EBHSG - JULY 1997 MEETING
TOPIC: "COMPOUNDING PHARMACIST"
Robert Horwitz, Pharm.D., is the owner of Doc’s Pharmacy in Walnut Creek. He spoke to the July 8th meeting of the East Bay Headache Support Group about his specialty of compounding medications. The meeting was held in the Ball Auditorium at John Muir Medical Center with 27 people in attendance.
Dr. Horwitz said his presentation would cover three main topics:
1) Types of Medications.
2) Different techniques to make medication-taking better.
3) Specific examples of custom medications.
There is one surefire cure for a headache: Have an opharectomy, where the surgeon severs the nerve between your eyes and your backside. (laughter)
There are many different dosage forms. Dr. Horwitz presented slides picturing many of them, such as:
a) Straws. A straw is prefilled with the exact dosage of medication, and the straw is then sealed top and bottom. This is a good dosage form to use when the patient can’t measure out the dosage easily; for example, when a child has to take liquid medication during the school day, or if the patient is shaky or traveling in a car, etc.
b) Lollipops. Lidocaine or another anesthetic or medication can be made into a lollipop to suck on.
) Popsicles. Similar to a lollipop, but one advantage is that it’s cold, which can help a patient with a sore mouth.
d) Troches (pronounced tró kes). Troches are lozenges which are put under the tongue (sublingually) and absorbed through the gum directly into the bloodstream. The medication reaches the blood stream very quickly as it doesn’t have to go through the stomach or liver first. Also, the patient receives a higher percentage of the medication and the dosage can be decreased, which may reduce the side effects. Some examples of medications which can be made up into troches:
• Hormone Replacement Therapy (HRT)
• Pain control
• Headache medications
• Addiction control
Dr. Horwitz told us the story of a cantankerous elderly male cancer patient who refused to cooperate in taking the medications prescribed for him. Dr. Horwitz created a chocolate-flavored troche laced with Atavan, a tranquilizer, for his patient, who soon calmed down enough to be able to take his medicine.
e) Transdermal Gels. The medication is made into a gel and placed on a patch which is affixed to the skin. Some examples of medications applied as a transdermal gel:
• Hormone Replacement Therapy (HRT)
• Relaxants
• Tranquilizers
• Motion sickness medication
• Pain control for patients in their last few hours of life.
f) Topical Sticks. The container looks like a chapstick, or a deodorant. The medication is rolled onto the skin and gets absorbed through the skin. Pain control medications can be applied in this manner. For a headache, the patient can apply the medication to his temples, or the back of the neck, for some relief.
g) Suppositories. Suppositories are for rectal and vaginal administration of medications.
They are the major method of administering medications in Europe, but unpopular in the United States. This is a good way for the patient to receive nausea control, that is, if you are suffering from nausea and/or vomiting associated with a headache, or caused by chemotherapy, the medication is absorbed directly into the bloodstream without having to be swallowed. One person asked if cocoa butter was used as a base in all suppositories, and Dr. Horwitz said that cocoa butter is now antiquated. Other bases are preferable to cocoa butter.
h) Capsules. Capsules are an oral dosage form, which the pharmacist can make in varying sizes to best fit the patient’s needs and body size. For example, if 20 mg of a drug provides relief for the patient, but causes undesirable side effects, the compounding pharmacist can reduce the capsule to 18 mg, or any amount, to get better results.
i) Liquids. Another oral dosage form is liquids. If you’re allergic to a food dye or some other ingredient in standard liquid medications, the compounding pharmacist can eliminate the offending ingredient. Dr. Horwitz can make up your medication in 60 + different flavors, including chocolate and peanut butter (which he created himself once when he was on a diet and craved his favorite chocolate/peanut butter candy bar).
As with capsules, he can change the percentage of the dose. Perhaps a dosage of 20 mg per teaspoon is too strong for the patient--he can reduce it down to 18 mg per teaspoon, for example.
j) Sprays. Sprays can be used topically or orally. Once a 29-year-old woman with serious bilateral breast cancer asked Dr. Horwitz for help. As a result of chemotherapy her mouth was filled with sores and she could not eat. Dr. Horwitz concocted a spray which included a topical anesthetic, an antiobiotic, her chemotherapy drugs, and some vitamins and minerals.
k) Medication Baby Bottles. The medication baby bottle has an oral syringe which sticks up through the inside to direct the medication directly to the baby’s mouth.
Some of us are not being helped by traditional methods.
Miscellaneous Ideas.
1) Combining multiple medications into one dose. For example, if the patient has problems swallowing pills or perhaps has to take many different medications per day, a compounding pharmacist can combine the medications into one dose. Dr. Horwitz does this frequently for patients.
2) A compounding pharmacist can create delayed release doses. For example, instead of taking three medications four times a day, the patient only has to take one medication twice a day.
3) Dosing bottles. A dosing bottle is a plastic squeeze bottle with two reservoirs for a liquid medicine and two caps, as pictured:
This can be used by a patient who has a hard time measuring out his liquid medication. Just squeeze the bottle until the correct dosage moves up the tube on the side of the bottle and into the smaller reservoir. The liquid can then be either poured into a spoon, etc., or swigged directly from the bottle.
Dr. Horwitz also mentioned that once an oncologist from John Muir asked him to develop a super moisturizer cream for his breast cancer patients undergoing radiation therapy. The radiation treatments tended to burn and dry out the tender skin on his patients’ breasts.
Dr. Horwitz now sells this cream over the counter (without a prescription); and he has a lot of other OTC products for sale at his pharmacy across the street from John Muir Medical Center. At the end of the meeting samples of this cream, with different scents, were available for the taking.
Once an anguished father called Dr. Horwitz about his four-year-old son’s bad cough. It seems they had a new baby in the house and "Andrew" had developed this cough which kept everyone awake at night. Dr. Horwitz wondered if maybe this was a pychosomatic cough, an attention-getting device for Andrew. He had the father bring Andrew in to the pharmacy where Dr. Horwitz got down on the floor with the boy and pointed out all the different flavors of cough medicine he could make. Andrew chose "tangerine" and his new cough medicine seemed to do the trick.
Adapta Cap with an oral syringe, as pictured:
The liquid medication can be put into a bottle with an Adapta Cap on it. An oral syringe is then inserted into the Adapta Cap and the liquid is drawn up into the syringe to get the correct dose. This is used to measure a liquid medication exactly and then it can be squirted directly into the patient’s mouth. Dr. Horwitz pointed out that teaspoons found in our households can range from holding 3.5 milliliters to 7 milliliters of liquid, whereas when a medical person says to take a teaspoon of medication, he means 5 milliliters. Dr. Horwitz frequently works with veterinarians to come up with ways to dose a cat or dog and the oral syringe is a good method for animals.
In review:
1) Combine medications.
2) Make delayed release medications.
3) Make custom flavors.
4) Can titrate exact doses.
A member of the audience asked Dr. Horwitz, "Do insurance companies pay for medications put into these various dosage forms by the compounding pharmacist?" Dr. Horwitz replied that some companies pay, while others do not.
He explained the National Drug Code to us. Every drug manufacturer has to have an NDC # for each of its products. Since the compounding pharmacist is creating a custom medication for you, there is no NDC # and so insurance companies are not obligated to pay.
Another said that she belonged to Kaiser. How could she get her medications compounded if the Kaiser pharmacy wouldn’t do it for her? Dr. Horwitz told her to have the doctor write up a prescription for the dosage form she wanted, such as sublingual troches, then to take the prescription to the Kaiser pharmacy. It they can’t fill the prescription, ask for a blue card and take the prescription to a compounding pharmacist. You must pay for the prescription out of pocket, but then Kaiser will reimburse you.
You cannot fill a prescription at your regular pharmacy and take the pills to a compounding pharmacist to have them put into a different dosage form for you. There is a law that states "once a medication leaves a pharmacy it can never return." Therefore, the compounding pharmacist is not allowed to use your prescription dispensed by another pharmacy.
Dr. Horwitz stressed that your doctor must write up a prescription for the dosage form you need. If your doctor doesn’t know about these various dosage forms, have him call Dr. Horwitz for information. It is good for the doctor/pharmacist/patient to work together to come up with the best medication for each individual patient. He said also that he would contact your doctor for you if you come to him with a standard prescription and ask for customization.
It can take hours of research to custom compound medications, but the actual ingredients used in the final product may cost only pennies. This is similar to pharmaceutical companies which must spend a lot of time and money to develop and test a new drug prior to approval by the FDA. The actual ingredients in the medication may not cost very much to make, but they must pass on their expenses to the consumer. A compounding pharmacist can save you money.
Specific examples of custom medications:
Dr. Horwitz then talked about some of the drugs used in the treatment of headaches. The first, Sumatriptan, or Imitrex, comes in an injectable form, which is not a favorite way of administration for many patients. Imitrex is now available in 25 and 50 mg sizes in tablet form in the U. S., and in Canada you can get it in a 100 mg tablet. A compounding pharmacist can provide the equivalent of a 50 mg dose in a 6 mg sublingual troche. This is because when the drug is taken orally it is torn apart by the liver, etc. before it can do its job. Taken sublingually, the drug gets into the blood stream faster, therefore a much lower dosage is required, and fewer side effects are experienced. Dr. Horwitz said he can make eight troches out of one 50 mg tablet. The shelf life for troches is nine months.
Donna Johnson, in the audience, commented that she had a cessation of side effects from Imitrex when it was taken in troche form. Before, she had to take an Atavan (tranquilizer) ten minutes before injecting herself with Imitrex.
Dr. Horwitz also works with herbal therapy. When asked about feverfew, he said he hasn’t personally worked with feverfew. "Herbs don’t go through the FDA for approval, but should receive the same care and attention by the government."
Ergonovine is mostly used as a prophylactic for migraine. It usually comes in a troche or capsule form. Ergonovine is related to Ergotamine, but is only one-tenth as strong. There are not many problems reported with Ergonovine use. Patients report good results with few side effects. When asked in what category this drug belongs, Dr. Horwitz replied that it is perhaps a vaso-constrictor.
"What about mixing Ergonovine and Sumatriptan?" Dr. Horwitz doesn’t have any experience with that.
Ergotamine Tablet: Tiny triturates--sublingual. Tablet made of sugars which melts.
Ketoprofen Gel: Topical--rub on skin. Orutis (Ketoprofen), an NSAID (non-steroidal anti-inflammatory drug). A topical medication is good for arthritis, or one can rub it into the skin at the temples or base of neck to relieve headaches.
Lidocaine 4% Solution Nasal Drops: an anesthetic. Frequently used for sinus headache.
It is important that you get the drop all the way up to the top of the nasal cavity. Therefore, to administer this medication you must get on your back with your head tilted down, and don’t stand up for awhile. Also, use a saturated Q-tip to get all the way to the eyeball.
Dr. Horwitz said that nose hairs can block a nasal spray, so drops work better.
DHE Nasal Spray (Dihydroergotamine): Acts in central way--gets into the blood stream fast.
Dr. Horwitz also mentioned a combination of medications in one capsule that provides headache relief for some people. The capsule contains riboflavin, ketoprofen, and caffeine. He mentioned that this should be kept as a prescription drug--should not be readily available over the counter.
One person in the audience mentioned trying Depakote, Nardil, and Tegretol. Dr. Horwitz said that Nardil is very dangerous if you also consume alcohol. He stated that what works for you will not work for the person sitting next to you.
There are 2,000 compounding pharmacists across the country.
At the end of his talk, Dr. Horwitz invited the audience to come up front and view the samples he brought of the various dosage forms, etc.
The notes provided above were taken by an EBHSG volunteer and have not been reviewed by the speaker for accuracy. If you have any questions regarding the notes, please contact the EBHSG.
The intention of the East Bay Headache Support Group is to provide information and resources. It does not provide medical advice, which should be obtained directly from a physician.