Hospice & Palliative Care in Developing Countries

Transcription

1 Hospice & Palliative Care in Developing Countries Compounding End of Life Medications WHO Recommendations to Developing Countries Russ Zakarian, Pharm.D. FASCP

2 What is Compounding? Compounding is the method of preparing customized medications to help meet unique physician and patient needs.

3 Pharmacy The art or profession of preparing and preserving drugs, and of compounding and dispensing medication according to the prescriptions of physicians. Early 20 th Century Webster Dictionary

4 Also known as a problem solver, a compounding pharmacist s ultimate goal in preparing customized medications is to help the physician and patient achieve a more positive therapeutic outcome.

5 Hospice Alternative routes of administration Individualized pain management Nausea & vomiting Inhalation therapy Emergency kits Mouth ulcers Saliva stimulants Adjunctive therapies

6 Meeting Unique Needs In: Hospice Pain Management Bio-identical Hormone Replacement Therapy Veterinary applications Household pets Equine Zoos Exotics Dental Dermatology

7 Compounded Dosage Forms Oral capsules and liquids Transdermals Lollipops and popsicles Troches, tablet triturates and sublingual drops Rapid dissolve tablets Suppositories, enemas and rectal rockets

8 Compounded Dosage Forms Nasal and otic preparations Topical creams, ointments, gels, powders and sprays Oral adhesives, mouthwashes and rinses Sterile products Inhalation solutions, injections, ophthalmics, TPNs

9 Compounded Capsules Medications formulated in capsules enable the patient to get the exact dosage needed, while avoiding unwanted dyes and fillers.

10 Compounding for Pain Management Capsules Morphine Sulfate SR caps up to 900mg/cap Oxycodone SR caps

11 Compounded Oral Liquids Preparing medications in a liquid form allowa the patient who can t swallow pills to get the appropriate medicine in a vast range of flavors, such as tutti-frutti or vanilla butternut.

12 Compounded Oral Liquids Difficulty swallowing Avoid unwanted ingredients Increased compliance Anhydrous formulations

13 Compounding for Pain Management Oral Liquids Magic Mouthwash Morphine oral solutions 50mg/ml (commercial dose is 20mg/ml)

14 Transdermal Gels

15 Transdermal Drug Delivery Drug Classes Used in Transdermals NSAIDS Muscle relaxants Antinausea agents Antiviral agents Anti-inflammatory agents Anesthetics Anti-anxiety agents

16 Transdermal Drug Delivery Drug Classes Used in Transdermals Anti-diabetic agents Antidepressant / anti-psychotic agents Anti-hypertensive agents Thyroid medication Antihistamines Anti-infective agents

17 Compounding for Pain Management Transdermal Gels ABHR Alprazolam Dexamethazone Diazepam Gabapentin Haloperidol Ketamine

18 Compounding for Pain Management, cont Transdermal Gels Hydroxyzine Metochlopramide Oxycodone Promethazine Temazepam Diphenhydramine

19 Medicated Lollipops Local effects Anesthetic Antifungal Antiviral Anti-inflammatory Saliva stimulant Healing agents

20 Medicated Lollipops Systemic effects Anti-anxiety Antipyretic Analgesic Narcotic Non-narcotic

21 Troches Soft gelatin-flavored troches, such as those prepared in the 24 and 30-count molds, provide medication in an easy-to-take and pleasant-tasting form.

22 Rapid Dissolve Tablets

23 Compounded Sterile Products USP <797> standard compliant Infusion pain management with CADD infusion pumps Routes of infusion: SQ, MediPort, PICC MS 50mg/cc Hydromorphone 10mg/cc Fentanyl 50mcg/cc Lorazepam 2mg/cc Midazolam 5mg/cc

24 Suppositories and Enemas Rectal or vaginal use Helpful to patients who have difficulty in swallowing, nausea/vomiting Injections cause pain, anxiety Rapid local affect

25 Compounding for Pain Management Suppositories ABHR Chloral Hydrate Diazepam Morphine Phenytoin Gabapentin

26 The Rectal Rocket

27 Quality & Safety Steps in the Compounding Laboratory

28 IAHPC Meds for Palliative Care Pharmacist Prospective List includes 33 medications of which 17 already included in WHO list. Medications were rated on effectiveness and safety profile. Final list was approved by panel of 28 professional organizations. Refer to handout for list of meds.

29 Anti-depressants TCA local anesthetic type properties due to its sodium channel blockade. Not shared by SSRI anti-depressants. Decreasing depression can de-amplify the sensation of pain. Plasma steady state takes 2 weeks.

30 Adverse Drug Effects Amitriptyline (TCA) Dose related Anti-cholinergic effects Co-morbidities such as CV disease and drug interactions limits its use. Desipiramine (TCA) Lowest risk of anti-cholinergic effects Mirtazapine/Trazadone Dual action of NaSSA and Tetracyclic Cymbalta (not on the IAHPC list) FDA approved for nerve injury pain

31 OPIOID ANALGESICS Opioids classifies as full morphine-like agonists. Do not exhibit dose-ceiling expect when limited by toxicities. Antagonize NMDA receptors mu, kappa, delta receptors are target molecules for analgesia

32 MORPHINE Gold standard IAHPC list both IR and SR forms WHO only list IR forms Highest dose list for SR is 30mg tabs MSIR sol dose listed is 10mg/5ml

33 SPECIAL CONSIDERATIONS Neurotoxicity Opioid Induced Hyperalgesia (OIH) more pain with more drug Tolerance Neuronal excitotoxicity via cell death Changes in glutamate availability NMDA receptor excitability Ratio of M6G/M3G NMDA blockers ketamine, clonidine, methadone Signal of disease progression

34 OXYCODONE mu & kappa receptor agonist Metabolized CYP 2D6 pathway Dose adjustments necessary with drugs that inhibit CYP 2D6 (Haldol,Paxil,Prozac) 10-20% metabolized to oxymorphone. Oxycodone IR 5mg on IAHPC list Oxycodone SR not included

35 FENTANYL Potent mu agonist PO conversion to patch Convert oral opioid to equivalent dose of oral morphine Half this dose and convert to mcg for appropriate patch size Reverse should not be used Metabolized CYP 450 3A4 25mcg for Opioid Naïve patients

36 METHADONE Elimination half-life (8-59 hours) is longer than its duration of action (4-5 hours) High dose and prolonged QT intervals a marker for deadly cardiac problems Dose conversion is challenging Not a first line drug DEA restricts distribution to 10mg tabs

37 LIST OF ESSENTIAL MEDICATIONS, CONT Bisacodyl/Senna/Mineral Oil Prednisone/Dexamethasone Acetaminophen Valium/Lorazepam Midazolam/Zolpidem Haldoperidol Gabapentin

38 List of Essential Medications,cont IBU Carbamazepine Codiene Loperamide Metoclopramide Tramadal

39 GETTING PAST THE STIGMA Reasons Pharmacist stock inadequate supplies of opiods Concerns with DEA monitor usage Illicit use and fraud Fear of theft

40 Questions??? For more information Russ Zakarian,Pharm.D. Model Drug Pharmacy