Specialty Susan Finstrom May 2020 Learning Objectives After this presentation you should be able to answer these questions Why is compounding an essential part of pharmacy practice How does compounding help to handle drug shortages ID: 1011590
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1. Compounding as a Pharmacy SpecialtySusan FinstromMay 2020
2. Learning ObjectivesAfter this presentation you should be able to answer these questions:Why is compounding an essential part of pharmacy practice?How does compounding help to handle drug shortages?How does a pharmacist assess a patient and help to manage the patient’s medication ingredient allergies or intolerances?
3. What is Compounding?In everyday terms, compounding is preparing a medication by mixing or altering the ingredients to make the medication specific to a certain person’s unique need.A patient may need liquid medications, for example, if they are tube-fed.Video–patient needing liquid medication - https://youtu.be/2mYqfh-fPJkPolling Question: Could the patient in the video successfully take manufactured medications?
4. How does compounding differ from manufacturing?CompoundingPrepared with a specific patient in mindOnly a limited quantity is preparedMay be prepared quicklyManufacturingProduced for distribution to the entire nationA large quantity is produced with limited varietyTakes time to adjust to increased demandBreakout rooms: Why is compounding essential?
5. When the manufactured dosage form may be inappropriate for the patientFor example: a patient is unable to swallow a tablet and needs a liquid form insteadA Non-Sterile Compounding PharmacistReasons why compounding is essential to healthcare
6. When an animal patient needs a human medication, but in a different dose or dosage form—think of the variety of animalsFor example: a dog needs medication for an ear infection and that medication is not in a manufactured medication.A Veterinary Compounding PharmacistReasons why compounding is essential to healthcare
7. Compounding for Veterinary PatientsAn example–Canine Chronic Ear InfectionsDogs have long and angled ear canals, making medication delivery deep in the ear canal challenging. A compounder can make otic (ear) gel.The medications are mixed in a special gel which is water-based, has bio-adhesive properties, and is biodegradable. It will remain in the ear for several days and eliminates multiple daily dosing. It goes in as a liquid, but body heat turns into a semi-solid gel.
8. When a preparation is not stable long enough to make it from manufacturer to patientA Nuclear Pharmacist preparing a radioactive medicationReasons why compounding is essential to healthcare
9. When a preparation is not available due to manufacturing shortagesA Sterile Compounding PharmacistFor example: Sterile injections are needed for ventilator patientsReasons why compounding is essential to healthcare
10. Compounding--Meeting the Need When Shortages HappenMEDICATION SHORTAGE FOR VENTILATORS?THERE IS NOW A COMPOUNDERS' SHORTAGE DRUG SOURCE FOR HOSPITALSThe Compounders' Shortage Drug Source for Hospitals lists what formulations are available from what pharmacies and outsourcing facilities. It’s a mean to connect supplier with buyer.
11. Compounding--Meeting the Need When Shortages HappenShortage!A Solution to the ShortageCompounded Hydroxychloroquine
12. Compounding Meets Special Medication NeedsReasons why medication shortages happen:A manufacturer’s production is stopped temporarilyA manufacturer decides to completely stop producing a medication (usually for financial reasons)More medication is being used than expected by analysts (demand exceeds current supply)
13. When a patient is allergic to an ingredient in the dosage formFor example: preparing capsules without using lactoseA Non-Sterile Compounding PharmacistReasons why compounding is essential to healthcare
14. Allergy/Intolerance to a MedicationIf a patient is allergic or intolerant to a medication, prescribers and pharmacists must ask:Can the medication be stopped?Can the patient take a different medication used for the same condition?Allergy or intolerance may be due to the active ingredient or it may be due to the inactive ingredients (excipients).Most often it is due to the active ingredient;But it could be due to inactive ingredients.
15. Synthroid and Allergy SymptomsSynthroid (active ingredient: levothyroxine) prescribing information states:Hypersensitivity (allergy) to levothyroxine itself is not known to occur. Hypersensitivity reactions to inactive ingredients have occurred in patients treated with thyroid hormone products. These include urticaria, pruritus, skin rash, flushing, angioedema, various gastrointestinal symptoms (abdominal pain, nausea, vomiting and diarrhea), fever, arthralgia, serum sickness, and wheezing. Discussion question—Is it the active ingredient or the inactive ingredients that could cause allergy issues?
16. Synthroid contains the inactive ingredients acacia, confectioner's sugar(contains corn starch), lactose monohydrate, magnesium stearate, povidone, and talc.Synthroid tablets contain no ingredients made from a gluten-containing grain (wheat, barley, or rye). Strength Color Additive25 mcg FD&C Yellow No. 6 Aluminum Lake50 mcg None(More strengths available, but not listed here)Let’s look at a polling question.An Example of a Manufactured Medication and Its Ingredients
17. The Compounding OptionIn the case of Synthroid, there may be other manufacturers’ products which eliminate the inactive ingredients that are causing the allergies/intolerances.If those products won’t help or aren’t available, there is a pure levothyroxine powder that a compounding pharmacist can use.
18. Focus on Lactose Intolerance: What happens in the gut?Lactose is a type of sugar found in milk.Lactase, an enzyme, is needed in the intestines to break apart lactose into absorbable parts.When there is a lactase deficiency, lactose remains in the small intestine.The abundance of lactose creates an osmotic effect, resulting in excessive water being retained, which can result in diarrhea.The undigested lactose begins to ferment, and the resulting byproducts can result in nausea, diarrhea, abdominal distention, cramps, gas, and more..
19. How Can a Compounding Pharmacist Help Patients with Lactose Intolerance?Eliminate lactose as much as possible from pharmaceutical preparations!X
20. A Case of Medically-Significant Lactose Intolerance45 year-old man with lactose intolerance who has to be on the anticoagulant, warfarin sodium.When he is exposed to lactose, he has ventricular arrhythmias, (this is an unusual reaction to lactose), but for him it could be life-threatening.Manufactured warfarin sodium contains lactose as a filler.The doctor said the patient must stay on the warfarin sodium.ECG examples of arrhythmias
21. A Compound of Warfarin SodiumHow did a compounding pharmacist solve this patient’s problem?The pharmacist was able to obtain the pure warfarin sodium powder.He used that powder plus a different filler than lactose, in this case, calcium carbonate, to make lactose-free warfarin sodium capsules for the patient. The patient did well, and he has continued on the compounded prescription.Reference: Glasnapp, Andrew. Alternatives for the Lactose-Intolerant Patient. Intl J Pharm Comp 2(6); Nov-Dec 1998:412-3.
22. Ingredients that May Cause Allergy or Intolerance IssuesLactose/MilkGlutenCorn-sourced productsSoyPeanutsTree nutsEggsSugarFood ColoringAnimal-sourced products like Gelatin ShellfishSesame oil
23. A Compounding Pharmacist Serves as a Medication Problem-Solver When Traditionally-Available Medications Do Not Meet Patients’ NeedsQuestions?
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