows a pharmacist to customize medication to the specific needs of each hospice patient

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

• Different approaches are required for end result- PO fails, TDG works

• Receptors are often damaged and fewer in number- standard anti-nausients are no longer effective- opiates require higher doses more frequently

• Fatty tissues breaks down in cancer patients- pain patches on chest and arms provide inadequate

relief

• Patients don’t sleep well and food intake is decreased- results in increased pain and restlessness

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

• Sublingual

• Transdermal

• Rectal

• Intra-nasal

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

• A compounded medication must be individually prescribed for a patient

• Bulk drug substance qualifies for use in compounds by any of three qualifications

1) Found in an FDA approved drug2) Listed in USP3) Listed as acceptable for pharmacy

compounding by FDA rule

The Health Care Triad

Types of Compounds and Criteria Limitations

Transdermal Gels – Suppositories (short acting or sustained release) – Capsules – Suspensions – Injections/IV

• pH

• Solubility

• Use By Date

• SuppositoriesPhenytoin 3:1

•Transdermal gels Gel can hold a limited amount of powder drug

Compounds for Pain Management

• Transdermal Morphine- with or without Hydroxyzine Pamoate

• Fentanyl Sublingual

• Dextromethorphan Capsules

• Morphine/Oxycodone with DM capsules (SR)

• Morphine/Oxycodone suppositories (IR and SR)

• Dexamethasone 8-10 mg TID- due to bone metastases

• Hydromorphone capsules (SR)

• Methadone

• Ketamine

Topical Compounds for Painful Sites, Joints, and Neuropathies

• Ketoprofen 20% Ibuprofen 2.5% PLO gel

• Ketoprofen 10% Ketamine 10% Guiafenesin 10% Lidocaine 2% Speed Gel

• Ketamine 10% Gabapentin 6% Lidocaine 2% PLO gel

• Ketoprofen 10% Ketamine 10% Guiafenesin 10% Lidocaine 2% Dexamethasone 2% Speed Gel

Compounds for Symptom Management

• Shortness of Breath/ Chronic Obstructive Pulmonary Disease

Morphine Sulfate 2-4mg/3mL

• Wet RespirationsScopolamine (single or double strengths)Hyoscyamine sublingual

• Nausea & VomitingProchloperazine TDGABR or ABHR TDG/suppositories

• Restlessness/AnxietyLorazepam DiazepamHaloperidolThorazine

• SleeplessnessChloral Hydrate 500mg SuppositoriesTemazepam TDG

•CachexiaHydrazine Sulfate 60mg capsules

Compounds for Symptom Management

Compounds for Wounds

• Wound Anesthesia (painful wounds that require dressings)

Ketamine/Bupivicaine Topical Spray

• Wound TreatmentNifedipineMisoprostolPentoxyfylline

Compounds for Specific Diseases and Conditions

• Decubitis UlcersKetoprofenLidocainePhenytoinNifedipineMisoprostol

• Shingles Deoxy-D-Glucose with Lidocaine Topical Spray

•Oral/Esophogeal Tissue Destructions (burns from Chemotheraphy or Radiation)

Misoprostol mouth rinse

• Maintenance (transdermal or rectal)

PhenytoinValproic Acid

•Immediate Relief (transdermal or rectal)Diazepam

Compounds for Seizure Control

Case Study 1

Your hospice patient with metastases to the brain and bone is currently experiencing good symptom control with PO

Morphine Sulfate 60mg SR Q8hLorazepam 1mg Q4-6hPhenytoin 100mg TIDDexamethasone 8mg Q8hProchlorperazine 10mg Q8-12h

But at 4pm you are contacted by family member who informs you that your patient is no longer taking PO medications.

What do you do?

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?

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

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?

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.

• Many hospice patients continue to suffer from pain and unresolved symptoms

• 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

Questions/Notes

195 Main Street - Chatham, NJ 07928P (973) 635-6200 / F (973) 635-6208

Thank you for your time